News

Neurologists and other physicians can expect Medicare reimbursements, medical liability reform, and prescription drug issues to be revisited this year as President Bush and Republican leaders attempt to leverage the fall election gains in the House and Senate. But enacting key measures is far from certain. Despite titular control of 55 seats in the Senate, Republicans are still shy of the 60 votes needed to overcome a Democratic filibuster. Passing such bills “is not going to be a slam-dunk,” said Jacque J. Sokolov, senior partner of Sokolov, Sokolov, Burgess, a health care consultancy in Scottsdale, Ariz. “But the likelihood of it happening is greater in a Bush- Republican Congress environment than it would have been in a Kerry environment.”

Christopher Reeve’s death this past October from cardiac complications after infection resulting from pressure ulcers is a reminder that patients with spinal cord injury (SCI) are more than their motility impairments. According to the Annual Statistical Report of the National Spinal Cord Injury Statistical Center (NSCISC), published last June, of 3312 patients for whom the cause of death was known, nearly 22% died of respiratory system diseases, 9% of infective and parasitic diseases, 8% of hypertensive and ischemic heart diseases, and 13% of other heart disease.

Neurologists, neurosurgeons, and other physicians are feeling a squeeze, and it isn’t the magical shrinking belts that follow holiday feasting. It is rising medical liability premiums. Some doctors are leaving states where escalating liability rates are making it harder to keep a practice open. In early November, no one was performing brain surgery in southern Illinois because the last holdout, B. Theo Mellion, MD, of Carbondale, left when his malpractice insurance carrier refused to renew his coverage and those carriers willing to provide coverage were quoting annual premiums of $200,000 to $300,000

Early applications ofstem cell medicine arelikely to be neurologic,targeting spinal cord injury,brain tumors, metabolic derangements,and disordersof movement and mood. Althoughtreatments are stillyears away, continual mediacoverage of the fledglingtechnology is fueling questionsin the doctor’s office.“For our patients with devastatingneurological conditions,stem cell researchgives them hope of newtherapeutic measures,” saidSandra Olson, MD, presidentof the American Academyof Neurology (AAN).

It’s a classic risk/benefit dilemma: Does preventing suicidality-assuming suicidality can predict suicide-justify scaring some doctors away from prescribing antidepressants for young patients?

Encouraging research emerged last month regarding vagus nerve stimulation (VNS) for the treatment of epilepsy patients. About 25 different presentations at the American Epilepsy Society’s annual meeting in New Orleans focused on VNS. The FDA approved VNS Therapy in July 1997 as an adjunctive treatment for adults and children older than 12 years with partial-onset seizures and resistance to antiepileptic drugs. Marketed by Cyberonics Inc, of Houston, Tex, VNS Therapy is the only FDA-approved electrical stimulation device for epilepsy. The device, which resembles a pacemaker, provides intermittent electrical stimulation to a patient’s left vagus nerve, which, in turn, activates areas of the brain. It is implanted in the left chest area, and wires run under the skin to the nerve in the neck.

Current therapy for acute ischemic stroke remains limited to intravenous recombinant tissue plasminogen activator (tPA) administered within 3 hours of symptom onset, but despite strong evidence supporting its effectiveness,1-5 only 2% to 4% of all stroke patients currently receive tPA.

Clinical Trial Enrollments

You have a 24-year-old pregnant patient with epilepsy. Which antiepileptic drug do you prescribe for her? Where’s the evidence and what do the guidelines recommend? At the American Epilepsy Society’s annual meeting last month, during a symposium on evidence-based medicine and practice guidelines, a series of speakers spelled out the difficulties in drawing up guidelines based on evidence, or lack thereof.

Gender is an important variable in medicine and psychiatry. The initial interest in gender issues was stimulated by recognition that women were absent from much medical research. Now, however, the field has expanded to include more specific and sensitive attention to men and the role of gender and gender differences.

Telepsychiatry has been hailed as the future of psychiatry. Proponents have claimed that it can reduce costs and allow access to difficult-to-reach patients. What are the promises and pitfalls of this new technology?

The prevalence of major depression following stroke ranges from 10% to 40%. Other psychiatric disorders, including anxiety disorders, apathy and cognitive impairment are also common. Psychiatrists need to be on the lookout for symptoms not just immediately poststroke, but up to six months after the event.

Worldwide, nonfatal deliberate self-harm is common among young people. However, when studying this phenomenon, methodological issues arise. Differences between genders have been found in presenting to the hospital following self-harm and in motive for engaging in this troubling behavior.

In the second part of this series, read about the special issues psychiatrists face when treating women, children and adolescents, and elderly people with bipolar disorder and dementia. What are the recommendations for care and monitoring strategies to maintain patients on effective, long-term treatment regimens?

Tricyclic antidepressants and antipsychotics are known to prolong cardiac repolarization and induce QTC interval prolongation, possibly putting patients with mental disorders at higher risk of cardiovascular diseases. The mechanism of gender difference in vulnerability for cardiovascular diseases is still unclear, but the role of hormones is one of possible explanatory factors.

Dr. Genova shares his insights on his career in psychiatry and his experience with dealing with cancer.

What special issues do psychiatrists face when treating women, children and adolescents, and elderly people with schizophrenia? Are there recommendations for care and monitoring strategies to maintain patients on effective, long-term treatment regimens?

poetry Anesthesiologist for a Cadaver

The issue of psychiatrists serving as forensic expert witnesses has long been controversial. What are the rules for serving as an expert witness, and what is expected of a psychiatrist who serves as an expert witness?

Hostage and barricade situations occur frequently in law enforcement practice. Commonly, police deal with hostage/barricade subjects whose motivation is influenced by psychiatric illness, substance abuse or extreme emotional states. It has been argued that mentally ill people comprise 50% of all hostage/barricade subjects. How can psychiatrists assist in defusing these intense situations?

Are the metabolic side effects of the atypical antipsychotics fueling the next round of malpractice suits being filed against psychiatrists? Guidelines are being created, but how can clinicians protect themselves and their patients, while continuing to give their patients the best care available?

The fallout from the FDA investigation into the risk of suicide for adolescents taking antidepressants has included calls for publication of all drug study results. Pharmaceutical companies are pledging to do so on dedicated Web sites. Can the industry be trusted to police itself or is governmental oversight required?

Although a lot remains to be learned, much is already known about the early childhood characteristics that predispose children to antisocial behavior and violence in adolescence and early adulthood, an expert in psychopathology said recently at a National Institutes of Health conference.

When disputes arise concerning custody and visitation, mental health care professionals can inform and assist judges by performing competent custody evaluations.

Despite the increasing number of elderly nursing home patients with dementia or Alzheimer's disease, there are problems providing appropriate care. Two of the major difficulties are lack of Medicare reimbursement and poor staff training. How can we better care for these elderly patients?

Years ago, when I still believedDr. Kildare could cure my father,I stayed awake past my bedtimeto learn to be a doctor.

It has been well established that there is a high incidence of depression in conjunction with Alzheimer's disease and other forms of dementia. What are the best assessment and diagnostic methods, and which treatments will produce the best results?

The relationship between depression and epilepsy is bidirectional as not only are patients with epilepsy at higher risk of developing depression but patients with depression have a three- to sevenfold higher risk of developing epilepsy. Several studies have found that the presence of depression in patients with intractable epilepsy was a stronger predictor of poor quality of life than the frequency and severity of seizures. The principles of managing depression in epilepsy are reviewed in this article.

Allegations of complicity by Chinese psychiatrists in abuse and persecution of members of the Falun Gong continues to trouble the World Psychiatric Association. Are the steps being taken to learn the truth enough? Dr. Stone provides a look at the events that have unfolded to date.

Migraine affects approximately 12% of the population, and a high percentage of these patients have comorbid psychiatric disorders. Knowing more about the interaction between headache and psychiatric factors can assist in evaluating and treating these patients.