Here are my predictions. You'll note it's Obama by an electoral and popular landslide:

I have Nevada going red even though recent polling data suggests that it will go Obama's way. For some reason I'm thinking that it will go Republican.

I'm also fairly certain that the Republican party has some serious thinking to do, and you'll see two schools of thought emerge:

• A further rightward shift will solve all of their ills
• A more progressive, center-leaning strategy

A further rightward shift would be suicide for Republicans at this point, just like Governor Palin ended up being the boat anchor for Senator McCain. While the idea was to "re-energize the base" to compensate for Senator McCain's relatively moderate political views, this was the wrong choice because hardcore conservatives were never going to vote for anyone but the Republican candidate to begin with. Rather, he needed to attract those independents that have been left out in the cold these last 8 years, and he only further alienated these voters.

A center-leaning strategy is their best chance, but it's my view that even a radical reinvention of the party will take the full four years to make its way into the American consciousness. The Republicans will not capture the Oval Office again unless they win Ohio, Florida, and Pennsylvania. Neither can the GOP afford to ignore the Northeast and West Coast, either. Most of the economic and educational outputs in this country are from these areas, and they rightly wield enormous political clout. It is my hope that the party does some serious soul-searching in the next few years and comes to the conclusions that it needs to have the best interests of the country at heart rather than the interests of big business and a small subsection of the population consisting of the middling rich and radical conservatives. (The super rich tend to vote Democrat.)

Speaking for myself, I have no particular litmus test for a presidential candidate, though I did when I was younger and the world seemed more black-and-white. Or rather, I thought I didn't have a litmus test, but I discovered — rather unpleasantly — that I do indeed have a few basic criteria that a candidate must meet: competence, curiosity, and equanimity. Governor Palin fails all of these in spectacular fashion, and her incredibly tenuous grasp of Constitutional fundamentals frightens me a great deal. It gives the lie to the McCain campaign slogan "Country First." Fortunately for the country, this short-sighted decision has backfired, and hopefully Governor Palin will go back to Alaska and quickly be forgotten as the national embarrassment that she is. A McCain-Romney or McCain-Lieberman ticket would have been a stronger bet. Coupled with better campaign management, I could see myself happily voting for a Republican ticket on Tuesday, but no longer.

Of course, Governor Palin is not herself running for office, and I have not seen Senator McCain himself exhibit much curiosity or equanimity these last few months. Rather, I have seen an angry man who hops from one stance to the next in an effort to find the most popular footing possible. I've seen a man who has run an campaign characterized by exclusive rhetoric; a man whose running mate has tried to characterize parts of America as being more "real" than others. That is not what this country needs right now. I do not believe that Senator McCain is incompetent, and I don't believe that he wants to see this country further divided into Red and Blue. However he did not choose a candidate who complements him — his admittedly poor grasp of basic macroeconomics coupled with his own lack of curiosity on the topic — makes for a dangerous combination when coupled with the likes of Governor Palin. It is quite clear that Senator McCain's VP pick was entirely political, and not in the best interest of this country.

Senator Obama, on the other hand, has displayed a remarkable sense of curiosity and equanimity throughout the entire campaign, and while his resume is indeed rather thin on both foreign policy and economic issues, I am comforted by the people he has chosen to surround himself with. His off-the-cuff reaction (page 2) to Senator McCain's move to cancel the first debate was certainly Presidential, and entirely unscripted. Senator Obama's VP pick displays a careful consideration of his own real strengths and weaknesses instead of just his political weaknesses. Senator Biden has rich foreign policy experience and is a member of the National Security Council. In economic terms, while a professor of constitutional law at the University of Chicago, Obama regularly spent time with professors from their renowned economics department, which demonstrates a necessary curiosity, and while lunchtime socialization does not equal real experience, Obama has surrounded himself with a team of economic advisors that's second to none. (Though I'm sure Greg Mankiw would disagree.)

I take strong issue with the idea of American exceptionalism, the idea that the rest of the world doesn't matter, and that somehow America operates in a global vacuum. This clearly isn't the case, as the collapse of the American financial markets has had a domino effect on the rest of the world. China's output is slumping due to falling consumer demand from America; Iceland is bankrupt and subsequently decided to go back to basics (i.e. tourism); the UK is on shaky financial ground even as Gordon Brown has engineered a unique bailout of their financial system, and the credit crunch is beginning to make its way down into the real economy. Despite these recent setbacks, globalization will and must continue, and America must repair her tarnished relationship with the rest of the globe, and the world overwhelmingly favors an Obama administration, by margins much greater than my own predictions: 9,115 to 203 electoral college votes. While the rest of the world is not voting, we must take into account their opinion because we have lots of ground to cover as we begin to unmake the current administration's mess.

Healthcare is not an issue that will change dramatically in the next four years. The medical blogosphere, of which I am a part, likes to talk about it regularly, but healthcare is so insignificant in the big picture right now that I view it as a non-issue. This country cannot afford a new social spending program on the order of magnitude that the likely winner, Obama, is proposing. And America will not be in a position to do so until she gets her feet back on solid ground.

Likewise, the educational funding proposals put forth by Senator Obama will also likely take a back seat for several years. When considering the costs of funding large-scale federal programs, one must take into account not just direct costs and where the money will be coming from today, but what spending that money today will mean for tomorrow. We do not exist in a temporal vacuum, and in a time where middle-eastern Sovereign Wealth Funds and Chinese banks are already reluctant to lend the US money, we must strongly consider whether these should be high priorities.

In my opinion, they should not, and should remain further down the list until we've gotten the rest of the country back on track. We must also consider the future, not just the next four years. How do we allocate our capital and labor to achieve the best results both for today and for our children? I believe that Senator Obama's green energy plans are better than Senator McCain's, though his lack of overt support for nuclear power concerns me. I also believe that while the healthcare sector will remain relatively stable even during this recession, it's going to be renewable energy that's going to power us out of our decline. Senator Obama wants to fix the economy and get this country on a path to energy independence. At this point energy independence is the same as renewable energy, and it's inextricably linked to growing out economy.

There will come a time for rethinking the US healthcare system, but that time isn't now. And when that time does roll around, we'll need to be talking more about revamping the system from its educational roots right up to a renewed focus on primary care as a cost saver and then on to our fractured tort system with many smaller milestones along the way.

In the meantime, we need a leader who is inclusive rather than divisive; a leader who can inspire; a leader who will be welcomed (gallery) with open arms by the rest of the world; and a leader can do a great deal for the image of this country simply by taking the Presidential Oath of Office; and a leader who supports rolling back the abuses of Executive power. For all of these reasons and many, many more, I will be voting for Barack Obama on Tuesday, November 4.

Patients 80 years and older who are in overall good health are perfectly able to withstand open-heart surgery, according to the latest study of Dr. Kevin Lachapelle of the McGill University Health Centre (MUHC). His findings were presented this morning in Toronto during the 2008 Canadian Cardiovascular Congress.

"Age should not be a reason for doctors to rule out the possibility of heart surgery for their octogenarian patients," explained Dr. Lachapelle. "If patients with heart problems are otherwise in good health, this surgery can significantly improve their quality of life."

Well that's fantastic. (It really is, I'm not being sarcastic.)

Economics is fundamentally the study of the allocation of scarce resources subject to effectively infinite demand, and while we like to think that healthcare is an infinite good, it most certainly is not. Specifically, normative economics is the process of incorporating value judgments into economic arguments. Most economists avoid making value judgments because there are always exceptional cases, and because it often leads to spectacular foot-in-mouth syndrome. That said, I can't help but have thoughts that tend toward the normative when I read paragraphs like the one I quoted.

Sure, octogenarians may survive and even have a net positive outcome. But what are the opportunity costs associated with operating on individuals who have already exceeded the mean lifespan for someone of their sex? Are we operating on these folks while leaving those that are younger — and therefore potentially more productive — in the lurch? Are we forgoing an operation on someone much younger? How does the fact that the average 80 year old is not as productive as the average 40 year old factor into this equation? Generally taxpayers want something in return for their investment. Do we want the government subsidizing a procedure on someone whose primary income is their monthly Social Security check, and if the answer is yes, how do we prioritize who goes first? How do we manage that inevitable wait list? Generally we subsidize healthcare because we expect some kind of benefit in return, usually in the form of economic output.

I've worded my questions provocatively, but I don't really have an opinion one way or the other, except to say that I'm glad that I won't be the one who has to make these decisions in the coming years. These questions aren't purely rhetorical either: these are very real, difficult questions that are going to have to be addressed as we move inexorably toward some kind of basic universal health coverage in the United States.

As I pointed out yesterday, Americans don't like to be told "No," and we don't like to wait for things, and I mostly include myself in that generalization. If we postpone, or worse, opt to forgo very costly surgeries on the elderly because a cost-benefit analysis doesn't add up, will our culture be able to accept it?

My guess is no, and as soon as it happens, there will be some very ugly public political lynchings.

What are your thoughts?

I'd imagine costs for DM2 care had risen, like everything else, but was surprised to hear the thoughts about public health & nationalized health insurance. It's been a long time since I took a public health class, but I'd been under the impression that they were cut from the same cloth. Now, that I think of it, I don't hear about Medicaid paying for diabetes education, but then, I'm not familiar with who utilizes the program, and who pays for it, whether Medicaid, Medicare, or private insurers would reimburse the provider for diabetes classes.

Because pharmacists and ancillary staff deal primarily with drug therapy, we tend to think of the rising cost of healthcare as a result of the increase in the cost of prescription drugs. However this isn't actually true. According to the CEO of Harvard Pilgrim, drug costs have been increasing at a rate of less than 5% per year, whereas medical expenses have been increasing at a rate of about 10%, so the increase in healthcare costs isn't really driven by prescription drugs as much as is commonly thought.

In the long run, drugs tend to be cost-savers rather than cost-centers when utilized correctly, but that's not news to anyone.

When you speak of $1 for public health are you saying 'education & prevention'. If so, I would agree conceptually. There are probably long-term studies that prove this beyond a doubt.

Yes, that is what I mean, but I was unintentionally vague in my first post. I consider public health to be education and prevention in the form of programs and legislation design to try to have a long-term impact. I also consider public health to be (mostly) a public good in the economic sense of the term.

But the government considers public health to be quite a bit more than that, ranging from the IHS to Medicare/Medicaid to the FDA. When you look at their FY2009 budget (121 page PDF), I would have to cherry-pick the bits and pieces that I consider public health, add up their budgets and calculate the percentage of the whole… So clearly that's not what Uncle Sam considers public health, and I should probably find a better term. "Education and prevention" like you suggested is good, but I think that's a bit limited, because I see the laws that are being passed that prevent the sale of certain types of food in public schools to be public health, as well. Then there's the work that the CDC does — particularly in containing and eradicating communicable diseases like smallpox and polio — and other things like providing clean drinking water and sanitation.

At the very least, though, I consider "public health" to be very separate from more traditional healthcare delivery.

And, so I'd venture your point is that any successful nationalized healthcare insurance-type or other type of program would need to incorporate a preventive arm with incentives for greater self-care. A lot of the obesity problem has to do with not bucking the current socially acceptable behaviors, i.e. too much availability of nutritionally cheap food, devaluation of importance of physical effort and exercise, sedentary lifestyle, plus knowledge deficits about foods and hidden human costs. Look at what happened when NYC banned trans fats, for example. I think the fallout will be realized in our lifetime, with a slowly falling domino effect.

Yes, a comprehensive wellness-type program would have to be instituted. I would go so far as to attach financial penalties to those who are wildly unhealthy. Think of it as almost like a Pigovian tax, if you will. Even if you return this money to the consumer at the end of the year in the form of an income subsidy, it's still a powerful motivator to change because there's a real financial pain associated with a specific aspect of their lifestyle. Then of course there's the perennial moral hazard problem that's never going to go away. It is true that if you are responsible for a greater part of your healthcare costs, you will go out of your way to make healthier choices to minimize the chances of becoming ill. (Just ask those who have consumer-directed health plans with high deductibles who pay out of pocket for "normal" medical care.)

But of course you need to fund pathways that would enable people to learn and make healthier lifestyle choices. You can't just take an overweight smoker who works in a coal mine and has less than a high school education and tell him to lose 100lbs or he'll pay more for his healthcare without setting a reasonable timetable and funding the education and exercise program that will help him get there. That's just rotten and doesn't help anyone.

What is troubling and will present problems in a nationalized system of healthcare is that Americans don't like to hear the word "No." We live in an entitled society where the customer is always right, and it's our God-given right to have cheap gas, drive SUVs, eat our fast food, and spend our the government's money on futile, end-of-life care. In other countries that have nationalized healthcare, there are very limited formularies in place, and many treatments and interventions aren't covered at all, or if they are, there may be a multi-month waiting period to have that procedure. That kind of rationing would be tough for America to swallow. We seem to have this bizarre notion that simply because we are living, breathing human beings, we are entitled to X, Y, and Z, and we should have it now.

Obviously we're not beautiful and unique snowflakes, and I think that the younger generations are beginning to recognize this as their thoughts linger on new ideas like "sustainability", but I get the sense that the baby boomers are going to resist these kinds of necessary limitations.

Anyway, hope I answered your question.

However, I am pleased to see that the Stanford researchers are interested in how much of this extra cost is due to costly new medications that may or may not be worth their price — a topic too rarely discussed in the Ivory Towers of academia. They cite Januvia and Byetta as potential cost centers, but I can't help but think that they're missing the mark just a little bit. In outpatient diabetes management — and I'm going to assume that institutions and hospitals are similar — Byetta and Januvia, while successful, aren't what I would consider blockbusters. They aren't super mainstream yet.

In terms of quantity and price, the TZDs — particularly Actos, since Avandia got thrown under the bus — are far more costly. Yeah, incretins, whether direct or indirect are the new CME hotness with the associated mindshare, but compared to your TZDs, biguanides, and sulfonylureas, they're a distant a second/third/fourth fiddle in volume, if not cost.

Drug companies market these new drugs with claims of greater convenience and better control of blood sugar levels, and physicians have increasingly used them as alternatives to injected insulin, Alexander said. Insulin use has correspondingly dropped from 38 percent of treatment visits in 1994 to 28 percent in 2007.

This particular sentence bugs me because the implication is that insulin is cheaper than most oral medications. This just isn't true, particularly with the modified human insulins that can be very costly indeed. At the very least, they're on par with the cost of oral meds, and let's not forget that most people with T2DM would prefer not to stick themselves with a needle, no matter how small.

Talk of direct costs aside, it is obvious that $1 spent in the name of public health has a greater marginal utility than $1 spent on a medical intervention — be that drug therapy, a procedure, or whatever. Ben Franklin was right, after all. Unfortunately, the long-run cost savings of public health programs are notoriously difficult to measure, and certainly nowhere near as sexy as a medical intervention. Perhaps that's why public health gets shortchanged? I've spent some idle moments wondering how much money we could save if we spent a third or even a quarter as much combating things like poor nutrition and obesity as we do on direct healthcare itself.

It seems like the bulk of the money spent on prescription drugs is spent to offset the poor lifestyle choices that we Americans like to make. Unfortunately we pay dearly for that privilege. Any sort of nationalized healthcare will have to take this God-given right tendency into account.

"Prescribing this medicine is like trial and error in finding the right dosage that works best for you," says Krynetskiy. "Five milligrams is a typical dose, but a little less or a little more could have dramatic consequences or no benefit at all."

Doctors call this optimal dosage the therapeutic window, and Krynetskiy is trying to find it through pharmacogenomics, the study of a person's response to drugs based on their genetic makeup. It's a collaboration that crosses campuses and includes Krynetskiy and fellow clinical faculty at the School of Pharmacy, clinicians at Temple University Hospital and Jeannes Hospital. The researchers are studying why people process the same drug differently. In this case, they're trying to find the correlation between genotypes, or a person's inner code of DNA, and the correct dosage of Warfarin. By collecting saliva samples and extracting DNA from 77 participants already on the drug, the researchers can look for variances, genetic clues, which make people metabolize the same drug in very different ways.

Sounds more like a fun lab experiment than something that'll be clinically valuable for something as cheap as warfarin. This might be more interesting in terms of cost-benefit by choosing a drug that's both expensive and has a narrow therapeutic index. Aminoglycosides, some cancer drugs, and then there's always the iatrogenic narrowing of therapeutic windows — especially via the P450 isoenzyme — that might benefit from this kind of relatively blunt pharmacogenomic hashing. At the very least, some interesting and possibly useful trends might be established.

Warfarin, as cheap as it is, probably isn't a bad place to start. At the very least, I bet it makes for an awesome lab — we never did anything nearly as cool when I was in school…

Update from Eric:

It's not the cost of the drug – it's the cost of the 29% of Warfarin users that are hospitalized in the first year due to a drug-related adverse event.

If this is indeed the case, then preventing just one hospitalization could pay for dozens, and possibly hundreds of these tests, not to mention the impact on human and opportunity costs associated with hospitalization and ADEs.

Targeted drug maker NitroMed Inc. plans to sell its BiDil drug business to JHP Pharmaceuticals LLC for a possible $26.3 million. New Jersey-based JHP, a privately held specialty pharmaceutical company, will buy the assets related to BiDil for $24.5 million in cash, plus up to an additional $1.8 million for inventory at the closing date.

[...]

NitroMed also reported its financial results for the third quarter which ended Sept. 30. The company's total revenues climbed slightly to $4 million, compared to $3.8 million for the same period in 2007. All of that revenue came from sales of BiDil, officials said. NitroMed's net loss dropped to $400,000 for the quarter, compared to a net loss of $8.4 million last year.

Yeah, sounds like it's time to off-load that to a company that has other winners in its lineup and doesn't need to maintain the marketing and manufacturing overhead required to keep BiDil on the market. Of course, they should have done that in the first place. You can't really build an entire company around an uninteresting drug priced too high to be relevant when its components are already available in generic form for pennies per tablet. It's not a bad drug; it's just too expensive for what it is.

If JHP is smart, they'll cut the price to about a third of its current cost, and let volume take care of the rest. Not that BiDil will ever be a huge winner, but it could certainly be bigger than it currently is if priced and marketed appropriately. Monopoly pricing only works when you have something people want, and are willing to pay for.

So…

I hope to start writing again soon. I've been absolutely mired in economics lately such that my time behind the pharmacy counter has been purely spent on auto-pilot. Truth be told, I'm not sure what to write about. Silly people aren't very interesting anymore, and there are other bloggers that do it better. Therapeutic stuff is interesting, but I haven't been thinking about anything interesting or controversial lately, and it's bad form to just make things up, so we'll have to see what comes down the line.

And really, I'd rather not bore you with economics talk, even though we are on the cusp of a nice little recession, and I could ramble for pages.

However LIBOR and TED are moving back in the direction of Sanity, which means the credit markets will continue to thaw, but that doesn't mean the rest of the economy isn't sputtering, and it'll take more than a non-stratospheric TED spread to get the real economy back chugging again.

Healthcare, of course, will continue to be relatively safe — if uninteresting — so long as your profit centers are relatively inelastic, and it's ultimately going to be green technology that really drives the market in the next ten years. Well, that's assuming that petroleum prices go back up to something like their true price, not their currently-low, market-determined price. I'm probably in the minority of people who wants to see gas prices go back up so we keep our eye on the renewable energy ball.

Pigovian tax for the long-run economic win!

I have erred always on the side of accuracy, opting to omit a word when I couldn't be sure that it was correct. Users have submitted their own additions, and I have folded them in, after verifying their accuracy to the best of my ability. Many of the words are quite obscure, as most of you can imagine.

Most recently, someone from Australia has created an Australian localization for the work, and I have added that to the page as well.

I think this is a better option for students and anyone else that wants a pretty comprehensive spell check word list, and doesn't want to pay Stedman's $100 to get one. This is also much more comprehensive than those $15 shareware dictionaries that you see floating around — many of which have spelling errors. (I know, I've looked at most of them.)

MeDic is, of course, freeware. And always will be. It's also available for OpenOffice.org, for those of you who don't use Word.

If you think it's useful to you or someone you know, please bookmark it, Stumble it, or even throw me a link to the MeDic main page:

Arthur Firstenberg says he is highly sensitive to certain types of electric fields, including wireless Internet and cell phones.

"I get chest pain and it doesn’t go away right away," he said.

Firstenberg and dozens of other electro-sensitive people in Santa Fe claim that putting up Wi-Fi in public places is a violation of the Americans with Disabilities Act.

Result:

The City Council has unanimously approved a plan to provide wireless Internet service in libraries and other city buildings, over the objections of those who say they are electrically sensitive.

That doesn't mean the legal wrangling is over, however.

Julie Tambourine, an advocate for the disabled and homeless, said after Wednesday's meeting that the legal analysis was flawed, because it didn't take into account those with diabetes, seizure disorders, respiratory ailments and other conditions that can be adversely affected by microwave radiation.

These idiots need to read up on the electromagnetic spectrum. Unless they're going to sit in a lead box all day long with no visible light on a carefully controlled diet, they're going to be exposed to all kinds of EM radiation, including gamma rays throughout their lifetimes. And even inside that theoretical lead box, there's no guarantee of being radiation-free.

For further comic value, these people's minds would explode if they had any idea of how many radio waves pass through their bodies each second. Theoretically, for physiologic purposes, 802.11b+g wi-fi signals (0.124-0.121m wavelength depending on channel) are no different than FM radio signals (~3m wavelength). Common sense would tell you that that's pretty insignificant.

But since common sense is often wrong, we look to the actual evidence. And the evidence in favor of wifi radiation sensitivity just isn't there.

This one's for The Angry Pharmacist:

And for keagirl and Dr Schoor:

God bless the tinfoil hat brigade:

Arthur Firstenberg says he is highly sensitive to certain types of electric fields, including wireless Internet and cell phones.

"I get chest pain and it doesn't go away right away," he said.

Firstenberg and dozens of other electro-sensitive people in Santa Fe claim that putting up Wi-Fi in public places is a violation of the Americans with Disabilities Act.

Psst, Arthur, this is what we call a somatization disorder.

Sante Fe, the rest of the country is laughing at you.

I could stamp all the ridiculous prescriptions and fax 'em back to the douchenuggets who wrote them.

Lucky for me, I can have one made… I wonder if my company will pay for such a worthwhile piece of office equipment?

Knowing me, I'd probably go around stamping people, too.

Come join a team of experts to design, build and ship the first version of a product that will change the world of medical imaging! We are a startup group with the goal of bringing cutting edge technology to the market in order to change the way medical image storage, distribution and interpretation happens. Our product will leverage Amalga* platform, creating a system that will enable physicians with completely new access to diagnostic images and other patient information. We have Medical imaging industry experts at the core of our team and are looking for additional expertise.

Job Description

We are looking for an expert software developer to join a team of highly experienced senior software engineers to build a solution that can seamlessly connect imaging systems from multiple departments and provide interactive visualization of up-to multi-GB datasets to physicians whether they are in the hospital or at home. You will work closely with domain experts in DICOM, imaging IT, Volume Rendering, large dataset handling and advanced image processing and you will be a key contributor to guide technology selection and strategy to solve data processing and distribution problems that have yet to be solved. You will work and collaborate with our distributed team across the globe (core team in Redmond, part of the team in D.C., supporting development team in Beijing, China and research team in Cambridge, UK).

The Health Solutions Group is the same group at MS that's responsible for their HealthVault product as well as the Amalga family.

So these are college bookstores inadvertently advertising prescription drugs to the entire college population. Well, more accurately, to the population that chooses to have their books shipped to their home, anyway. I don't know if the bundles that can be picked up have similar advertising info.

Merck's going about it in a strange way, though. They're sticking the prescribing information into these boxes. No fancy brochures, just the PI packet, which I find rather bizarre.

I can't say it doesn't make sense, or that it's a terrible idea — I think it's better than advertising Ambien on television — but it does make me wonder what's next… Cephalon advertising Provigil to high school and college kids? Med students? Pharmacy students?

Hey, why not?

(No discounts for having advertising in your box of books, either. )

This week's topic is panic disorder and relapse in patients with and without a history of substance abuse. Fun topic, really, and one close to my heart.

Case study:

[You are] working with a 32 year old man who comes to you for an evaluation of panic in August in Lowell. He meets the diagnostic criteria for panic disorder and has been experiencing untriggered episodes for the last 2 months. Name three factors that would guide your selection of medication and then discuss your pharmacologic plan for this unfortunate man.

One of the responses — by a prescriber in my area — was to encourage deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, and starting an SSRI. If panic continues, start a benzo.

This strikes me as fairly typical approach for a primary care provider in dealing with someone who presents during an acute panic attack, but I think that it's doing the patient a disservice. Perhaps it's also a typical response for a psychiatrist who is afraid to use benzodiazepines.

I'll post my response here, verbatim, because I think there's a deep (and common) misunderstanding of what panic is, and what having a panic attack is like.

It seems like you're thinking of panic as something that can be gotten out of, as though it's a normal fight-or-flight type response where removal from a stressful stimulus means no more panic.

This is dangerous thinking, and forgive me if I've read you wrong.

It can be harder than perhaps some practitioners think to identify a trigger. While triggers can often be identified, I think it's important to note that when a patient first presents, and you make a diagnosis of panic disorder, discovering these triggers will be more complex than simply avoiding a stressful situation, or simplifying and eliminating stressors from one's life. (Which is a very time-consuming process.)

You can't turn the ship on a dime.

Please don't fall victim to the idea that because you've been scared out of your wits a few times and your heartrate went up and your BP went through the roof that that is a panic attack. It's not. Panic attacks usually appear in a completely idiopathic manner, particularly the first time they hit. It's not an "Oh Gee, you scared me," type of thing, it's more of a "DEAR GOD I'M DYING, SOMEONE PLEASE DIAL 911" type of thing.* (The caps are appropriate there. )

Panic attacks can, and do hit without any warning in an otherwise comfortable, relaxed setting. Watching a movie in your living room, for example.

It's not like [situation] -> panic attack a few minutes or an hour later with a clear antagonist. It can come days after the stressors. It can also take a few weeks and lots of practice to build up an arsenal of effective coping mechanisms to return oneself to a calming state in the middle of an active attack.

Re: Deep breathing. This can also be problematic as at the point where one's lungs are fully inflated one can experience a PVC or PAC, which is VERY disconcerting to someone who's already acutely aware of what their heart is doing. I can actually trigger PVCs in myself by doing this.

–

I don't mean to lecture. I'm not the professor, and perhaps I've read too much between the lines of what you've written. As someone who didn't get out of bed for 3 weeks the first time I had a panic attack, I feel very strongly about the issue, and combatting it aggressively rather than taking a more laid back, it'll-fix-itself approach. Particularly this: "deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, [etc.]"

Those are all great long-term approaches, but the short-term is what someone with panic disorder in an active phase cares about most. Long term stuff can come after, just get me through right now.

And I am keenly aware that my personal experience should never cloud my clinical judgement inasmuch as that is humanly possible.

* I tried to dial 911 my first time, in the middle of a biochemistry lecture, no less. But I couldn't see well enough to dial the number. In retrospect, knowing what I know now, I'm glad I couldn't because that would have been a misuse of medical resources. :p

Early in panic, people are usually not capable of accessing the skills to use behavioral coping mechanisms. You usually need to halt the panic quickly and this is where BZDs are needed. Panic is such an uncomfortable and painful experience, the BZD's are in a way like pain medications in the early stages of treatment.

Do they think I'm stupid? I can't count the number of times I've put the phone down with the person still talking at me (without having said more than "May I help you?") done something, and then come back with them still blowing hot air.

The more words someone uses, the greater the chances are that they're full of shit.

This is in contrast to someone with a legitimate issue who will tell you their story in as few words as possible, and then ask what they need to do. Even people who typically blow smoke talk less when they're actually telling the truth and they have, for instance, a police report to back it up.

Every retail pharmacist in the world knows exactly what I'm talking about, and I'm sure most ED types do too. Remarkable that the bottom-feeders on the planet haven't figured out that if they just kept their mouths shut, I'd be 2-3x more likely to believe them. I would have thought such a skill would be accidentally uncovered and remembered. But perhaps idle chatter is the verbal form of a nervous twitch, and many of these folks are halfway decent candidates for the Darwin Awards anyway, so I shouldn't be surprised that they haven't learned from past successes.

In any event, they'd all be shitty poker players.

This is going to be quick and dirty because I've got some other things to do, but I've been putting it off far longer than I've meant to. (No time like the present, right?) In the January 2008 issue, CR ran a feature on how people could save money on prescriptions meds. Generally speaking, I am in favor of this kind of thing. I like people to know the alternatives, and how they can save money.

Generally-speaking, it's not a good idea to have word-choice errors in a piece that's supposed to be professional. (See image.) Maybe they should get a medically-trained copy editor and add them to the list of peer-reviewers. Ridiculous.

I've re-created the table they have:

I'll go through it quickly:

Zyrtec is now available OTC, and is comparable to the cost of Claritin. Claritin doesn't work for a goodly number of folks, so Zyrtec is a better option. Zyrtec went OTC the month after this was published — and it wasn't a big secret that it was going to happen.

For ADHD, Strattera is not a popular option. It doesn't work for many people, and ADHD people have a hard time remembering to take their meds consistently, which makes this option less desirable, particularly where it takes a little while for Strattera to begin working. I'm surprised this drug was listed at all, as it's rarely a first-line choice for ADHD spectrum disorders. Even comparing atomoxetine (an NRI) to methylphenidate (a stimulant) is a bit… off, and IMO, does the consumer no favors. Strattera is usually used where someone is at risk for drug abuse or has comorbidities like hypertension or anxiety (iatrogenic or otherwise) and so cannot tolerate stimulants.

Depression… don't have much to say there. Fluoxetine tends to be more stimulating than Lexapro, and there are other subtle differences (half-life, solubility, etc.), but for most people, switching from one to the other is probably not impossible.

As for Diabetes… well. Using a biguanide is usually the first step in treating metabolic syndrome, and then you add other meds on top of that. I'd be skeptical of any doctor who used Actos before using metformin without a given reason. Diabetes treatment tends to go in stepwise fashion like most other chronic illnesses. Removing a TZD from a pre-existing diabetic regimen can be done, but it's not as simple (or desirable) as this little blurb makes it seem. And a TZD isn't normally used as monotherapy. Frankly, I think suggesting Glucotrol rather than metformin would have made more therapeutic sense. And in terms of good use of space, I think think they would have been better going after the ARBs and hypertension in general here.

Heartburn and GERD? Nexium 20mg? Who even uses the 20mg strength Nexium? I see it maybe 3 times a year. They should have done 40mg Nexium and suggested 40mg of Prilosec. (Hilarious sidenote: 40mg Prilosec caps (the one without a generic) cost ~$60 more than 40mg Nexium caps.) Generally, though, this one wasn't too bad.

Insomnia: Eh, probably okay I guess. Insomnia is a poorly-treated condition in this country, and frankly, I'd rather see other methods explored before reaching for the BZRAs at all. But the BZRAs are the easiest, and they keep patients happy. Unfortunately, not enough time is spent diagnosing the underlying causes of insomnia, resulting in a poorly quality of life. There are differences in the polysomnograms of patients on eszopiclone and zolpidem, too, which are not talked about. I'd rather see ramelteon tried before any BZRA, and also see a psychologist about diagnosing an underlying cause for the insomnia in the first place, if a primary care provider cannot take the time (due to financial considerations) to do it themselves. And 5mg of Ambien might help with sleep induction, but the relatively short half-life will do next to nothing for those with sleep maintenance problems.

I'd rather have seen trazodone suggested, since insomnia is usually secondary to some kind of other psychiatric disturbance — a type of uni- or bipolar depression.

Not much to say about arthritis, but I hardly ever see Celebrex used anymore. Now that it stands alone as a COX-2 inhibitor, it's also the most expensive anti-inflammatory in the book and insurers are loathe to use it. I'd rather see diclofenac recommended over ibuprofen, and suggesting that 400mg of ibuprofen daily is anywhere near equivalent to 200mg of celecoxib is laughable.

Schizophrenia. SCHIZO-FREAKIN-PHRENIA? CR is going to tackle SCHIZOPHRENIA in an article about how to save money?!?! I am having difficulty wrapping my brain around that one.

But okay, here goes. Schizophreniform disorders should be managed by a psychiatrist or psychiatric NP, IMNSHO. Diagnosis is tricky, and management is always tricky. All that said… while first generation antipsychotics are often as effective as their second gen counterparts, I am extremely leery of merely saying that Y could be substituted for X. At least CR has the good grace to state "The antipsychotics have major side effects and response to them is highly variable" — AKA "Take our advice with a monster grain of salt." Not the least of the worries are akathisia, tardive dyskinesia, other extrapyramidal symptoms, weight gain, and about a bazillion other possible side effects. My mind is still boggled that they even went there.

Curiously, however, discontinuation rates of perphenazine in schizophrenic patients are lower than with any second gen antipsychotic save olanzapine (Zyprexa) — though people tended to d/c Zyprexa due to its metabolic effects and weight gain, and perphenazine for its extrapyramidal symptoms. Something to consider, I suppose.

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All things considered, it's nice to see the mainstream media promoting saving money on drugs, but it bugs me that they did it in the way that they did.

Got a phonecall from an FP's office across the street from the pharmacy. Medicaid patient had brought in his Risperdal Consta injection for his bi-weekly shot. The nurse dropped the injection in the office, which broke it, resulting in some non-emergent, but non-trivial lacerations to herself in the process.

Could we get another one? Of course, it's 4pm on a Friday, and MassHealth doesn't do lost/damaged precription overrides — if they did, their budget would probably double (TAP doesn't make this shit up, you know) — but could we pleeeeeeease try. And they would, of course, call MassHealth themselves.

Risperdal Consta is about $650 per dose.

Of course the answer was no, but with both of us on the phone, MassHealth said they could do it tomorrow (that would be today, I guess) as a once-in-a-lifetime early-fill don't-ever-ask-again override.

I'm so glad it worked out, and I feel terrible for this nurse. She's probably wishing she had dropped some cyanocobalamin instead. We'd have just given it to them for nothing had it been something like that.

Based on Dino's examples on the oops meter, I'd give this a solid 8. Right next to breaking wind in front of your boss. On the elevator.

We adopted Doc — a name given to him by his previous owners — about 2.5 months ago from the local animal shelter. He's 8 years old, which is about middle age for a Beagle, and if I told you he barely makes a peep, you probably wouldn't believe me. But it's true — he only blows his horn when someone walks by outside with a dog, and not even then when I take him down to the city where that sort of thing is common.

He does have an irritating habit of trying to mount every female he encounters, however, but he makes up for it by making an excellent vacuum cleaner where food is involved.

Sporting large sunglasses, the winner, a pharmacist, came forward, but she refused to provide her name or where she lived. An occasional player, she bought the winning ticket at a gas station at 851 S. Sutton Rd. in Streamwood.

The first step wasn't to get the money. A family member referred them to Wood Dale attorney Terry Zimmer, who assembled an advisory team, including estate planner Richard Kuenster.

"I told her get an unlisted number A.S.A.P.," Kuenster said.

The team helped the family create the JYS Family Limited Partnership and put together entities to keep the winner's identity from the public, and shield the money from some taxes, creditors and frivolous lawsuits while providing for her, her husband, children and any future grandchildren, Kuenster said.

"We're so proud of them for taking that time," said acting Illinois Lottery Superintendent Jodie Winnett. "What a sharp winner we have in Illinois and we hope that the rest of our community will hear this and that they'll take a deep breath and consider protecting themselves."

I think everyone has thought about what they'd do if they won the lottery. Most of the thought cycles probably spent on how they'd spend the money, rather than on how they'd protect themselves. I've given the collection, protection, and diversification of a large sum of money some thought in the past when Powerball has gotten up into the hundreds of millions. (It's fun to dream isn't it?) The lawyer and financial advisor seemed no-brainers to me, but an estate planner didn't occur to me. Naturally, doing everything in my power to remain anonymous is also right up there, but the third-party organization as a shield was a new one, but a smart one given her profession.

Good on her.

(The press conference is required.)

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Anecdotally, we have a past lottery winner that comes to our store, and like this pharmacist, she is very discreet, and has managed to not blow all of her winnings in spectacular fashion. Smart people do, in fact, win the lottery sometimes.