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Transplant Patients Receive HIV Infected Organs

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Sadly, four transplant patients in the Chicago area recently discovered that their new organs were infected with HIV and hepatitis C. This is the first case of infected organ donation in the past 20 years, with over 400,000 successful, healthy transplants completed in that time period.

I’m actually a little surprised that this is the only known case of infected organ transplants in the past two decades, since the tests to rule out HIV and hepatitis C rely on antibodies. It takes the body at least three weeks to produce antibodies to these viruses, and so people who are infected with HIV and hepatitis C have false negative tests for the first few weeks. So there is always the risk that an organ donor could have contracted these viruses within 3 weeks prior to his or her death.

I asked Dr. David Goldberg, an infectious disease specialist in Scarsdale, NY, to weigh in:

Are there any tests available now that can detect the viruses themselves, or only antibodies?  How early after infection could we detect them?

Traditional serologies measure antibodies against the viruses which take weeks or months to develop, whereas there is a more rapid test, called “PCR,” that is a direct measure of the number of viruses in the blood.

HIV reproduces rapidly, so the virus can usually be detected in the bloodstream within 8 days of infection. By contrast, hepatitis C virus replicates more slowly, so the virus may not be detectable until as long as 8 weeks after exposure. So the use of the HIV PCR test in addition to antibody tests would pick up almost all cases of HIV, but the hepatitis C PCR might still miss a number of early infections.

How can we protect future organ recipients from such a tragic event?

PCR is not generally performed because the test is time-consuming and many organ donors are trauma victims, which leaves little time for testing. However, PCR testing could theoretically reduce the number of HIV infected organs that are transplanted (from recently infected individuals), but would not improve the odds in hepatitis C because of the slow growing nature of the virus. In the end there’s no perfect test or 100% guarantee that organ donors don’t have HIV or hepatitis C.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Fly The Ball

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I had lunch with an extraordinary physician today. She came to the US from Pakistan 30 years ago with a medical degree, a little girl and a baby on the way. Since she was a foreign medical grad, she had to accept a position at a less competitive residency program in New York’s inner city (even more violent and dangerous then than now). She made it through, with several near muggings and death threats but longed to work at a hospital where she and her girls could be safe.

One day she came upon a large, clean naval hospital and on a whim decided to join the military so she could work there. She served for two decades as a navy physician, and learned many life lessons along the way.

As I hung on her every word, my friend told me about her experience with navy pilots. She said that one of the scariest maneuvers is landing a plane on a dark aircraft carrier on a rolling sea. The pilots dreaded these drills, and truth be told, the officers were more worried about losing a 3.2 million dollar jet to the ocean waves than the life of one of the pilots. “There will always be another pilot. They’re not in short supply. But the planes are expensive.” This was the attitude drilled into the young aviators.

In order to land the plane in the dark, the pilot had to learn to trust completely in his optical landing system. It more or less consists of a pin icon with a ball on top, and a series of red, yellow, and green lights. The goal is to keep the ball well centered so that it remains green for landing. Achieving this is called “flying the ball.” In total darkness with crashing waves and a rolling deck, a successful arrested landing is difficult and perilous.

As I looked at my friend, a petite and beautiful woman, I tried to imagine what life was like for her as a young Pakistani resident – pregnant and alone in a concrete jungle filled with graffiti, trash, and drug addicts. Her life has been an incredible journey with ups and downs, and amazing success against all odds.

“How did you do it?” I asked her, shaking my head. “How did you get where you are today through all that adversity?”

She paused for a moment, then grinned slowly as she replied: “I learned how to fly the ball.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Why Do People Enjoy Being Frightened?

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As Halloween approaches, I was asked a really interesting psychological question from Lauren (of Love, Lauren fame) at Revolution Health. She asked, “Why do people like to be frightened? I don’t like horror movies or haunted houses, but some people love that stuff. Why, Dr. Val?”

I scratched my head and looked at her for a moment as images of Saw, Freddie Kruger, and Jason Voorhees (the only Dutch Halloween “slasher” protagonist I know) went through my mind. I offered an unsatisfactory reply, and promised to take this up with someone more learned in the ways of fear. Luckily for me, Dr. Andrew Gerber– a thoughtful psychiatrist whose research focuses on brain response to emotion (how perfect) was up to the task. Here’s what he had to say:

Our enjoyment of being afraid is a wonderful example of how the human mind works in mysterious ways that are often not immediately transparent to our own introspection. Psychiatrists, psychologists, and cognitive scientists are coming up with new ways to study exactly these sorts of things (located in a psychological structure called the “dynamic,” “adaptive,” or “cognitive” unconscious) and have a variety of possible explanations.

1. We like to feel things strongly.

Even if something has a negative part to it, it can be overridden by our preference to feel something as opposed to nothing. This may be the same phenomenon that drives our curiosity (even when it gets us into trouble, like a cat), our restlessness, or the discomfort of boredom. Increasing evidence from brain imaging studies tells us that a large part of our brain is devoted to processing intense emotion. It’s pretty likely that these regions were very important in our evolution and survival as a species.

2. We love the experience of a building up of tension and relief.

The best part of all about being scared on Halloween or in a scary movie is the huge relief at the end when we or our hero emerges safe and sound. A part of us remembers the whole time that relief is coming, so the tension part is worthwhile. There are lots of experience in our life that have the same kind of tension and relief pleasure to them – for example, missing a loved one and then seeing them, being hungry and eating a delicious meal, or being really tired and then getting to relax. You might say that the more the tension builds, the more the relief feels good. Brain imaging studies show that motivational systems located in the deep and archaic part of the brain operate on a tension and relief principle. When this works well, we feel motivated to go about the business of our lives. This very system can go awry in disorders such as depression and drug addiction.

3. We like to work through old situations and make them come out better.

For better or for worse, humans are consummate problem solvers and when things didn’t go well in the past, we like to replay the situation and have it come out differently. We all recall the experience of being scared as a child when it didn’t feel so good. This makes it all the more fun as older children or adults to replay that experience but this time to have the experience come out in a more positive way.

And there you have it – our brains crave “tension and release” to feed parts of our large emotion-processing centers, we like to problem solve in controlled environments where the outcomes are not truly dangerous, and we derive pleasure from strong emotions. That being said, I prefer action flicks to the horror movies myself. Though I’m a sucker for a good Sci-Fi thriller. What about you? What’s your favorite “tension release” movie?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

What’s Causing Increasing Suicide Rates in Teens?

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Two new studies reported increasing suicide rates in teenagers.  The first noted a trend between decreased use of anti-depressant medications (SSRIs) in teens and an increase in suicide, the second reported an increase in female teen suicide in particular.

What could be causing these tragic increases?  I interviewed Revolution Health psychologist, Dr. Mark Smaller and child psychiatrist, Dr. Andrew Gerber, to get their take on this disturbing trend.

1. In previous research,
increased suicidality was associated with SSRI use in teens.  Now this study
suggests that lower SSRI use is associated with increased suicidality.  How do
you explain this?

Dr. Smaller: Following the previous research, parents and some physicians cut back on SSRI use for depressed teens.  However, in doing so they may have neglected those teenagers who could have benefitted from an antidepressant.  The problem with these medications is that they effect so many parts of the brain that it’s difficult to predict how different patients will respond to them. Also, these medications are often prescribed in too high a dosage.  What needs to happen is that the patient, teen, child, or adult must have a full psychosocial evaluation that takes into account the whole person, and the environment in which he or she is living.  A clear treatment plan combining talking therapy (individual or family) and perhaps medication must be implemented.  This is not being done in enough instances.  With a proper evaluation and a carefully designed treatment plan (as well as close monitoring of the teen) therapy may be further customized to the individual.

Dr. Gerber: The possibility of an association between suicidality and SSRI use in children
and adolescents is of clear concern to many people, including all psychiatrists
and parents of children on medication. Despite all the accumulated research to
date, it is still very unclear how this association works. However, we do know a
few important things.

First, in all the studies of SSRI use in children, there
is no report of a completed suicide attempt in a child who was taking an SSRI.
This goes to show that completed suicides in children, while tragedies whenever
they do happen, are rare events and therefore very hard to study methodically.

Second, in those studies that have shown a possible association of suicidal
thoughts (though not actual suicides) with SSRIs, there is a lot of disagreement
and controversy over how to best measure these thoughts in an accurate way. How
one does this influences the results considerably.

Third, it is important to
keep in mind all the ways in which an association between SSRIs and suicidal
thoughts may appear to exist because of how the data are collected, even if SSRIs
really don’t bring about suicidality at all. For example, it’s certainly true
that doctors are most likely to give medications to the kids who are the most
depressed and the kids who are the most depressed are most likely to be
suicidal. So it might look like SSRIs are related to suicidality, when they are
really being used to treat those kids who are most likely to develop it.

The
best way to really tease these apart is to randomly assign enough children
either to SSRIs or non-SSRI treatment and then observe what the differences are.
The problem, is that (1) the data are so good that SSRIs help many kids with
depression that it would be unethical to withhold treatment from half the
children in order to complete such a study, and (2) suicidality is rare enough
that this study would have to be enormous, and thus is impossible to
do.

With all this said, it is not surprising at all that an overall
decrease in the use of SSRIs, most likely due to the greater caution that
clinicians now have in using these medications in children, would lead to more
suicidality on a broader scale. We know that SSRIs help most children who take
them and this is undoubtedly a more powerful effect than any extent to which
SSRIs cause suicidality (if this is true at all).

2.  Is there a role for
SSRIs in teens?


Dr. Smaller:
I think so but only after a full diagnostic evaluation is made by a skilled mental health professional who works with teens, family and is familiar with the developmental phase of adolescence.

Dr. Gerber: There is unquestionably still a role for SSRIs in teens as long as they are
monitored carefully by a well trained clinician who, following agreed upon
guidelines, has decided that an SSRI is the right treatment for this teen. Of
course, as always, other treatments and their advantages and disadvantages
should be considered too. But for the best interests of kids and teens, SSRIs
need to remain a possibility.

3.  What would you counsel
parents about these drugs?

Dr. Smaller: Get a full physchological evaluation and treatment plan so that you can make an informed decision about what might help.  The mental health professional and the parent must have a working alliance to insure that the treatment is successful.

Dr. Gerber: I would advise parents that it is always good for them to be well informed and
vigilant about the risks and benefits of all treatment that they consider for
their children. There is much that we do not know about child psychiatric
illness and we are working furiously to learn more. In the meantime, though we
have to be careful to keep an open mind to both sides and to not make premature
judgments either in favor or against any one treatment. SSRIs have shown
themselves to be useful with many children and, in the hands of a well trained
professional, can continue to be very helpful to the right children and their
families.

4.  What do you make of
the suicide rate increase in girls?  What could be behind
this?

Dr. Smaller: This is alarming.  The onset of adolescence for girls and boys is a hugely disruptive developmental phase, and maybe more so for girls with the onset of puberty.  The teen years can be fraught with family issues that exacerbate moods and create symptoms.  Our culture puts huge demands on all of our adolescents and this research might be showing that it is taking a high toll on girls.  Social roles, peer pressure and issues, academic demands and family strife all contribute.  The high incidence of eating disorders among teenage girls is a clear example of a symptom to which many teenage girls are vulnerable.

Dr. Gerber: The greater increase in suicide rates among teenage girls is surprising and
experts are unsure of how to interpret this. Since the overall number of
suicides is small – 94 in 2003 and 56 in 2004 – it is hard to interpret what was
different in this group of teenage girls. There are so many increasing pressures
on teenage girls today – from issues around body image and weight to balancing
complicated societal expectations, what some experts term pressure to live up to
a “superwoman ideal” – that one might speculate it is leading more and more
teenage girls to feel overwhelmed and hopeless. However, what we really need, as
with the SSRI controversy, is more carefully collected data and thoughtful
discussions between families, patients, and clinicians, to understand what is
happening and how we can prevent it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Crohn’s Disease: Update From Dr. Susie Kane

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Dr. Susie (Sunanda) Kane is a Crohn’s Disease expert who just moved from the University of Chicago to join a team of researchers and clinicians at the Mayo Clinic in Rochester, Minnesota.  Susie was kind enough to answer some questions about Crohn’s recently.  We used the phone interview to create a short article at Revolution Health, but I think that listening to the entire conversation could be of benefit to those who desire deep and broad information about the disease.

In fact, a dear blogger friend of mine has a daughter with severe, fistulizing Crohn’s disease.  She has been in the hospital for 2 months, unable to eat.  It is my sincere hope that interviews like this one will go a long way to frame the discussion of the multiple treatment options for those struggling with this challenging disease.

We asked Dr. Kane what the common misconceptions are about Crohn’s disease, then she described the 3 types of Crohn’s disease, how they’re diagnosed and treated, and the latest cutting edge research that make a substantial improvement in the lives of those living with the disease.  The interview is about 30 minutes in total.  Enjoy!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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