SciQuest.org

Yes, the practice of medicine is a joy. But your doctor does get irritated at times. We know what irritates patients…waiting too long, being put on hold, doctors rushing you out the door. Do you ever wonder what yanks your doctors chain? I’m willing to bet these are universal:

• Calling for a drug refill on weekends or nights and not knowing the pharmacy phone number. “Oh it’s the pharmacy I always use”. Let me tell you…I don’t want to search information for your pharmacy number. Be prepared. Better yet, call during office hours.

• When we call you to report your test results it is usually at the end of a long day. It’s not the time for you to bring up brand new health issues. We want you to have your results but those phone calls are keeping us from getting home. Please just say thanks. We dread those calls because what should take a minute can drag on and on.

• Please don’t call and cancel your appointment at the same time you are supposed to be there. Would your hairdresser stand for that?

• I want to concentrate on you when you have an appointment. Please don’t ask medical questions about your friend, relative, acquaintance. That is not a good use of our time and it is irritating as hell.

• Please don’t call me to get the test results that another doctor ordered. It is time consuming to pull your chart, call you back and try to interpret tests that someone else thought was necessary. We hate it when you say “Oh, Dr. Jones is so busy…I couldn’t get through to him so I called you.” Guess what, I’m busy too and now I’m irritated and busy.

• Please don’t ask for handicapped placards if you aren’t really handicapped. The same goes for jury duty excuses. I serve on jury duty and so do my employees. Enough said.

We docs love our patients. That is why we do it. We get our irritations from your insurance company, Medicare and the price of gas. We promise to try not to annoy you too.

Head on over to Unprotected Texts for the best of this weeks medical blogs. Good reading from various docs, nurses and patients with an assortment of opinions and points of view.

Disease/Infection News

Scientists and researchers have taken a big step closer to a cure for the most common strain of avian influenza, or “bird flu,” the potential pandemic that has claimed more than 200 lives and infected nearly 400 people in 14 countries since it was identified in 2003.

Researchers at the U.S. Department of Energy’s (DOE) Argonne National Laboratory, in conjunction with scientists from China and Singapore, have crystallized and characterized the structure of one of the most important protein complexes of the H5N1 virus, the most common strain of bird flu.

All viruses, including H5N1, contain only a small number of proteins that govern all of the viruses’ functions. In H5N1, perhaps the most important of these proteins is RNA polymerase, which contains the instructions that allows the virus to copy itself along with all of its genetic material. The Argonne study focused on H5N1’s RNA polymerase protein, which contains three subunits: PA, PB1 and PB2.

After performing X-ray crystallography on the protein crystals at Argonne’s Structural Biology Center 19ID beamline at the Advanced Photon Source, the researchers saw a surprising resemblance in the protein structure’s image. “When we mapped out the PA subunit, it looked very much like the head of a dragon,” said Argonne biophysicist Andrzej Joachimiak. “One domain looked like the dragon’s brains, and the other looked like its mouth.”

During RNA replication - the phase during which the virus “reproduces” - all three of the subunits of the protein assemble themselves in a particular configuration. In order for this congregation to take place, the researchers determined the end of the PB1 subunit has to insert itself and bind to the “dragon’s mouth” part of the PA subunit.

This unexpected relationship between the two subunits could inspire a number of different therapies or vaccines for H5N1 that rely on muzzling the “dragon’s” jaws with another molecule or chemical compound that would block the PB1 subunit’s access to the PA site, according to Joachimiak. “If we can put a bit in the dragon’s mouth, we can slow or even potentially someday stop the spread of avian flu,” he said. “Since we are talking about a relatively small protein surface area, finding a way to inhibit RNA replication in H5N1 seems very feasible.”

Joachimiak hopes to more precisely identify the types of compounds that could inhibit RNA replication in H5N1 by looking at the atomic-level grooves and pockets within the PA “mouth” region. According to Joachimiak, scientists must gain a more thorough understanding of the geometry of that small region in order to effectively synthesize drugs that could prevent the further spread of bird flu.

http://www.anl.gov/

Medical Research News

Some parents of children with autism evaluate facial expressions differently than the rest of us–and in a way that is strikingly similar to autistic patients themselves, according to new research by neuroscientist Ralph Adolphs of the California Institute of Technology and psychiatrist Joe Piven at the University of North Carolina at Chapel Hill.

Adolphs, Bren Professor of Psychology and Neuroscience and professor of biology, and his colleague Michael Spezio (now at Scripps College in Claremont, California) collaborated with Piven and autism experts at the University of North Carolina to study 42 parents of children with autism, a complex developmental disability that affects an individual’s ability to interact socially and communicate with others. Based on psychological testing, 15 of the parents were classified as being socially aloof.

“This manifests as a tendency not to prefer interactions with others, not to enjoy ’small talk’ for the sake of the social experience, and to have few close friendships involving sharing and mutual support. This characteristic is really a variation of the normal range of social behavior and not associated with any functional impairment,” says Piven, director of the Carolina Institute for Developmental Disabilities.

The parents participated in an experiment that measured how they make use of the face to judge emotions. The subjects were shown images depicting facial expressions of emotion that were digitally filtered so that only certain regions of the face were discernible–the left eye, for example, or the mouth. The subjects were then asked to decide as quickly as possible if the emotion depicted was “happy” or “fear.” The part of the face shown, and the size of the revealed area, randomly varied from trial to trial.

An analysis of the subjects’ correct responses revealed that “aloof” parents relied much more heavily on the mouth to recognize emotion than they did on the eyes, as compared to nonaloof parents and, to a greater extent, to a group of parents of children without autism. Prior studies by Adolphs and his colleagues have shown that humans normally evaluate emotions by looking at the eyes–but studies by Adolphs and Piven have shown that individuals with autism do not.

“We found that some parents who have a child with autism process face information in a subtly, but clearly different way from other parents,” says Adolphs. “This is evidence for the hypothesis that the parents with the autistic child have brains that function somewhat differently as well”–an idea that he and other researchers are currently investigating through brain imaging studies. One area of interest is the amygdala, a region located on either side of the brain in the medial temporal lobe that is known to process information about facial emotions and may have abnormal volume in both autistic individuals and their nonautistic siblings.

The finding indicates that certain aspects of autism do run in families. Although such a genetic link was noted in the 1940s in the earliest descriptions of autism, “our study adds considerable specific detail to the story,” Adolphs says.

“Our data strongly suggest that genetic factors make a substantial contribution to autism, but that does not mean that the entire cause of autism is genetic. Together with many other studies, our study argues that genetic factors play a very important role in autism, while leaving open a role for other, environmental factors,” he says. “We hope that this research contributes toward a cure for autism, even if only indirectly.”

“It may lead us to finding genes that are responsible for the face-processing component in autism,” Piven adds.

“A very important part of our paper,” stresses Adolphs, “is that we are not claiming all people with autism, or their parents, are ‘impaired.’ Instead, our study shows that parents who have children with autism–like the autistic subjects themselves–are different, and do things differently.”

http://www.caltech.edu/

Medical Studies/Trials

Temptation may be everywhere, but it’s how the different sexes react to flirtation that determines the effect it will have on their relationships. In a new study, psychologists determined men tend to look at their partners in a more negative light after meeting a single, attractive woman. On the other hand, women are likelier to work to strengthen their current relationships after meeting an available, attractive man.

Men may not see their flirtations with an attractive woman as threatening to the relationship while women do, according to findings from a study in the July issue of the Journal of Personality and Social Psychology, published by the American Psychological Association. Researchers found that women protect their relationship more when an attractive man enters the picture but men look more negatively at their partner after they’ve met an available, attractive woman. Men can learn to resist temptation when trained to think that flirting with an attractive woman could destroy their relationship, said lead author John E. Lydon, PhD, of McGill University in Montreal.

Researchers conducted seven laboratory experiments using 724 heterosexual men and women to see how college-aged men and women in serious relationships react when another attractive person enters the mix.

In one study, 71 unsuspecting male participants were individually introduced to an attractive woman. Roughly half the men met a “single” woman who flirted with them. The other half met an “unavailable” woman, who simply ignored them.

Immediately after this interaction, the men filled out a questionnaire in which they were asked how they would react if their “romantic partner” had done something that irritated them, such as lying about the reason for canceling a date or revealing an embarrassing tidbit about them. Men who met the attractive “available” woman were 12 percent less likely to forgive their significant others. In contrast, 58 women were put in a similar situation. These women, who met an “available” good-looking man, were 17.5 percent more likely to forgive their partners’ bad behavior.

“One interpretation of these studies is that men are unable to ward off temptation. We do not subscribe to this. Instead, we believe men simply interpret these interactions differently than women do,” said Lydon. “We think that if men believed an attractive, available woman was a threat to their relationship, they might try to protect that relationship.”

Using virtual reality scenarios in the last experiment, the researchers wanted to see if 40 men could learn not to flirt when mingling with attractive women if they formed a plan or strategy beforehand. The researchers prompted half the male subjects in this experiment to visualize being approached by an attractive woman. They were then instructed to write down a strategy to protect their relationship. These men were more likely to distance themselves from an attractive woman in the subsequent virtual reality scenarios.

Lydon says women, on the other hand, don’t need to be trained to withhold any reactions when approached by attractive men. “Women have been socialized to be wary of the advances of attractive men,” says Lydon. “These findings show that even if a man is committed to his relationship, he may still need to formulate strategies to protect his relationship by avoiding that available, attractive woman. The success rate of such strategies may not be 100 percent but it is likely to be significantly higher than if the man was not made aware of the specific consequences of his actions.”

http://www.mcgill.ca/

Medical Studies/Trials

Researchers at The University of Nottingham have shown an association between certain past diagnostic radiation procedures and an increased risk of young-onset prostate cancer - a rare form of prostate cancer which affects about 10 per cent of all men diagnosed with the disease.

The study, the first of its kind to report the relationship between low dose ionising radiation from diagnostic procedures and the risk of prostate cancer, was funded by the Prostate Cancer Research Foundation (PCRF) and is part of the UK Genetic Prostate Cancer Study (UKGPCS). The results of the study have been published online in the British Journal of Cancer.

The study showed that men who had a hip or pelvic X-ray or barium enema 10 years previously were two and a half times more likely to develop prostate cancer than the general population. And the link appeared to be stronger in men who had a family history of the disease.

The research was led by Professor Kenneth Muir, from the Division of Epidemiology and Public Health at The University of Nottingham, in association with Dr Rosalind Eeles at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust.

Professor Muir said: “Although these results show some increase in the risk of developing prostate cancer in men who had previously had certain radiological medical tests we want to reassure men that the absolute risks are small and there is no proof that the radiological tests actually caused any of the cancers.”

Four hundred and thirty one men, diagnosed with young onset prostate cancer - men diagnosed with the disease before the age of 60 - took part in the study.

The exposure to radiation was part of normal medical procedures which were performed 5, 10 or 20 years before diagnosis. Procedures included hip and leg X-rays, for example taken after an accident, and barium meals and enemas which are used to diagnose problems with the digestive system.

At this stage the evidence linking diagnostic radiation procedures and prostate cancer is still weak. This research suggests that further investigation into this link should be undertaken.

X-ray procedures used for diagnostic purposes deliver very small amounts of radiation per procedure. Their use is minimised in current medical practice. For most people X-rays do not increase the risk of developing cancer.

http://www.nottingham.ac.uk/

Medical Studies/Trials

Although sickle cell disease is a single-gene disorder, its symptoms are highly variable. In a study published online July 14 by the Proceedings of the National Academy of Sciences, scientists at Children’s Hospital Boston and the Dana Farber Cancer Institute (DFCI), in collaboration with the Broad Institute of MIT and Harvard, report five gene variants that could potentially be helpful in predicting sickle cell disease severity, perhaps even leading to better treatment approaches in the future.

The gene variants influence blood levels of fetal hemoglobin (HbF), which are known to affect symptom severity in sickle cell disease-with some patients experiencing frequent, severe pain crises and organ damage, while others are scarcely aware of their disease.

“Our study is a first step towards a better understanding of fetal hemoglobin regulation in patients with sickle cell disease,” says Guillaume Lettre, PhD, of the Broad Institute and Children’s Hospital Boston, and co-first author on the paper. “But further validation experiments are needed before these findings can become useful in the clinic.”

“Eventually, understanding the factors giving rise to heterogeneity in HbF levels might allow us to take severely affected patients and make them more like those with more benign symptoms,” adds Vijay Sankaran, co-first author on the paper with Lettre and an MD-PhD student in the laboratory of Stuart Orkin, MD. (Orkin is chair of pediatric oncology at DFCI and a Howard Hughes Medical Institute investigator at Children’s.)

In sickle cell disease, a single genetic mutation results in the production of an abnormal type of hemoglobin, the main component of red blood cells. The abnormal hemoglobin molecules tend to form long chains, causing red blood cells to become stiff and sickle-shaped. The distorted cells have difficulty passing through blood vessels and can block the smaller vessels, resulting in severe pain and eventual organ damage as tissues are robbed of their blood supply. The sickle-shaped red blood cells also have a very short lifespan, causing patients to be chronically anemic.

Previous research had established that retaining high levels of another type of hemoglobin-HbF, found at high levels in the fetus-can ameliorate sickle cell disease symptoms. At birth, HbF comprises between 50 to 95 percent of a child’s hemoglobin, gradually declining as the switch is made to adult hemoglobin production — consistent with clinicians’ observations that newborns diagnosed with sickle cell disease usually do not become symptomatic until they are about a year old. Population studies in Saudi Arabia and parts of India had identified groups of sickle cell patients with very high levels of HbF and relatively benign forms of the disease, and additional epidemiologic studies led by Orah Platt, MD, chief of laboratory medicine at Children’s, showed that HbF is an ameliorating factor. “The more you have, the better off you are,” says Sankaran.

Studying 1600 patients with sickle cell disease, the researchers found that previously identified DNA sequence variants in three chromosome locations (small regions on chromosome 2, 6, and 11) were associated with high or low HbF levels. When they added these five variants to a model previously designed by Platt to predict disease severity, which also factors in age, sex, degree of anemia and HbF levels, the model’s predictive ability was enhanced.

The findings need to be validated in large, prospective clinical studies, but the researchers are hopeful about the possible future clinical implications of their work. “As we find gene variants that regulate HbF levels or predict severity, we might eventually want to genotype patients for these variants, to get more predictive information on their disease,” Sankaran says.

Finally, once this study is validated, understanding how these variants actually affect HbF levels might someday lead to new drugs that do the same thing. “If we can gain better insight into what these variants are doing, we may eventually have better, more targeted therapies for sickle cell disease,” adds Sankaran.

http://www.childrenshospital.org

Medical Condition News

The expectation that East-Asian people emphasize physical symptoms of depression (e.g. headaches, poor appetite or aches/pains in the body) is widely acknowledged, yet the few available empirical studies report mixed data on this issue.

A new study from the Centre for Addiction and Mental Health (CAMH) debunks this cultural myth, and offers clinicians valuable insight to into cultural context when assessing a patient, leading to more accurate diagnosis.

Lead by CAMH Clinical Research Director Dr. R. Michael Bagby, in collaboration with Dr. Andrew Ryder, Concordia University, Steven Heine, University of British Columbia and a number of collaborators from Second Xiangya Hospital of Central South University, People’s Republic of China, this study recruited more than 200 participants, half from an outpatient clinic in China, and half from a clinical research department outpatient clinic at CAMH, and tested two central hypotheses: 1. East-Asian participants will emphasize somatic or physical symptoms of depression more than North American participants, and 2. North American participants would emphasize psychological symptoms of depression (e.g. report feeling sad, crying spells, or a loss of self-confidence) more than East-Asian participants. Dr. Bagby and his team also wanted to examine the role stigma and alexithymia (difficulty using words to describe emotions) play in how each culture presented and expressed depression symptoms.

This rigorous work is one of only a few studies to address these questions with a direct cross-cultural comparison of clinical patients. Also, it is the only study to use three assessment tools (spontaneous report of problems during unstructured discussion with doctor; clinician-rated symptoms in a structured clinical interview; and a symptom rating scale in questionnaire form) translated into both English and Chinese (Mandarin) and modified to address cross-cultural differences.

As Dr. Bagby explains, “the onset of depression triggers a biological response that takes place within a specific social context, resulting in a cascade of somatic and psychological experiences that are interpreted through a particular cultural lens. Careful translation and adaptation of our assessment tools helped us clarify if different approaches lead to different symptom profiles and conclusions about patients.”

Overall, the data demonstrate a consistently greater level of psychological symptom reporting in the North American sample, regardless of assessment tool. This suggests a tendency for Western cultures to emphasize psychological symptoms of depression (psychologization), rather than a tendency for those from East-Asian cultures to emphasize physical symptoms (somatization).

East-Asian participants did report a significantly higher level of somatic symptoms when reporting through the spontaneous interview and structured clinical interview. Also, these participants reported higher levels of stigma and alexithymia. A refined examination of this link revealed that the observed cross-cultural differences in somatic symptom scores relates, in part, to cultural differences in internally versus externally oriented thinking. This suggests that people who do not frequently focus on their internal emotional state are more likely to notice somatic symptoms.

While this data may help clinicians be more aware of how culture can impact how people talk about their illness, this data does not constitute a norm for depression worldwide. More work should be done to understand the interaction of biology, culture and individual differences in predicting variations in how people present symptoms of depression.

http://www.camh.net/