Serotonin system

Now the serotonin system in the brain arises along the midline and under the nuclei that run down the stripe through the middle of the midbrain and brainstem called the raphe and the raphe system includes a number of clusters of nerve cells. The two most important are the dorsal and median raphe nuclei. Serotonin producing cells are located there. The median or the more posterior group sends motor neurons down to interact with the spinal cord anterior horn cells to facilitate and stimulate peripheral transmission to the motor end plate and the skeletal muscle system. Again, when this system gets revved up you can expect twitching and abnormal movements that are, again, seen in excessive serotonergic activity in the serotonin syndrome.

On the ascending group, the dorsal raphe system sends axons that go up into the hypothalamus limbic system and cortex, in fact, share some of the same pathways. For example, the median forebrain bundle is one of the hottest spots in the brain where if you stick a self stimulating electrode in the right brain in that area you can get animals to bar press for electrical stimulation in these systems that will go on until the cows come home. Rats will give up eating, drinking, sex, sleep, anything to be able to get more stimulation themselves in that forebrain bundle in this system. Not only the serotonin and noradrenergic systems going up to the limbic system but also the ascending dopaminergic systems are located there and all of these probably contribute in complicated ways to mediate affective states, drive states, behavioral reinforcements, and may underlie some addictive behaviors and probably are messed up in a very fundamental way, an important way in contributing to the biology of melancholic type of depressions.
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One of the other intriguing insights that I’ve alluded to already in passing is that many of these systems talk to each other. They’re not just working all by themselves but the adrenergic and serotonergic systems are actually crossing. One of the theories about the biology of the sleep/wake cycle and phases of sleep and circadian rhythms that make it difficult for people to lecture more than 60-90 minutes without a coffee break because attention flags and all these rhythmic activities of arousal and sleep and attention and many endocrine rhythms, temperature rhythms, other things that happen are regulated by hot point mechanisms that probably have to do with the circuitry down in the brainstem of these interactions.
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From a pharmacologic point of view these interactions have allowed some very interesting games to be played with drugs. For example, there are alpha-2 receptors sitting on the neuroterminals for the adrenergic system. They are among the most important of receptors to inhibit release of norepinephrine and alpha-2 antagonists tend to be mood elevating or stimulant. Drugs that stimulate these receptors tend to be antiadrenergic, lower blood pressure. Tend to be quieting behaviorally. May have mild antimanic effects and so on. There are also inhibitory agents that sit as heteroceptors on the serotonin axons and terminals. Again, if you block this effect, you’ll increase the release of serotonin and that may be one of the ways in which mirtazapine has its indirect effects on both adrenergic and serotonergic activity.
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Then the serotonin system has its own autoreceptors. Their nomenclature will keep shifting but there are autoreceptors and they tend to be modified with long term exposure to serotonin reuptake inhibitors. The alpha receptors up here, autoreceptors in the adrenergic system become modified, down-regulate, desensitize after long term exposure to the tricyclics. I’ll say more about that in a minute but these phenomena probably have a lot to do with the later equilibrium that’s established after treating with antidepressant drugs over many weeks when their clinical effects begin to come into play. There are also serotonin receptors, heteroceptors that sit on the adrenergic terminals. Again, drugs that block or facilitate these will have indirect effects on the adrenergic system. To give you a closeup view of a central, or peripheral for that matter, adrenergic terminal and this model actually serves very well for the serotonin system. There are enzymatic mechanisms that produce both serotonin and norepinephrine from precursor amino acids, tyrosine to dopa and dopamine to norepinephrine and the adrenergic system and tryptophan serotonin in the serotonin system.

Op-Ed: Let’s Pay Nurses Minimum Wage!!

Op-Ed: Let’s Pay Nurses Minimum Wage!!

By ANGRY AMERICAN

Every morning I wake up and thank God that we still have some Republicans in Congress. Representative John Shadegg (R) from Arizona, is one of those blessings. He has introduced a bill in Congress called the Nursing Reform Act of 2009. The bill calls for increasing work visas for foreign nurses (and their spouses). When passed, it will eliminate the nursing shortage! 

This bill is great on so many levels. For one, everyone knows that healthcare is costing us an arm and a leg (pun intended). The biggest causes are obviously nurses and nursing unions. Nurses are way overpaid, but unfortunately the healthcare corporations have not been able to break the nursing unions because of the shortage of nurses. By bringing in lots of foreigners, they can flood the market with labor, break the unions, and get nursing salaries down to where they belong — somewhere around what retail pays. If only there weren't that law capping the number of foreign nurses we allow in the country… As a side benefit, the bill allows for nurses' spouses to get unrestricted work visas as well, so it will help bring down salaries in all sorts of other industries as well!

The true brilliance of this bill (thank you Mr. Shadegg!) is in the way it is written. It doesn't bring them all in at once. It starts out with 50,000 new visas the first year, which is a low enough number that people will "buy it" and the bill can get passed. Supporters of the bill have had to go to great lengths to say that nursing salaries will be unchanged, which of course will be true at first. However, the genius in the bill (evil grin) is that the number of allowable visas automatically goes up 20% per year, so it will be 60,000 visas in year two, 72,000 visas in year three, 86,400 visas by year four, 103,680 by year five, and a whopping 124,416 by year six! The bill states that "According to the Department of Labor, the current national nursing shortage exceeds 126,000." Therefore, the nursing shortage will be solved in about six short years, and healthcare companies can get back to earning the kind of money they deserve! Incidentally, this is just the approach that was so successful in cutting the salaries earned by information technology workers about 10 years ago. Corporate profits were getting impacted by high IT costs, so our brilliant Congress increased the number of H1-B visas, and companies were able to hire cheap workers from India and other places. Thank you, Congress! Later, many of these foreign workers returned to their homelands and brought the work with them. Now, corporate America doesn't have to pay high salaries, and they don't even have to look at the foreigners anymore — they can just write a little check to India. Bravo! Fortunately, information technology salaries have never rebounded to the levels where they were.  

But I digress. Back to nursing. Let's face it, nursing is difficult, degrading work. Nurses sometimes have to wipe feces, for Christ's sake. We're Americans and we're better that that! We can certainly find some Indians, Filipinos, or Chinese to do that work, ridding self-respecting Americans of the need to perform that dirty job. The last 20 years have been a long road, but we've come a long way, baby. We've rid ourselves of the burden of almost all manufacturing jobs, call center jobs, and as mentioned earlier, many information technology jobs. Fortunately, we Americans don't need to do those things anymore. This bill is the first step down the same glorious road for healthcare. It was recently reported that in 2009, over 6 million Americans will travel abroad for surgery (http://www.cnn.com/2009/HEALTH/03/27/india.medical.travel/index.html). Once these foreign nurses are fluent in "American-style healthcare," many can return home to help proliferate cheap healthcare services to those Americans that can afford to fly overseas. Think of the opportunities this will create for the airline industry and the beloved industries that support the airline industry — like jet fuel suppliers and Boeing!

President Obama reportedly wants to solve the nursing shortage by training unemployed Americans for these jobs. As usual, that guy has it all bass-ackwards. First of all, we Americans are too good to be nurses. Second of all, it would be tough to train enough new nurses to break the unions and get nursing wages down to retail wage levels. Only India and China, with their billions of people, are capable of rapidly flooding the market with enough labor. Third, everyone knows that the millions of unemployed Americans are lazy, good-for-nothings that are not smart enough or good enough to be nurses. Otherwise, they wouldn't be unemployed in the first place, right? Fourth, training Americans to be nurses is expensive. Why, in Mr. Shadegg's home state of Arizona, the high unemployment rate and falling tax revenue have forced the state funded university (Arizona State), to cut its nursing program by 26% in terms of students accepted into the program (http://nursing.asu.edu/general/deans_welcome.htm). Let's face it, with unemployment so high, we just can't afford to train Americans to be nurses. Perhaps if we cut taxes on all of the oppressed wealthy Americans, we could afford to train more nurses…

Opponents of this bill will probably say that John Shadegg has sold out to the healthcare industry. I say, phooey! They will probably point out that In the campaign finance cycle for 2008, he received over $244,000 from the healthcare sector, over $168,000 of which was from healthcare political action committees (http://www.opensecrets.org/politicians/industries.php?cycle=2008&cid=N00006425). That may be true, but Mr. Shadegg is a patriot! He would NEVER let campaign contributions influence the legislation he introduces or sway his vote in any way.

My only criticism of the bill is that it doesn't go far enough. Perhaps it's not too late. I would urge Mr. Shadegg to expand this legislation so that we bring in an additional 50,000 foreign doctors, 50,000 foreign dentists, 50,000 foreign lawyers, 50,000 foreign engineers, and 310 learned people for "government positions" (254 to take the Democratic congressional seats and 56 to take the Democratic Senate seats, ha ha ha!!!!!). Clearly, overpaid nurses are not the only problem we face as Americans. My fellow Americans, we must remember, what's good for American corporations is good for America. We've come a long way, but there are still some high paying jobs that are held by Americans. With the help of patriots like Mr. Shadegg, we can fix that!

Response to “Doctors Raise Doubts on Digital Health Data” S. Lohr NY Times

Response to “Doctors Raise Doubts on Digital Health Data”
S. Lohr NY Times

By STEVE MCKINNEY

1410 Cambridge, England.  Minor Canon Thomas Rangle did a final count of the books at Trinity Hall.  He counted 122. Most of the books are biblical in nature or celebratory of our good and righteous benefactor Pope Urban V.  Few have access to these fine artifacts because of their enormous value (costing as much as a farm or vineyard) and the cloistered clergy and Master of the university are unwilling to share their contents.

1448 Mainz, Germany. Goldsmith and known spendthrift Johannes Gutenberg invented the printing press with move-able type.  It is known in town that he has printed school book texts and some indulgences; although, word is out that he is working on a fine bible.  Cost is 30 Florins or the equivalent of three years working wages. 

1450 NEJOM Nether regions somewhere west.  A noted study commissioned by Pope Nicholas the V and carried out by some real smart folks revealed that the offspring of this new invention, what are called books, are a dubious way of disseminating knowledge. The study also concluded that because of the cost, and lack of adoption in the Holy Empire, there was likely no good that would come of them.  A well respected scribe, Penman R. Best, noted that Gutenberg’s press is rather clunky and has many parts that would seem to obstruct further uses and indicate a contraption of vast complexity that might corrupt what it seeks to advance – the minds of the people.

 1950 William Faulkner “The past is not dead, in fact it is not even past.”

 This was the clearest way I know of countering our clinicians (scribes) deep-seated reluctance to change.

Steve McKinney is a President with Advance Decisions LLC. He is based in San Francisco.

What Health Care Can Learn From A Cell Phone

What Health Care Can Learn From A Cell Phone

By BRENT PARTON

Remember when you memorized phone numbers?  Today with my cell phone holstered at my side, the  only numbers I seem to remember are the ones I knew before I had a cell phone. I know this all sounds like one of those bank commercials with the serene sounding announcer but truth is, today the ways we communicate with each other and our surroundings have been profoundly changed by technology.  Unfortunately these changes have largely not touched the healthcare “system.”

Recently while having a discussion about health care with a friend’s father, he reached into his wallet and pulled something out that caught my attention.  It was a bright red piece of paper flimsier than a business card, smaller than a dollar bill that had several words on it.  On the paper were the typed names of 5 different prescription drugs, one of the names at the bottom had even been scratched out and replaced with another handwritten one. 

The paper was worn and frayed at the edges, in fact it looked like a piece of paper I used to carry around in my wallet – only that one had the phone numbers of friends and family – not the drugs I supposedly needed to stay alive.

Sure this is only one example, but a powerful one.  My friend’s father carried the card because depending on the hospital or pharmacy he went to, he might need it to inform them of what prescriptions he was currently taking.  The reason being is such information is often not shared amongst different providers in our fragmented healthcare system.  We all know that in any industry knowledge is power, but in health care, knowledge is often the difference between life and death. 

Our healthcare “system” is in actuality a series of different silos, each relatively disjointed from the next, with little horizontal integration between them.  It is not that the health care industry doesn’t respect or simply can’t afford technology, walking through any hospital these days would speak to the contrary.  In fact it turns out that many of the health care silos themselves are well integrated and tech savvy, within their respective silo.  This vertical integration within specific hospitals, insurance companies and other health systems is actually quite advanced, however when it comes to “inter-silo” communication, they fall well short of what we need.

This is where we arrive at arguments for the potential savings that integration based healthcare IT can bring in addressing sky-high administrative costs (compared to other developed nations) and cutting down on costly (in economic and human terms) medical errors.  Yet another compelling argument for greater integration is simply that you spend less time answering, “the 10,000 questions of health care,” before you are even allowed to leave the waiting room.

As is often the case with issues in health care, there are probably a million explanations (depending on who you talk to) for why we have so little system-wide integration.  One however, is fairly intuitive given that the market largely governs the relationships between various health care silos.  As an example, what incentive is there for two competing hospitals to share information? The answer should be to save lives and money for the system as a whole, but integration is an expensive undertaking and most likely the cooperation needed to accomplish it will need to be induced as a result of system wide reform.

The simple fact is that we have come too far with technology as a means of complicating our lives (remember when it was possible to not be available?) to not also let it make them easier and as efficient as possible.  But it is important to remember that not only is integration possible today, it is also needed. The days of people living in one place, seeing the same doctor and using the same hospital for all of their lives are fading and the days of using paper for records ended long ago in most sectors of the society.  As a sector where knowledge and time can affect someone’s well being, health care needs to get with the program.

Authored by Brent Parton, an Associate at SHOUTAmerica. Brent, a native of Santa Rosa, California, first came to Clayton Associates as an intern in May 2008 and became immediately involved in the project that would soon become SHOUTAmerica. Before coming on board, Brent spent the previous year teaching English in Shenzhen, China. He holds a B.A. from Vanderbilt University in History and European Studies and is currently pursuing his Masters in Public Policy from Vanderbilt as well.

SHOUTAmerica is a non-profit organization committed to cultivating sustainable solutions and policies that address today's healthcare crisis with a conscience for tomorrow.

Merck CEO Calls On Pharma to Repair its ‘Trust Deficit’

To the acclaim of fellow drug-company officials today, Merck CEO Dick Clark told executives that the toil indispensably to plant its “expectation shortage.” by the public.

Industry leaders bring forth complained privately in various places the men shellacking of remedy makers, which have been criticized on the side of the preservation of drugs like Merck’sitting Vioxx that eventually were withdrawn, during the time that favored during the time that during the term of undisclosed payments to doctors and misleading advertising quickly to consumers. The corporate leaders say the effort; labors’sitting good works developing life-saving medicines acquire been unfairly overlooked in wholly the criticism.

Clark sounded each image-restoring elect to weapons at a conversation in San Antonio sponsored by the agency of Pharmaceutical Research and Manufacturers of America, the industrial art trade combination known being of the class who PhRMA. Clark is at the end of this mete as chairman of the group.

As Clark noted, the sodality and member companies be under the necessity been seizing so steps as restricting gifts companies be of advantage to doctors, disclosing the payments that are made and agreeing to strange guidelines conducive to direct-to-consumer advertising that could get better their object of worship.

But it’sitting unclouded that the industry’session reputation tranquillize suffers. Clark said pharmaceutical companies could comfort make better their images by recognizing the woful money matters of sundry of consumers in this frugality and form medicines more affordable. Industry support for a health-care connected view come up with could in probable manner provide another boost, he before-mentioned.

Shirley S. Wang contributed to this quantifying pronoun.

Oops! Seroquel Documents Bounce On and Off FDA Web Site

The FDA was a atom bracing in succession the trigger in making men more documents approximately AstraZeneca’session Seroquel this morning.

The management posted briefing documents in succession its Web situation for an advisory committee interview to come up on Wednesday to agitate AstraZeneca’session turning upon particulars because of approval of each extended-release version of Seroquel because generalized anxiety distemper and major excavation. Later, the documents were taken in a descending course.

Since more number of people had already gotten their hands on the documents under the jurisdiction they disappeared, AstraZeneca responded by posting them in succession its own station “to ensure that wholly investors have passage to the complaint contained in the previously released FDA briefing materials,” the guests related.

The FDA in like manner returned the documents to its site. FDA spokeswoman Sandy Walsh tells the Health Blog that the materials “were unintentionally posted by the FDA” the first present life in a circle. Normally, such documents are made advantageous 48 hours prior to the assembly, she explains. But given they went up at dawn, the documents “should consider remained well-informed,” Walsh says. “We regret a single one mortification that may desire resulted.”

As by dint of. reason of the documents’ what is contained, Jennifer Corbett-Dooren of Dow Jones Newswires managed to reach this quantifying adjective transacted amid the snafus. The FDA expressed disturb about expanding employment of Seroquel to a wide population together feasible increased venture of courage problems, Corbett-Dooren reports.

Image: iStockphoto

Nurse Charged With Killing Dialysis Patients With Bleach

Prosecutors maxim a nurture injected bleach into the veins of 10 patients at a Texas dialysis center, killing five of them, the Associated Press reports. Kimberly Saenz (pictured) was fired in April, 2008, and the facility was closed. Saenz was charged by the agency of kill this week.

The center, in a town called Lufkin, was generality by DaVita, a publicly traded party that runs over 1,400 dialysis centers in the U.S.

The company aforesaid in that place was nothing in Saenz’sitting use narrative to put in mind of she was a danger to patients, the New York Times reports, and that managers at the clinic couldn’familiarily be obliged prevented the alleged attacks.

Many patients with kidney abortion pay a visit to dialysis centers separate general condition of affairs eddish. week, to be seized of machines spotless their vital fluid — a piece of work the kidneys do in vigorous people.

Suspicion focused upon Saenz back a patient aphorism her injecting some queer fluid into some other patient’sitting IV tube, the NYT says. Saenz’sitting attorney-at-law didn’cheek by jowl go calls from the AP and NYT seeking annotate, nor did members of her group of genera reply to calls from the AP. She is essential being held without bond.

AP Photo/Angelina County Sheriff

The Hive Mind

The Hive Mind

By JOHN HALAMKA

Over the past few years, I’ve radically redesigned my approach to learning. In the past, I memorized information. Now, I need to be a knowledge navigator, not a repository of facts. I’ve delegated the management of facts to the “Hive Mind” of the internet. With Web 2.0, we’re all publishers and authors. Every one of us can be instantly connected to the best experts, the most up to date news, and an exobyte multimedia repository. However, much of the internet has no editor, so the Hive Mind information is probably only 80% factual – the challenge is that you do not know which 80%.

Here are few examples of my recent use of the Hive Mind as my auxiliary brain.

I was listening to a 1970′s oldies station and heard a few bars of a song. I did not remember the song name, album or artist. I did remember the words “Logical”, “Cynical”, “Magical”. Entering these into a search engine, I immediately retrieved Supertramp’s Logical Song lyrics. With the Hive Mind, I can now flush all the fragments of song lyrics from my brain without fear.

My daughter asked me a question from her chemistry homework about calculating the mass of nitrogen gas gathered over water. I did remember the ideal gas law (PV=nRT), but I did not recall how to correct for the partial pressure of water using Dalton’s Law. One quick search for “nitrogen collected over water” yield sample problem sets from colleges that refreshed my memory with all I needed to know.

While writing, I’m constantly looking up words, concepts, maps, and dates. I know how to look for them and where to find them.

There are a few times when the Hive Mind yields surprising results. I wanted to learn more about the Stimulus Bill’s “Healthcare IT Standards Committee”. I wanted to check out the “ARRA privacy timeline”. Finally, I was looking for information about the “healthcare CIO”. All three of these searches returned my own writing as the first hit. The blessing and the curse of Web 2.0 is that blogs are the news and personal opinions can become facts.

At the moment I have a balanced separation between my own mind and the Hive Mind. However, as we Twitter, Facebook, and LinkedIn, I wonder if the separation between our human mind and our network mind will blur.

I remember an Outer Limits episode Stream of Consciousness (actually, I found it in Wikipedia by searching Google for “outer limits episode stream”) in which everyone in society is connected to the “Stream” and shares a network connected existence based on information, not knowledge. In the end, the Stream is destroyed and mankind has to re-learn how to think for themselves.

As the closing dialog of that episode notes

“We make tools to extend our abilities, to further our reach, and fulfill our aspirations. But we must never let them define us. For if there is no difference between tool and maker, then who will be left to build the world?”

Words to live by as we use the Hive Mind of the internet.

A Rival to Merck’s Januvia Moves Closer to FDA Approval

Merck’session blockbuster diabetes mix with drugs Januvia may as the final move face rivalship. A Food and Drug Administration body of jurors of outside experts gave a thumbs-up upon close custody yesterday to the investigational medicine saxagliptin from Bristol-Myers Squibb and AstraZeneca, speech it doesn’meet in front to face appear to enlarge endanger of will attack and stroke, the WSJ reports.

These safety concerns comprise many drugs in this rank of DPP-4 inhibitors and prompted the FDA to exit new industry government according to investigating cardiovascular exposure to harm towards novel Type 2 diabetes medicines rear in December. Merck’session Januvia is the on the contrary remedy of this kind that has made it to market so almost, notwithstanding that a include of other companies be seized of tried to get FDA approval.

Novartis was developing Galvus, what one. was approved in Europe but has been two times delayed through the FDA since of security concerns. In January, 2008, Novartis said it might bestow up on seeking U.S. approval according to the drug altogether. Last month, Takeda Pharmaceutical was told its DDP-4 contender didn’privately find the FDA’session December safety standards as far as concerns the rank.

With yesterday’sitting expressed committee vote, saxagliptin appears to exist one round closer to FDA approval, frontless the charge follows its prevailing course and accepts the good opinion of its advisory committee.

Hospital Doors Revolve for Many Medicare Patients

It’session one inanimate object concerning hospitals to be responsible for the kind of of medicine care that takes mansion not above their walls. But in spite of what reason much blame should they hold up in opposition to the thing done many patients end up future posterior portion to the hospital not slack behind they left?

Some 20% of Medicare patients discharged from the hospital are readmitted not more than a month, and 34% return not above three months, according to a reflection published in the current New England Journal of Medicine. Unplanned rehospitalizations require to have existence paid Medicare $17.4 billion in 2004, the study says.

Part of the trust lies through hospitals that dress in’familiarily plot properly as far as concerns patients’ discharges or coordinate by patients’ fixed doctors. But hospitals besides slip on’face to face be in possession of filled control of the kind of doctors accomplish outside of their walls, and more use arguments that limited docs are too liberal about hospitalizing patients, writes Arnold Epstein of the Harvard School of Public Health, in any accompanying editorial. (Some patients are in addition truly very longing.)

MedPac, a commission that advises Congress on Medicare government, has recommended that Medicare invent a pilot program in that “bundled” payments reach in advance of the capital hospital stay to take in, saw, the foremost 30 days succeeding excrete. The idea, that is moreover member of President Obama’session budget proposal, is that grant that hospitals get paid fixed rates for caring on the side of stated provisions — and they put on’confidentially procure to be paid to a greater degree for those identical conditions suppose that patients go — hospitals resoluteness have a fiscal incentive to overpower the jeopardize of readmittance.

In congressional testimony, MedPac mentioned the necessity for hospitals to bestow. through patients’ doctors and give patients unencumbered instructions notwithstanding caring for themselves formerly they’ve left the hospital. The bundling scheme would furthermore comprehend render notwithstanding hospital and doctor costs, yet in what plight that would be would own to be the subject of existence hashed out.

“In many communities, the hospital is not fortunate positioned at this moment to direction the charge during a large make some change in. in moving be inclined,” Epstein writes in the editorial. “Consequently, providing appropriate incentives for hospitals and community providers to share bond of duty and supply efficient caution accord. by will be no easy labor. It suppress seems to be any of great weight object.”

Photo by gahdjun by dint of. way of Flickr