The Daily Dose: What's In Your Medicine Cabinet?

A perfect circle

2009-08-29T12:19:00.000-07:00

Today is the last day (sniff) I promised myself I would not cry (sniff), but I just can't help it (weeping uncontrollably).

But, seriously it will be somewhat weird to not have to be working on something for www.rateadrug.com, at least as far as the internship is concerned. I have my final paper basically written, I just need to put in some more supporting information from my survey results, and I should be done. That will be weird, I have worked on this thing practically nonstop since I got the raw data. Although, it will be nice to focus only on school, this is intended to be my last semester seeking a degree and thus I don't have the option of taking things again if I don't do well. Plus, I want to take a glassblowing class and that will take up more time.

When I began this blog I started out by talking about the medical treatments for Hydrocephalus. It seems only fitting that I finish with talking about that subject. It makes the whole thing tie up in one neat knot, I think.
We have talked about Acetazolamide and Furosemide and illustrated the mechanisms by which they work. In the case of both of these medications they are essentially used to decrease the amount of CSF that is retained in the body - commonly known as loop diuretics (for further info on those two drugs check out the links to previous posts). And, according to http://emedicine.medscape.com/article/1135286-treatment both Acetazolamide and Furosemide work well for infants. Basically any medical treatment for Hydrocephalus must cover only the acute as long term use of either Acetazolamide or Furosemide can cause damge to the body. Chronic Hydrocephalus must be treated surgically.

I have, however, found a new medication I was previously unaware of: Isosorbide.
I will talk about Isosorbide, and if I can, I want to find a video of the shunt insertion surgery, I can't guarantee that I will, but I think I can at least link it.
The use of medication to treat Hydrocephalus is a controversial topic. It is believed that the best way to provide a 'normal' life for anyone who has Hydrocephalus is to perform a surgical procedure and either shunt - punt in a valve that dumps off excess pressure - or to perform a interventriculostomy - basically a hole is drilled between the ventricles of the brain to allow for absorption of CSF and to relieve pressure by spreading it out across the brain.

Isosorbide Mononitrate looks like this to a chemist:

Unfortunately, I am taking biochem this semester, so I can't talk about what this thing does in your body exactly, but I do have some good resources at my fingertips.

Isosorbide mononitrate is in a class of drugs called nitrates. Isosorbide mononitrate dilates (widens or relaxes) blood vessels (arteries and veins). When blood vessels are dilated, it is easier for the heart to pump. Also, more blood, which is rich in oxygen, can flow to the heart.
(http://www.drugs.com/isosorbide_mononitrate.html)

And, of course, www.rateadrug.com has some interesting resources for anyone who is taking Isosorbide, or wants to know more about it. According to
Dlmeyers1970:

When I first started taking the medication it gave my significant headaches, dizziness and a stomach ache, but after one week the side effects stopped. I am so glad for this medication because it has stopped my coranary artery from spasming and the chest pain is finally gone. I used to have chest pain, in varying strengths, all day long, and now I am chest pain free.
(http://www.rateadrug.com/Isosorbide-Mononitrate-side-effects.aspx)

Of course, that person is talking about taking the medication for angina and other heart-related troubles, but it can be used for short term treatment of Hydrocephalics as well.

I have managed to get some videos of the procedures I have been talking about. The first will be a short animation about insertion of a VP shunt - the VP shunt is the most common shunt that I see opst-operatively. Basically with the VP shunt the end of the catheter is placed in the periotoneal cavity so the body can re-absorb the extra CSF.
The second is from a thing I found on youtube.com where a neurosurgeon is giving a basic definition of Hydrocephalus.

Lastly, there will be a link to a video of an actual surgical procedure. I can't, and won't, post that on here due to it's code and it's gory content, but the link is well worth watching. The video should be about an hour long.
http://www.or-live.com/distributors/NLM-Flash/nep_2553/rnh.cfm?id=838

Sorry, it took me so long to figure out how to post video, but I did at the end! Best for last!

That concludes our internship, and our internship blog. Thanks for staying tuned. I have really appreciated tdoing this work. Thanks also to www.rateadrug.com for giving me a shot at working with them in this internship.
Bye, and stay classy internet.

Decisions....decisions....

2009-08-25T11:12:00.000-07:00

Well, here we are. Finally at the end. The paper is due this coming Saturday, and I don't think anyone has done any additional surveys for about 2 weeks now. I have been working nearly non-stop over the last several days on the final write-up. I think I have a final subject figured out and it is nearly complete. Just need to add some more data from my surveys. I won't explain everything that it is about because it will be published on the www.rateadrug.com site and I want you to take a look at there. For a teaser, though, I will say that my final article covers ground that apparently relatively few studies have covered before. It should prove to be a good read. After all of the work I have put in, I think that it will be a good paper, but that remains to be seen. Typically when I put in the same amount of work on other things, I get grades in the A ranges, so we will see.

Today I don't have a drug feature, I just wanted to talk about the paper and the end briefly, but later this week I will post my last and final feature. That is part of why I am not going to do one today, I don't want the one that I am going to finish off with to seem less by comparison. It might be possible, I don't want to get your hopes up, but it might be possible to have a video posted. Can't guarantee anything, but sure gonna try.
That is about all for right now, things are winding down well, and I have kept busy with this final write-up.
I would also like to give public credit to my editor, without whose help I would not be so good at this thing.

So, until later I will to get everything done so that I can have a really cool final feature. See you all later, I have some homework I have been neglecting!

Here I go again on my own

2009-08-21T14:15:00.000-07:00

Time keeps on ticking, ticking, ticking...into the future.
I am no nearer reaching a conclusion on what to write about for my final write-up. In an older post I discussed what had been the most troubling thing for me; that is most likely what I will end up writing about. Although, that seems more like a study in society than it does a study in medications and pharmaceuticals, although I guess it still qualifies if I use my Pharm data as supporting evidence for my claims.
(Sorry if my sentences don't make much sense, I worked last night and then slept until 3 today, that kind of messes with your head. Also, anyone interested in industrial music should check out this band that I found on youtube.com the other day. I am listening to it right now, good stuff!)
So, that is where I am at on that account. IRB approval is grinding along slowly. Maybe the woman I talked to about the finance review is on vacation or something. Doesn' really matter because I am done collecting surveys, now it is all about writing the paper.

Today, however, I am going to do a brief discussion of a medication that I have seen used, and it seems, abused. On my unit we often talk about patients that are 'frequent flyers' meaning that they are in and out rather often. Actually, come to think of it, it has been about 6 months since the last time I saw the 2 most famous. One of those most famous, however, has been accused by some of the staff of being addicted to a med that is often used as a painkiller. That med is known as Dilantin, and last night I witnessed it's use again - not on this 'frequent flyer' patient mind you - and that got my brain a-thinkin'.

So, today we are going to talk about Dilantin:

Here, like always, is the organic molecule. I should do a feature of something like Lithium - used as a mood stabilizer - because the molecule would look cool, and it is not organic. I will think about that...
Anyway, Dilantin works by:

In chemical structure, Dilantin (phenytoin) is related to the barbiturates.

The mechanism of action is not definitely known, but extensive research strongly suggests that its main mechanism is to block frequency-, use- and voltage-dependent neuronal sodium channels, and therefore limit repetitive firing of action potentials.

At usual levels, there is little or no change in normal patterns of firing. At high or toxic levels, however, phenytoin can impair the function of healthy neurons.(http://professionals.epilepsy.com/medications/p_dilantin_mechanism.html)

It is interesting how many drugs they are not sure on the exact mechanism of action with. According to this information though, it sounds like Dilantin can be used for anti-epileptic activity. That is interesting. If you have been a follower of my blogs then you understand at least in part, how sodium channels in the body and the neuronal pathways work.

The preceding graphic illustrates, basically, how the sodium channel operates in the human cell. Each cell has a door that will open only for certain materials; usually only ions can pass into or out of cells, by so doing the cell maintains an electrical potential that it uses to carry out chemical reactions essential to it's survival. By adding a med like Dilantin the cells potential is altered in a certain direction which then alters the flow of Na2+ ions and alters how that cell will react. When carried out over a chain of cells and, in this case, neuronal transmitters the ultimate effect is to reduce the repeated firing of that neuronal transmitter and thus reduce epileptic activity or pain.
Any questions?

This has been interesting information for me to gather. I am glad I did Dilantin today, now I know more about it, and I know more about how it works. This fall I have a Bio-Chem course that I am nervous about, but also excited because we will be talking all about this sort of stuff. I still remember the day I read the back of the shampoo bottle and I knew what the chemicals were, and what they did... That was a good day...
But, enough about chemical memory lane, thank you for learning about Dilantin with me.

I probably won't post until next week sometime, and then it will be a fond farewell, (sniff). Oh, I am no good at goodbyes..

Pride cometh before the fall...

2009-08-20T10:14:00.000-07:00

While the end may be nigh, I find myself with a plethora of medicines and pharmaceuticals that I can talk about. I would like to at least keep this blog going until the end, which is August 29th as far as I am currently aware. Plus, I have some weeks that I need to make up for; like when I was on vacation etc.

Recently at work I have thought myself quite the expert on the medications. This, of course, has been a consequence of my being in this internship and keeping this blog. As I have done research on medications that I have come across at work I have learned things about how they are administered, and what they are used for. It has been rather enlightening. So, I have considered my knowledge great and have volunteered this knowledge like a 5 year old kid who just learned to spell. Often I am wrong, which is what leads us to the feature for today. I would say the feature for this week, but I am trying to squeeze in some extra time on the blog, so it will be a daily feature for today.
My last post was about Klonopin, and since that time I have volunteered my knowledge on the subject to anyone that would listen; however I have begun to mistake Clonidine for Klonopin. It seems like an amateur mistake, but I am an amateur at pharmaceuticals and medicine, so there you go. With this in mind the feature for today will be Clonidine. I want to know what it is and what it does so that I won't have to make the silly mistake again. You can all come with me as I blog along!

Here is the organic molecule:
This is an interesting molecule. Rather simple if you know much about organic chemistry, but there are definitely some areas that can interact.
Here is what it looks like in the box:
In most previous blogs I have known things solely by their brand names, but it seems that this time Clonidine is the generic name and Catapres is the brand name.

Clonidine is most often prescribed for the treatment of hypertension. It has also been used to manage the symptoms of narcotic withdrawal, nicotine withdrawal, diabetes-associated diarrhea, diabetic neuropathy, hot flashes associated with menopause, and as an adjunct to manage severe cancer-related pain. (http://www.pharmaenergy.com/CLONIDIN-AWN-75-Kaps-x100-pr-824.html)

The above webiste is also where I found the picture of Clonidine in the box - it seems that they sell it on this website, although they are out of stock right now DANG!
However, it seems that it is entirely possible to acquire Clonidine without a prescription. I found that rather surprising - it is possible that it is a dosage based thing. A simple google search told me that if I want it I can get it, which is true of most things on the internet, but I didn't have to pass a bunch of firewalls and passcodes to get there, so I suspect it is legit.

Anyway, the largest use of Clonidine is for hypertension or high blood pressure. It seems that it is also very useful for all kinds of other things. This quote is a bit redundnat, but interesting nonetheless:

Clonidine lowers blood pressure by decreasing the levels of certain chemicals in your blood. This allows your blood vessels to relax and your heart to beat more slowly and easily.

Clonidine is used to treat hypertension (high blood pressure). It is sometimes used together with other blood pressure medications.

Although not approved by the FDA for these purposes, clonidine has also been used to relieve alcohol withdrawal, as an aid in methadone and opiate detoxification, as an aid in quitting smoking, to treat diabetic diarrhea, to treat Tourette's Syndrome. Clonidine has also been used to reduce menopausal flushing, to treat postherpetic neuralgia, to treat ulcerative colitis, and to diagnose pheochromocytoma. (http://www.drugs.com/clonidine.html)

I find that rather interesting. How does Clonidine do that you ask? Well, let's find out; shall we?

Clonidine is a centrally-acting alpha-2 agonist. It selectively stimulates receptors in the brain that monitor catecholamine levels in the blood. These receptors close a feedback loop that begins with descending sympathetic nerves from the brain that control the production of catecholamines (epinephrine, also known as adrenaline, and norepinephrine) in the adrenal medulla. By fooling the brain into believing that catecholamine levels are higher than they really are, clonidine causes the brain to reduce its signals to the adrenal medulla, which in turn lowers catecholamine production and blood levels. The result is a lowered heart rate and blood pressure, with side effects of dry mouth and fatigue.

An analogy would be the lowering the temperature of a house by holding a lit match under the thermostat connected to the furnace.

(http://www.experiencefestival.com/a/Clonidine_-_Mechanism_of_action/id/1237669)

That is a rather succinct definition. I have also found information that concludes that the channels are opened via Ca2+ ions. Essentially that means that the neuron channels open to allow Calcium ions to enter thus initiating the whole process. The graphics illustrate the basic process. And this other graph shows how Ca2+ ions increase as a consequence of having Clonidine on board

This stuff is all rather fascinating to a nerd like me. After this semester - my last seeking a degree - I will have taken BioChem and will understand all of these principles that much better. I have to say that although I rather suck at it, I think Chemistry is just fascniating.
It also make sense that Clonidine would be administered in the setting that I work in because a lot of our kids have hypertension issues after trauma or because of Hydrochephalus, Seizures etc.
Thanks for figuring out Clonidine with me. Stay tuned as I try to work out what to write for my final report. I have some ideas swishing around my head, and some other stuff I wrote about months ago that I might ressurect to come to a conclusion.
See you in a few short hours!

The Final Countdown

2009-08-19T09:26:00.000-07:00

Hello one and all. It seems that it is finally time to be finishing up the internship. I have my raw data in hand and need to spend most of my time working on the final report. I will, however, try to get a few more neurological meds posted before the end. I need to make up some weeks that I missed so I will try to post a few more things over the course of this week and next.
School starts again next week, which should be interesting. Especially considering that this is supposed to be my last semester seeking a degree from the University of Utah. I am sort of freaking out. It is really hard to think that I won't be going to school in the spring. School has been such an integral part of my existence for so long.
Also, it is weird to think that the internship is about over. I have worked on this for such a long time as well. It has been about 6 months since I first signed up with www.rateadrug.com - and now it is almost over. Some of the other interns have really put up some good numbers too, it makes my initial efforts look rather pathetic. I was once #1 in the entire program and now I am down to #5. I sort of feel like Andre Agassi after he married Brooke Shields - if you don't know what I am talking about you are too young and need to google that particular incident.
Anyway, this is just intended to be a brief description of where things are. I will try to post a neuro med either later today, or tomorrow.
Tomorrow being the most likely.
Be good my faithful followers.

King Klonopin

2009-08-06T08:59:00.000-07:00

Ah, finally back to the swing of things. I apologize for making you all sit through my photos, but I needed to show SOMEONE how awesome Japan was. That is nowhere near the amount of photos we took either.

Anyway, back to business as usual. Things are going well with the internship. I have slipped to second place as of this week, but I have an ace or two up my sleeve. Part of me wonders if I was passed because of my advice, although the other interns probably have way better ideas anyway.

So, we are back with the 'Drug of the Week' feature. This week I decided to take a look at some of the resources that are found on www.rateadrug.com (the link there is for Klonopin itself). It has been nice being able to refer to that stuff when I need to. After looking on that list for about 2 secs I found a medication that I have seen used many times in my work at the hospital. That med is Klonopin. I have seen it used, but like so many of the other 'DotW' features I have no idea how it works.
You have certainly already guessed that this weeks feature shall be: Klonopin.

Old tricks are usuall the best, so here goes the organic molecule (actually I forgot this and had to come back, can you believe it? How many of these drugs posts have I done now, and I forgot? Silly).
Ah, that is better.
I thought this was kind of cool too, these are the pills themselves. Each tablet is 5mg, this is obviously the brand name version because the big K's and the fact that the pills say Roche, or the pharmaceutical company that makes Klonopin, on them.
Klonopin is part of a class of drugs known as benzodiazepines. Some of the drugs that belong to this class that I might also be featuring in the next little while are Ativan - another relaxant or anti-seizure medication - and one that most people are familiar with Valium.
(http://www.drugs.com/klonopin.html)

Clonazepam is a potent AED [Anti-Epileptic Drug] and the drug of choice for myoclonic seizures and subcortical myoclonus. It also is effective in generalized convulsions and, to a lesser extent, in partial epilepsies. It rarely is used as adjunctive treatment of refractory epilepsy because of its sedative effect and tolerance, which are similar to those of other benzodiazepines. It is very effective in the emergency treatment of status epilepticus, like diazepam, and can be given IV or rectally. Withdrawal from clonazepam may induce status epilepticus or exacerbation of seizures.
(http://emedicine.medscape.com/article/1187334-overview)

A seizure reflects an imbalance between excitatory and inhibitory activity in the brain, with an increment of excitation over inhibition. The most important inhibitory neurotransmitter in the brain is GABA....GABA has 2 types of receptors, GABA-A and GABA-B. When GABA-A receptor is stimulated, chloride channels open to allow the influx of negative ions (ie, chloride) into the neuron and cause hyperpolarization, moving the membrane potential further from the cell-firing threshold. The GABA-B receptor is linked to a potassium channel....The GABA-A receptors have multiple binding sites for benzodiazepines...
(http://emedicine.medscape.com/article/1187334-overview)

Essentially, Klonopin works, like all other benzodiazepines, by interacting with GABA-A and altering the sodium channel in the neuron, making in negatively charged so it moves farther away from the 'cell-firing threshold' and decreases the activity of the seizure.

This is a simplified mechanism of how the alteration of GABA-A and GABA-B affect seizure activity.

Klonopin is also known as Clonazepam, which I did not know. I have seen various movies and television programs where people are taking Clonazepam. Usually the characters are taking it to help them 'relax'. Sometimes in a clinical sense, and sometimes in a recreational sense.

It also seems that any form of barbituate will have a negative effect with Klonopin. On the www.rateadrug.com page that shows the comments made about Klonopin someone stated that they had problems with alcohol abuse and Klonopin really threw them for a loop. That makes sense, if Klonopin is a moderate to high-end relaxant or anti-anxiety drug then a barbituate like alcohol would really cause some problems.

The other list of counter-indications or medications that might cause problems with Klonopin is as follows (http://www.drugs.com/klonopin.html):

propantheline (Pro-Banthine);
an antifungal medication such as fluconazole (Diflucan), itraconazole (Sporanox), ketoconazole (Nizoral), or voriconazole (Vfend);
an antidepressant such as amitriptyline (Elavil, Etrafon), doxepin (Sinequan), imipramine (Janimine, Tofranil), nortriptyline (Pamelor), and others;
a barbiturate such as amobarbital (Amytal), butabarbital (Butisol), mephobarbital (Mebaral), secobarbital (Seconal), or phenobarbital (Luminal, Solfoton);
an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate); or
medicines to treat psychiatric disorders, such as chlorpromazine (Thorazine), haloperidol (Haldol), mesoridazine (Serentil), pimozide (Orap), or thioridazine (Mellaril).

And, this is a list of common and not so common side-effects
(http://www.drugs.com/klonopin.html):

confusion, hallucinations, unusual thoughts or behavior;
hyperactivity, agitation, hostility;
unusual or involuntary eye movements;
weak or shallow breathing;
depressed mood, thoughts of suicide or hurting yourself;
chest tightness, fast or pounding heartbeats;
painful or difficult urination, urinating more or less than usual;
pale skin, easy bruising or bleeding; or
new or worsening seizures.

Less serious Klonopin side effects may include:

drowsiness, dizziness, spinning sensation;
memory problems;
tired feeling, muscle weakness, lack of balance or coordination;
slurred speech;
drooling or dry mouth, sore gums;
runny or stuffy nose;
loss of appetite, nausea, diarrhea, constipation;
blurred vision;
headache;
nervousness, sleep problems (insomnia);
skin rash; or
weight changes.

Personally, I have seen Klonopin administered after a patient has had a prolonged seizure. It certainly seems to be effective. It is interesting the more I learn about various medications, the more I am interested in Pharmacology. I can't wait to move on with my education!
Thanks for staying tuned in, look forward to another discussion next week!

Worth a thousand words...

2009-07-25T13:26:00.000-07:00

Finally, we come to the last post that I will make regarding my trip to Japan. I know I am dragging this out rather long, but we took A LOT of pictures. It is also my hope that someone who is also going to undertake a trip to Japan will come across this blog - or at least the 3 posts that concern Japan - and find information or ask questions about it. That way my knowledge can become someone elses.

As far as things relating to the internship all is going well. I have completed paper surveys for anti-bacterial medications which have already helped me. I got about another 15 surveys over the last weekend by taking some paper surveys with me. Just yesterday I submitted the last thing I needed for IRB approval and spoke with the woman in charge of billing and she said we should be good to go. Now I just wait, but soon I should have access to the patients at 3 major hospitals in the valley. That should work out just fine...

Anyway, let's get on with the photos, I also have some video to post for which I am excited. So far I have not had an opportunity to post any videos.

So, at this point in our journey we are in northern Honshu Japan.
All over the place people had really neat and well maintained gardens.

This was taken from a cemetery cloes to where we were staying. I can't be sure, but I think that the ashes of the deceased are in the tomb. People will also bring personal belongings and favorite foods or drinks of the deceased person as offerings for their spirit. Most people are married in Shinto ceremonies, but buried in Buddhist cemetaries.

Here is a shot of me standing at the Tori gate of a Shinto shrine just down the street from the cemetery in the last photo.

This is a package of Octopus that we saw in the fish market in Hachinohe
Also from the fish market. You can't tell, but the crabs in this box are still alive and crawling around.

These are tentacles from a Giant Octopus. Even though they had been cut of from the main body of the Octopus they were fresh enough that they would dilate and react to touch. My hand is there to give an idea of the size of these things.

These are squid guts that I ate at the fish market. They were about as good as they sound, but it was rude to refuse if someone offered you something. I tried to be a good ambassador of my country by keeping it down; felt kind of ill the rest of the day though.

This was from a mall in Hachinohe. The floats that they build for festivals put any and all of our floats to shame.

While we were in Misawa - the place that we stayed for the remaining 2 weeks we were gone - we went to the Aomori Show Restaurant. It was a bit pricey, but so worth it. This is a picture of the apetizer a big plate of all kinds of sushi.
Japanese food is not for the feint of heart.
This is the rest of the meal from the Show Restaurant. Each level is a different course.

This is in a place called Oirasse Gorge. It is hard to over-state the beauty of Japanese landscapes.

Also in Oirasse Gorge. There is a legend about this spot, that a beautiful woman once lived under that rock and seduced travels so that she might murder them and steal their things.
This is me and my wife in front of a waterfall also in Oirasse Gorge.

This is a badger that we happened upon while visiting the area.

This is from 'Shipwreck Beach'. The name fits the place rather well, as you can tell.

(Unfortunately after trying for several hours I won't be able to post video after all. I am messing with file converters, but so far I have not come up with anything that works. I will have to post video later when I can get the thing working.)

This is the 100 yen sushi store. All of the dishes come across on a conveyor belt and you pull off the things that you want to eat. I am not sure of all the stuff we ate because it was all in Kanji.

This is the seagull shrine. Not sure of the real name, that is just what we called it because of all of the seagulls. I wish I could get the video to work, the noise is just deafening. If you have ever seen Alfred Hitchcock's movie, 'The Birds' it was A LOT like that.

This is Tanasashi Seaside Park. It is where we ate lunch, just a pretty place to look at.

And finally, we got to see some Snow Monkeys. They are so called because they live in the northern part of Japan where there is heavy snow. These monkeys survive by hanging out around hot pools during the cold winter months. This part was pretty cool, I had never seen monkeys before!

That concludes my photo adventures through northern portion of Honshu Japan. I really enjoyed this trip. I think anyone that can should go, I am definetly going to try to get back. Thank you for looking at all of my pictures, I know there have been a ton. Starting next week the features will be back and life will continue as normal, at least for this blog and for my internship.

Summer, summer time

2009-07-14T08:08:00.000-07:00

I love summer.
This has been the first summer I have taken off since I have been in college. It has been nice.

Ok, back to business (side note: have you ever wondered why it is that the format for blogging takes the shape it does? Why does everything I write end up in this cramped column down the middle of the page? That is odd to me, there is a lot of wasted space). Yesterday I completed another paper survey, it is just awaiting approval from Sara so I can go ahead and print and administer. Also I spent some time yesterday working on getting to the right channels so that I could get IRB - institutional review board - approval so that I can start doing surveys at clinics with my hospital and other hospitals that are in the network. For obvious reasons facilities tend to be really careful about who they let gather information from human subjects. This is especially true of the pediatric and infirmed populations. For a long time I worked at a group-home for the developmentally disabled and it took a lot of time and documented work to be able to remove rights from our clients if they could not handle them. It is, however, hard to describe how difficult and complicated it is to try and get to the right people when trying to conduct any sort of research. You never get the right person and they usually have no idea what you are talking about (side note: I just found the right person to talk to and will be sending out the online application within moments. Hooray for me!).
If I can get that done fast enough I should be off and working in no time at all. For some reason I am still holding the lead in the internship, I assume that will change soon, but once I have my new surveys ok'd I can go out and bug people in the neighborhood and get some more surveys in no time at all. Entering the data later kind of sucks though.

Ok, this will be the last post detailing my adventures in Japan. Last night on the radio I heard an advert for travel in Beijing China for a really good price, for some reason though my wife seemed hesitant to pay another several thousand dollars on a vacation in the fall.
After this post I will return to my discussions of medications. Recently when making the new paper surveys I found that www.ratedrug.com has a listing of medications based upon the condition that is being treated. That opens up huge areas to talk about other medications for the neurological patient. There were a lot on there that I know about, but for some reason just forgot.

When we last left off we were traveling north to Misawa. Actually we did not stay in Misawa proper, it was more like a suburb. The name of where we stayed was Oirasse. Most of the people in Japan consider the place that we stayed to be the 'backwoods' of Japan. Kind of like how we tend to think of people who live in the Ozarks.
As you can plainly see I am working with a different format for the photo. I also think I will ditch the parenthesis. Too much punctuation just gets in the way.

This is just kind of a cool pagoda we saw when we stopped in Matsushima Bay. It is supposed to be one of the top 5 prettiest places to see in all of Japan.

Here is antoher picture of Matsushima Bay, this is looking out over the bay. That bridge can be crossed for a fee, we didn't do it because the people we were with were cheap.
This is my mother - the blonde woman on the right - with my sister's family at a shrine/ grotto around Matsushima Bay. She and her husband are the people who showed us around Japan for 3 weeks because he is in the Air Force and is stationed at Misawa Air Base. Everywhere we went it was that pretty and green.
Here is another shot of the grotto/ shrine. There were a lot of cool Buddhas and Bodisatvas too, but there will be a lot of Buddha pictures, so I won't linger too long here. I do miss how pretty it was though. I can see why they have a pseudo-nature worship culture.
I had to add this picture. This tree is over 700 years old and was just growing in some guys yard. I think it is a Juniper.

Here is an example of local cuisine. We walked past a woman who was grilling a squid and putting some sort of soy baste on it. The things that look like snails are actually scallops. The scallops were not too good, but I liked the squid pieces. She even threw in some tentacles for free.

This is another great example on Engrish. This was found at the Daiso or 100 Yen store - which kicks the crap out of our dollar store. They had all kinds of things for sale there.

Finally up north we were able to see this outside of Aomori; the biggest Buddha in all of Japan. If you look closely you can see me and my wife standing in front of it - this should give you and idea of the scale.
This is the Buddha's head sticking out over the treetops - once again, this should help you appreciate the scale of this thing.

These next several will be of the aquarium also in Aomori.

This was cool. It is a local style of dining where you have a grill set in the table and they give you raw vegetables and meat to cook and you cook it yourself on the grill. I would like to set one of these up in the states, but I bet a lawsuit would be right around the corner from some idiot who burned himself.
Here is that same table covered in plates, now that we ordered our stuff.

This was a carrot field just on the other side of the road from where we stayed. I think that picture is cool.

It is at this point I realize that I must make a third chronicle of my adventures in Japan. I have posted another 10 pictures and I still have at least that number left to go. I will try to post later this week - more like next week - but because I am going out of town on Thursday next week seems much more likely.
Thanks for your time, I hope you found my photos as fun as I did. I will hopefully finish off the last in the next post.

Land of the Rising Sun

2009-07-08T07:24:00.000-07:00

Greetings one and all. I know that it has been almost a month since I last posted anything here. That is because I have been on a rather long vacation to Japan. It is hard to describe how cool Japan is unless you have been there. I have never felt more tall in my life and I am only 6 feet tall.
Even though I was only there for about 3 weeks I find that some part of me will miss things about Japan for some time to come; it is a place that makes a large impression.
My wife and I took about a million photos so I will subject you to at least a few of the cool ones (I will also place captions so that they make more sense as to just what you are looking at). Obviously I can not post all of my photos - it is not that they are not all good, there are just too many of them for this forum. If you are really interested in seeing them all I will send emails. The pictures are going to be posted at the end of this blog so that you have some incentive to read to the end, unless you just scroll down, in which case; enjoy!

As far as looking into how medicine is done in Japan I must admit I did little to none of such checking. I spent the whole time as a tourist taking pictures of everything. I did learn some things about how military medicine works, but those points are more procedural and administrative than pharmaceutical. One of the coolest things I learned was about a program that is known as 'Flight Doc' where you are part of the Air Force flight crew, but you get to practice medicine too. That sounded rather awesome to me because I could get to fly in F16 fighter planes and such, but still be a doctor. So, I am looking into that as a short-term long-term goal - can't do that forever you know.

Internship stuff plugs along nicely. Today I am going to work on making some new paper surveys for anti-bacterial medications like Penicillin, Amoxicillin, Erythromycin etc. Those are both interesting and I think that almost no one in western medicine has not used them. I plan on taking these surveys to the people who live in my apartment complex sometime later this week. That should get me some more information, and might help to shape my final analysis. Also today I need to re-read the information that was sent to me regarding the 'Page Manager Program' with www.rateadrug.com so I can ask any and all questions that come to mind. It sounds like an interesting program.
So, look to this space next week - maybe later this week - to find more information about medications as I do the 'Drug of the Week' features and get back into the swing of things.

We flew into Narita airport, which is to the East of Tokyo and stayed in a hotel there the first day. Then over the course of the next week we visited sites all over Tokyo and Kyoto. Japan is full of shrines, neat plants, and really cool architecture. They have a way of blending natural things with synthetic things that is just beautiful.
Anyway, without further ado: the awesome photos of Japan!

(This is a photo of Tokyo as seen from an Army base in the center of Tokyo)

(We just thought it was funny how many Kanji symbols it took to say, 'No Smoking')

(This is the Meiji shrine, a Shinto Shrine in the heart of Tokyo)
(This is a neat Azalea bonsai that was at the Meiji shrine. Ever since seeing all of the cool bonsai I have started growing my own from a Trident Maple)
(This is a samurai or guard house on the imperial grounds in Tokyo. I forgot the Japanese word for samurai house; you try looking up words in Japanese on google!)

(This is part of the imperial gardens. All over the place we saw beautiful gardens. When I got back to Utah I realized I really DO live in a desert)

(This is Harajuku, which is sort of like the teen fashion district of Tokyo)

(This is the kabuki theater where we watched a kabuki play. It is sort of like Japanese opera)

(This is me and my wife standing in front of a Buddhist temple in Tokyo)

(This is a picture of Mt. Fuji that I got from the bullet train going to Kyoto. The Japanese term for the bullet train is Shinkanssen)

(These last 2 are of our hotel in Kyoto. The beds are really short, about 18 inches high and really firm. The bathroom was also super small, just to the right of the sink, that is the toilet and the tub was about 3 feet square)

(Now we are at the imperial palace in Kyoto. This is a building from the 15th or 16th centuries (I forget) said to house one of the three national treasures of Japan that are presented to the emperor when he 'takes office')

(Here is an interesting item: the Jell-O soda. It is like a normal soda, only with pieces of gelatin. You have to shake it up before drinking. Sounds kind of weird, but they are addicting. We decided we like the orange flavor better)

(After many attempts to try and understand this prime example of 'Engrish' we think it means that you are not supposed to have open bottles while exploring Nijo Castle in Kyoto. This was on the machine we bought the Jell-O soda from)

(Also in Kyoto at a place known as Gion corner. That is my wife walking with two Miko - they are sort of like Geisha in training. Not the best shot becuase the Miko girls would not stop for a photograph)

(Lastly here is a picture from our hotel room the last night we were in Tokyo. It is like Blade Runner, the city just goes for miles. It is hard to appreciate in this small frame)

Ok, that is about all of the photos from the middle of Japan. At this point in the trip we drove up north to a place called Misawa, where the US Air Force base is located. I will post more pictures of the trip there and stuff we saw there in my next posting. I am sure you are getting sick of looking at pictures, and this post is getting rather long.
So, until then be good my faithful followers!

A New Beginning

2009-06-06T10:49:00.000-07:00

Hello faithful followers of my internship blog. It seems that I was hasty in my declaration that the end of the internship was nigh. The actual program continues on through mad-August. I have decided to stick around and be a part of www.rateadrug.com until the end in August. There are, of course, questions about how this is going to work because I will be fleeing the country for the next 3 weeks and I have sent emails talking to the people in charge. It seems that interns are still being brought on board; because I have been here since February I think I might have an unfair advantage over the new people, but they assure me that everything will work out. It is not that I think I am some sort of super-star at this stuff, it's just that I will have been doing it twice as long.

Anway, I will try to post something over the weeks that I am gone and to share some observations about how medicine works in Japan (yeah, that is where I am going). Also I will give serious consideration to taking the second half of this internship to talk about medications that are administered for patients undergoing rehab therapy. I have recently learned that a large amount of our patient population is not just related to neurological issues but to rehab issues as well. There are some interesting meds there that would be worth discussing. I might also spend some time talking about medications that are used in the treatment of cancers. At the hospital there is a position open for someone to work with kids who are undergoing treamtent for cancer; and that has got my brain thinking.

In the next post I will explain what I will talk about for the last half and show some cool pictures of my vacation to the orient.
Cheers!
Tristan

The End...?

2009-05-27T12:00:00.000-07:00

I am not certain of the final day for the internship. Needless to say I am now in the last week or so of actual time. My vote is to end fairly soon. I will be traveling out of town in about a week's time - I will be going to Japan of all places - so I won't really be focusing on the internship during that time. If it continues, the 3 weeks that I am gone is going to make for a lot of lost time.
I do still have fliers that I didn't hand out though, I keep thinking that I am going to hit the neighbors up one of these afternoons when I find myself with time to work on this thing.

I honestly don't know what to say this week. I find myself wishing that I had saved some sort of, 'best for last' type of thing. Honestly I was giving all I had during the length of the internship itself, so I don't have much left.
It is not as though there are no more meds to discuss; but most of my focus is now centered on doing the final analysis. All of the information might be interesting, but without a summary statement of some kind...all other effort would be sort of lacking.

This week I am going to skip doing a feature. Until I get an email telling me when the program is going to officially be over this could very well be my last post.
Over the last 4 months I have noticed several things; in previous posts I have made brief mention of some of these things, but I think now would be a good time to list them in greater detail. Also, doing this will help me to write out some ideas for a final analysis.

After all of the research and work I have put into this the most I think I have learned is about people. There is so much of social construct in what we do. Whenever I approached someone about their medications they were quick to inform me that they did not take medications, or drugs, of any kind and they tried to be as natural and healthy as possible. That is what prompted me to make the paper surveys in boring old OTC medications, because then I could talk people into doing surveys. There is not a single person from the western world who has never taken an over-the-counter anti-inflammatory drug; I am sorry, but to say you have never taken Tylenol or Ibuprofen ever is just laughable. We even have a version that is made for kids that they can chew and is supposed to have a bubble gum flavor or something.
The other thing that is funny is this idea that somehow introducing a 'foreign substance' like Tylenol into your body is a bad thing. Yet another thing that seems to have happened to us in the western world is this idea that older cultures somehow knew what they were doing and we are just a bunch of fools putting toxic things into ourselves. Not all natural things are good; if the body were left to it's own devices - as it often was in older times - to sort out a fever or broken bone etc. then the person either didn't live long, or walked with a limp and so on. One of the ancient codes of law known as Hammurabi's Code talks about there being a punishment affixed for botched surgery, and it affixes the payment. There are futher instances of surgical codes, but I have chosen to quote the two that are most relevant to our discussion.

If a surgeon has operated with the bronze lancet on a patrician for a serious injury, and has cured him, or has removed with a bronze lancet a cataract for a patrician, and has cured his eye, he shall take ten shekels of silver.

If a surgeon has operated with the bronze lancet on a patrician for a serious injury, and has caused death, or has removed a cataract for a patrician, with the bronze lancet, and has made him lose his eye, his hands shall be cut off. (http://www.commonlaw.com/Hammurabi.html)

If the age of something makes it better or more 'natural' then why are we currently using surgical stainless steel in place of bronze lancets?

I have also learned that there is no pharmaceutical treatment of the hydrochephalic child. That seems a shame to me. There are treatments for adults, but not children. In one of my earliest blog posts I mentioned a drug called Diamox which is being used for treatments of this kind, and may one day be used for treatments for children as well. More research is needed before any solid answers can be given. I have been thinking about this for a long time now, over the course of this internship all the way back to when I had occasion to speak with a man who is doing research on hydrocephalic rats - who happens to be a good friend of one of our neurosurgeons. This researcher talked about there being possibilities for pharmaceutical interventions, but also told us that the medications have been known to turn the patients' teeth yellow so they would not be considered in pediatric populations (I ask you, what is better? To have to have a shunt and potential revisions and ALL of the complications that go with that, or to have yellow teeth? Seems a no-brainer, in my opinion).

Though, despite all of these concerns and complaints I am better off for having this experience. I find that there are ideas rattling around my brain in relation to what I should write my final analysis on, but when I see the raw data I think I will have things narrowed down considerably.

Until I know the nature of things better, these are my thoughts today, I will hopefully post at least one more time, but who knows?

Continuity

2009-05-23T12:16:00.000-07:00

If you are reading this for the first time, and you got a card in your door, then you have come here for more information. My last post talked about that stuff too, but I figured maybe some people were still checking this place out to know what exactly is going on. If you would be so kind please look at the top banner. I have taken the liberty of explaining the basics of my blog and internship there as well as some basic instructions as to how to fill out surveys and give me credit. If you have further questions please give me an email at tristanbennett@radpprep.com and I will get back to you as soon as I can.
If you are interested in learning more about my personal work then read on good friend! And don't forget to post comments on what you have found.

This is to be the day when I continue all of my old posts. After searching for some time I found that I really only had one that I had not finished completely; my post of Fosphenytoin. I feel as though I did a thorough job of explaining the med - at least as far as the confines of this blog go - but I did not do a good job of explaining possible side effects.
Discussion of side-effects seems somewhat relevant to me right now because I spent most of my day on Thursday keeping an eye on a patient who had come into the ED (Emergency Department) for a 3+ hour long seizure.
I am not certain about this, but would be rather surprised if the patient was not given Fosphenytoin in an attempt to stop the seizure and restore normal function as quickly as possible. I had to sit with this patient as a consequence of being so loaded up with anti-seizure medication that they did not no what they were doing most of the time and needed someone to make sure the didn't hurt themselves.
The chart that I posted in the original Fosphenytoin post that compared seizure length to mortality rate should be a compelling enough reason for my thought-process.

Without further ado, the 'Drug of the Week' feature is (drum-roll please): FOSPHENYTOIN - PART 2!

As I have already discussed the basics of this med and shown the organic molecule, I will skip right to the continuation.
I did not give adequate time to side-effects. In fact, not much time has been spent talking about the secondary effects of the meds that have been featured. However - especially due to my experience this last week at the hospital, and the fact that I MUST finish the 'to be contined...' - I will now give a description of Fosphenytoins side effects.
This link: http://version2-6.blogspot.com/2009/05/well-we-are-nearing-end-of-our-journey.html will put you at the original post so that any questions as to the mechanism and etc. will be answered. I won't re-post it because of length, time and laziness.

Like all medicines Fosphenytoin has both common and uncommon side effects (actually it is quite funny to list off the less-common side effects to someone who is taking that medicine; they kind of freak out now that they know all of the things that 'could go wrong' but most likely will not). Common side-effects of Fosphenytoin are: confusion, dizziness, drowsiness, vomiting, nausea. The less common list is a bit longer, so I am going to block quote it:

Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); abnormal muscle movements; back and forth eye movements; blurred or double vision; chest pain; clumsiness or unsteadiness; fever or sore throat; irregular heartbeat; joint pain; pain, swelling, or tenderness of the lymph nodes; rash; severe burning, itching, or numbness of the skin; severe stomach pain; shaky movements; slurred speech; staggering walk; swollen or tender gums; unusual bruising or bleeding; yellowing of the skin or eyes.
(http://www.drugs.com/sfx/fosphenytoin-side-effects.html)

www.rateadrug.com (this link will send you straight to the survey for Fosphenytoin Sodium if you doubt that www.rateadrug.com has a more extensive list) has a good list of side-effects associated with all meds. They list the common and less-common side-effects of Fosphenytoin as being: abdominal cramping, allergic reaction, anemia, blurred-vision, coordination/ balance problems, depression, concentration/ focus problems and lastly: diziness, drowsiness, fatigue and nausea. The less common side effects are as follows: mood swings, apathy/ indifference, hair growth, sore/ swollen gums, impaired thinking/ judgment, lethargy, osteoporosis/ loss of bone mass, infection, liver failure, skin rash, fever, aplastic anemia, bleeding, blistering, decrease in platlet count, decrease in white blood cell count, sore, thinning/ loss of hair, liver damage, mouth sores and pancreas problems.
If I was on a med and knew all of that stuff could go wrong, I might kind of freak out too.

http://www.drugs.com/sfx/fosphenytoin-side-effects.html has some statistics that help explain what percentage of people experience side-effects; and what percentage of the time that they experience them. I am trying to get some interviews at local neurological clinics so I can get some serious survey work and questions answered about side effects and etc. The information is found on two different tables.

TABLE 2. Treatment-Emergent Adverse Event Incidence Following IV Administration at the Maximum Dose and Rate to Patients With Epilepsy or Neurosurgical Patients
(Events in at Least 2% of Patients Treated with Fosphenytoin Sodium Injection, USP)
BODY SYSTEM Adverse Event	IV Fosphenytoin Sodium Injection, USP N = 90	IV Phenytoin N = 22
BODY AS A WHOLE
Pelvic Pain	4.4	0.0
Asthenia	2.2	0.0
Back Pain	2.2	0.0
Headache	2.2	4.5
CARDIOVASCULAR
Hypotension	7.7	9.1
Vasodilatation	5.6	4.5
Tachycardia	2.2	0.0
DIGESTIVE
Nausea	8.9	13.6
Tongue Disorder	4.4	0.0
Dry Mouth	4.4	4.5
Vomiting	2.2	9.1
NERVOUS
Nystagmus	44.4	59.1
Dizziness	31.1	27.3
Somnolence	20.0	27.3
Ataxia	11.1	18.2
Stupor	7.7	4.5
Incoordination	4.4	4.5
Paresthesia	4.4	0.0
Extrapyramidal Syndrome	4.4	0.0
Tremor	3.3	9.1
Agitation	3.3	0.0
Hypesthesia	2.2	9.1
Dysarthria	2.2	0.0
Vertigo	2.2	0.0
Brain Edema	2.2	4.5
SKIN AND APPENDAGES
Pruritus	48.9	4.5
SPECIAL SENSES
Tinnitus	8.9	9.1
Diplopia	3.3	0.0
Taste Perversion	3.3	0.0
Amblyopia	2.2	9.1
Deafness	2.2	0.0

TABLE 3. Treatment-Emergent Adverse Event Incidence Following Substitution of IM Fosphenytoin Sodium Injection, USP for Oral Dilantin in Patients With Epilepsy
(Events in at Least 2% of Patients Treated with Fosphenytoin Sodium Injection, USP)
BODY SYSTEM Adverse Event	IM Fosphenytoin Sodium Injection, USP N = 179	Oral Dilantin N = 61
BODY AS A WHOLE
Headache	8.9	4.9
Asthenia	3.9	3.3
Accidental Injury	3.4	6.6
DIGESTIVE
Nausea	4.5	0.0
Vomiting	2.8	0.0
HEMATOLOGIC AND LYMPHATIC
Ecchymosis	7.3	4.9
NERVOUS
Nystagmus	15.1	8.2
Tremor	9.5	13.1
Ataxia	8.4	8.2
Incoordination	7.8	4.9
Somnolence	6.7	9.8
Dizziness	5.0	3.3
Paresthesia	3.9	3.3
Reflexes Decreased	2.8	4.9
SKIN AND APPENDAGES
Pruritus	2.8	0.0

As you can no doubt see this table has the side-effect and the body system seperated into different categories. Fosphenytoin - like all drugs - has different effects on different parts of the body. http://www.drugs.com/sfx/fosphenytoin-side-effects.html#system_7389 explains the commonly associated side effects and the relevant body systems in more detail. I was going to write the information as part of this post, but decided it might be a bit redundant with the two tables explaining the information already.

All medicines have side-effects. It is impossible to introduce a foreign body into the human anatomy and not have it cause several different consequences. Generally the medicines that we commonly use or have prescribed to us are those that have been found to be safe. There are of course the extreme examples. The television screen often blares messages about users of medications and the latest class-action lawsuit taking place against the makers thereof (don't even get me started on tort law and the necessary reforms).
Clinical trials and studies have been done and done and redone to find out the long and short term effects on medicines. Those studies are effective, interesting and helpful. However, they are under controlled circumstances that do not always catch all problems. Thus, www.rateadrug.com has come along. Now there is a database where people can check on their meds or see what others have to say about them.
Drug surveys for the drug user is what I always say.

Be sure to tune in next time, as we are nearing the end of our run, as I discuss yet another interesting and compelling medication!
Until then faithful readers!

For more info.

2009-05-18T09:04:00.001-07:00

Hello,
My name is Tristan Bennett and I am a premed student at the University of Utah. If you are checking this out then you should have recieved a flier on your door talking about www.rateadrug.com telling you to do some surveys and check out this blog for more info, but no matter all are welcome!
Surveys range from anything you have ever taken - you can do as many as you like - and from hard prescription stuff to over-the-counter supplements.

If you choose to do a survey please go to www.rateadrug.com, type in the name of the medication you want to survey, click the link that says 'take the survey' and fill it out. If you are not comfortable entering your personal email you can enter tristanbennett@radpprep.com; that is my email and will work just fine.
At the end of the survey - after you have pressed submit for the first time - the survey will ask how you heard about www.rateadrug.com; please enter premedprogram/TB927 in the two drop down menus so I can get credit for having talked to you.

Thanks for your interest! Be sure to read other posts on this blog so you can see more about what we are all about; and post comments about your thoughts and questions!
Tristan

Free squishy brain

2009-05-16T09:53:00.000-07:00

I want to begin this blog with whining a little. I should not do that though as I am doing quite well, at least that is what Cathleen - the person in charge of answering my silly questions and keeping me motivated - keeps telling me. I am just sort of frustrated because one of the doctors I attempted to speak to is not interested in working with www.rateadrug.com. To be honest I don't think the guy even looked at the materials that I dropped off for him, but I guess it doesn't really matter. Above all I wish I could have gotten some feedback so I would know what to do to alter my approach when speaking to other physicians.

Instead of complaining, though, I will choose to focus on happier things. I am nearing the end of the 'Drug of the Week' features. That will be a sad day. It has been cool to learn things on my own about the medications that surround me daily.

There are, of course, cool things that are going on in the hospital. The unit I work with is going to be allowed to use ICP monitors soon - I actually got a free promotional squish brain as part of the training. Discussion of ICP monitors is outside of the scope of this blog, but if you are interested in learing more, click the spot I linked and click on the picture, it gives a basic definition. That will be kind of cool to have those around, before only the PICU (Pediatric Intensive Care Unit) was allowed to take care of those patients. We are getting them now on sort of a trial period.

Anyway, the squishy brain got me thinking about promotional stuff. I see a lot of promotional stuff working in a hospital - duh - but one thing I hear about a lot intrigues me, it is a medication called Keppra.
As far as I know Keppra is another anti-seizure medication.
However, this is the point of this blog! To learn more about medications and drugs that surround us daily! Let's learn together shall we?

Here is Keppra as an organic molecule:

And here is a space filling molecule:

Both images tell us the same thing, but I like the pretty colored one.
Keppra's brand-x name is: Levetiracetam, but I usually know stuff by the brand name, so that is what we are going to call it.

KEPPRA is an antiepileptic drug available as 250 mg (blue), 500 mg (yellow), 750 mg (orange), and 1000 mg (white) tablets and as a clear, colorless, grape-flavored liquid (100 mg/mL) for oral administration.
(http://www.rxlist.com/keppra-drug.htm)

Keppra is used in the treatment of different types of seizures based upon the age of the patient. The types of seizures include: Tonic-clonic, parital onset, and myoclonic. This page has a great deal more information, including charts that relate the side-effects and the dosages. I have tried to get a picture posted here, but I can't seem to find the link. So, here is the link for the webpage for those of you who are interested in learning more.

I like pictures, in case you can't tell, so here are some more pictures!
These pictures are actually rather compelling, they show the efficacy rates of several different AEDs medications or anti-epileptic drugs:
Due to the fact that there is no way to illustrate the effectiveness of one AED medication over another, basically some statistical math was used to show the rate at which one medication would cause a 50% reduction in seizure activity versus a placebo.
(http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=epi&part=ch12)

Keppra works according to this model:
The Keppra molecule can be seen binding to the SV2A synaptic vesicle site (I got this image from a webpage that discussed how an AED medication can be used as a mood stabilizing agent, which shows that Keppra is not just a one-trick pony).
The Keppra molecule is the one that looks like this:

The shortest definition I could find to explain just what the SV2A vesicle protein site is is this defintion:

SV2, an integral membrane protein present on all synaptic vesicles, is a small gene family consisting of three isoforms, designated SV2A, SV2B, and SV2C. SV2A is the most widely distributed isoform, being nearly ubiquitous in the CNS, as well as being present in endocrine cells
(http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=470764)

Further reading from this page demonstrates that the exact mechanism of Keppra is under investigation, but that the protein binding of SV2A is involved and will most likely lead to further understanding of seizures via pre-synaptic response.

I am always amazed when I come across a medication where the exact mechanism is not known. I am also amazed when I come across a medication where they DO know the exact mechanism. Some of the science and study involved in this stuff is so detailed and minute that it is mind-blowing.
Medicinal chemistry would be kind of cool, but there are so many years of finding and fixing nothing for that one second of discovery. Tedious work if you ask me.

That concludes our discussion of Keppra. Be sure to tune in next time as I attempt to explain and make good on all of my 'to be continued...' posts from this internship. You don't wanna miss it!

Shaken not stirred

2009-05-09T12:07:00.000-07:00

Well, we are nearing the end of our journey. I feel as though I have made good progress. I should be somewhere near 180 surveys (I have some paper surveys that I still need to enter from the last week). In the next 3 weeks I hope to not only hit the required 200 surveys, but to surpass it.

This has been a good experience. I feel like I know much more about the medications that I am constantly around, and I feel like I have gained a lot of insight into research in general. I am glad I got to do this thing.

As far as the matter of 'Drug of the Week' features go there has been some straying off the chosen topic. Mostly because of things I have wanted to learn more about that were issues that I was personally dealing with or issues that the world at large was dealing with (see last weeks post about Tamiflu and the Swine Flu Virus). We will, however, be getting back on schedule. Especially because I have had occasion to speak with a large amount of Neurologists in the last week trying to get their support so that I can get some more information about anti-epilepsy medications.

With this in mind I am going to post today on a med that is relative new to me: Fosphenytoin. The brand name of this drug is Cerebyx, but we will just call it Fosphenytoin.
So - drum roll please - let us begin with...! THE ORGANIC MOLECULE!
And, here is the 3D model. The 3D model doesn't really help us understand anything about the drug itself; it just looks cool.
'The colors children! The colors!'

Fosphenytoin was approved by the FDA for use in treating epilepsy on August 5, 1996.
Fosphenytoin is used for treating certain types of seizures ie: status epilepticus (I have often heard this term at the hospital when referring to children who have come out of a seizure but are still a little loopy. Basically after a major seizure the brain needs time to sort itself out. That time varies depending on the length of the seizure, a lot of children just fall asleep after a prolonged seizure due the exertion on their bodies)

According to the Epilepsy Foundation Status Epilepticus referrs to any seizure activity that lasts longer than 30 minutes. Other defintions exist, but that was the most succint I could find. Typically neurologists at work have a standing order to be paged when seizure activity lasts longer than 5 minutes and to administer Atavan (It is easiest to think of Atavan as like mega Valium, it mellows you out in a hurry. I will probably post on Atavan in the next few 'DotW' features).
This graph illustrates the damaging effects of continued Status Epilepticus activity. After viewing this graph it is not hard to see why a drug like Fosphenytoin is administered for 'status-type' seizure activity.

Fosphenytoin is also used to prevent potential seizure activity after brain or nervous system surgery. (http://www.drugs.com/cdi/fosphenytoin.html)
This would likely explain why I seem to hear of it's use fairly frequently because we work with neurosurgeons in addition to neurologists. Fosphenytoin is administered as a subcutaneous injection - read needle.

Seizure activity is usually measured via a procedure known as an EEG or Electro Encephalograph. This device measures electrical activity in the brain. Here is an example of what the read out looks like:
Despite having seen countless patients having this procedure done, I still can't read the thing worth a darn. The EEG techs and neurologists can; all I ever know is if the leads are connected properly.
This image was actually taken from an EEG where a patient had been treated with Fosphenytoin which altered the electrical activity, but did not help the patient clinically.

The next image is one comparing the relative concentrations of Fosphenytoin and the length of time that was required for a seizure to stop. Administration in this case was for a Status Epliepticus type seizure:
Phenytoin is essentially the same thing as Fosphenytoin; they act in the same way.
The primary anticonvulsant mechanism is modulation of sodium channels.
(http://www.medlink.com/medlinkcontent.asp)

Well, I am trying to think of some way to some up my research and interest in this med. Personally I like to see when things are administered for preventative measures. It will be interesting to see the results of the paper surveys that I am giving out to local neurologist offices. I will be in a better position to understand what, if any, problems and complications are associated with this med and I will get it from those who have tried it.

So, I think I will have to say, to be continued....

H1N1 vs. Tamiflu

2009-05-02T09:37:00.000-07:00

Let's talk about some news. I have done my first trial with paper surveys, so far things are going well. I need to clean up some of the language and try to make it a little more clear, and to try and make the font smaller or maybe print both sided. Right now the paper surveys work out to about 5 pages, which is a deterrent for some people I have talked to. It is funny how it is hard to talk people into doing surveys for even simple OTC anti-inflammatory meds. I don't personally take many drugs, but if I need to pound some Ibuprofen - like when I had Strep Throat around Valentines Day (see previous blog post on Ibuprofen) - I don't really have a problem telling people about it. I need to work on how I present the survey maybe; better explanation is always a useful thing.

We are nearing the end of the internship. This has been a lot of hard work, but I am glad that I did it. I have learned a lot of stuff about medications, a lot of stuff about research and a lot of stuff about communication.

Since we are so near the end - and since every blog deserves one REALLY long post - I think that this week I will be featuring a drug that has come to the forefront of a lot of people's minds right now: Tamiflu.
The Swine Flu, or H1N1 has received a lot of press lately. Inevitebly we as people will find something to panic about. This 'new' flu virus has caused a lot of uproar. Recently at work I was talking with the man who is in charge of education on my unit and he asked what I thought of the Swing Flu. Working in healthcare we are poised to be taking care of the children who are diagnosed with Swine Flu, this is especially true of the fact that we give very specialized care at my hospital. I told him that I thought that we might see a few cases - half-a-dozen at best - but that would be the extent of it. I could be wrong, but I doubt it.
According to: http://www.theblogofrecord.com/tag/jama-influenza-flu-death-mortality-studies/ nearly 36,000 Americans die every year from the 'normal' influenza virus and cnn.com reports that 615 people are currently infected with Swine Flu worldwide and out of all the the worldwide infections, 16 persons have died.
While the loss of human-life is not good on any scale, the number of deaths is not consistent with the panic. At least, not in my opinon.

So, what is Swine Flu? The Swine Flu, or H1N1 is a type A flu virus that is usually transmitted to individuals who spend a lot of time around pigs, but it can be transmitted from person to person. The symptoms are usually the same as the 'normal' flu, but in children there have been some reports of dirhea and vomitting associated with the virus. Like any other influenza virus the H1N1 Swine Flu virus any underlying medical conditions are exacerbated by the virus.

The news is, of course, not all bad. It seems that the Swine Flu virus is susceptible to the standard anti-viral medications. One such medication that is important in this fight is Tamiflu.
(http://www.cdc.gov/h1n1flu/eua/pdf/tamiflu-patients.pdf)

There are A LOT of online resources about Tamiflu. I am not going to take the time to look it up, but I bet the number of hits is pretty high right now.

So, let's begin the discussion with an' old favorite; the organic molecule:

I also found an image that details all of the steps required to convert Shikimic Acid - the botanical starting product that is eventually converted to Tamiflu - into Tamiflu. This is obviously a multi-step synthesis. The diagram is probably a bit too complicated for the casual reader - myself included! - but it was too cool to pass up the picture of how the make the stuff.

For best result Tamiflu must be taken within the first 48 hours of symptoms.

Tamiflu acts as a neuraminidase inhibitor meaning, among other things, that it inhibits infected cells from transmitting virions to other parts of the body. Neuraminidase is used to cleave the bond between an infected cell and a virion, when that process is inhibited by introduction of Tamiflu, the infection is slowed or even halted totally allowing the body to fight the infection.
(http://www.fluwikie.com/index.php?n=Consequences.NeuraminidaseInhibitors)

Time will tell if I am wrong, or if I am right. But, if you think of the times when people have been agitated or panicky about some worldwide problem - think of Y2K here - it has proved to be minor and in some cases nonexistent.

Let's get going on our stuff

2009-04-25T16:45:00.000-07:00

Sorry about this being a title that sat with no other info. I didn't know that was going to happen like that.
Well, I have finally done it. After much urging from my wife about how I should make some paper surveys and send them around to people I have finally completed some.
There are two versions, one with just OTC painkillers - by far the most popular survey I have done to date - and one with my personal interest, neuro meds. I have called a local Neurologists office to send out some feelers and see if they are interested in taking a look at the surveys and letting their patients fill them out for me.

Hopefully this will bring good things. I have no doubt that the OTC surveys will bring up some numbers. Especially because I can pass those out in some of my classes and get people to fill them out right there and then collect them at the door. That is my advice of the day, make some paper surveys and pass them out.

Just waiting for approval from my wife and from the directors of the internship. Hopefully I have these bad boys hot off the presses by tomorrow.

Time for me to get some lunch!

Sorry, we don't allow any B.L.T.s

2009-04-22T17:30:00.000-07:00

In addition to seeing traumatic injury and neurological dysfunction we also work with patients that need orthopedic care. One of the most common surgeries that we see, at least post-operatively, is a spinal fusion.
If any one has had contact with this, or any, type of spinal surgery then you know it is a very invasive, complicated and painful surgery. For some reason the orthopedic surgeons usually choose to do spinal fusions on adolescents. This is good for the patient for several reasons, but usually translates into difficult care because of how these patients react to the surgery.
Pain Service - the folks that administer and track the use of pain medicines, usually the hard-core narcotic stuff - used to just place a single epidural, basically a needle is placed in the spinal nerves were pain medication is administered, this often resulted in a lot of pain for both the patient and the care staff.
Recently, however, they have started placing two epidurals and that has resulted in much lower pain levels which eases anxiety and increases the patients ability to recover. http://www.or-live.com/distributors/NLM/rnh.cfm?id=321 - this link is to a real surgery video for a spinal-fusion on an adolescent. It was interesting and informative to watch, but it is not for everyone for obvious reasons.

After thinking about this situation I decided to look into what it is that is being administered to the patient through the epidural line. Often the medication of choice is known as Fentanyl. Often Fentanyl is paired with another analgesic known as Bipuvacaine, but we can only focus on one drug due to my time and length restrictions. With these ideas in mind, this weeks 'DotW' feature is going to be about Fentanyl.
Let us begin, as always, with the organic molecule:

Fentanyl has gotten a lot of press lately due to the fact that several deaths have resulted from overdose in the past little while.

Fentanyl is an analgesic of high potency, approximately 300 times that of morphine...The first CsA (case of abuse) of fentanyl came to the attention of law enforcement in late 1979 but was not identified until 1981. In the next three years a procession of new fentanyl CsA's appeared in the illicit drug market. The abuse of fentanyl CsA's peaked in 1985 and has since decreased dramatically, a phenomena which was the result of DEA successfully terminating the operation of the responsible laboratories. However, the ripple effect is still being felt as international and national meetings have been held to discuss the problems presented by CsA's.
(http://designer-drug.com/synth/index.html)

Fentanyl is used illegally for a feeling of intense happiness that is provided by narcotics such as fentanyl. However this feeling is often followed by some of the negative side effects listed below. Another reason that fentanyl is bad to use illegally is because it is highly addictive. Since it is taken most often using a shot, when used illegally some of the transmitted diseases such as AIDS and hepatitis can be transmitted as well.

Fentanyl falls under the category of narcotic analgesics, this means basically that it is a pain reliever that relieves pain without the patient losing consciousness. Another narcotic analgesics include morphine and oxycontin. Fentanyl is used in two major ways: by taking orally or by using a patch.
(http://web1.caryacademy.org/chemistry/rushin/StudentProjects/CompoundWebSites/2004/fentanyl/Uses.htm)

Shortly after its discovery in 1960, another form of fentanyl was discovered that is widely used today and that is fentanyl citrate. Fentanyl citrate allows for patients to have fast pain relief, up to 80 times that of morphine, by simply sucking on a "lollipop". This lollipop however is supposed to be bitter.
(http://web1.caryacademy.org/chemistry/rushin/StudentProjects/CompoundWebSites/2004/fentanyl/History.htm)

It is also possible to snort or smoke Fentanyl for the desired effect. Fentanyl is a dangerous drug in the wrong hands because it is similar to the drug heroine in its uses and in its addictiveness.

The way in which I see Fentanyl administered is through an epidural line in the patient. It is often combined with another medication known as Bipuvacaine. When it is administered in this way it looks like a thick almost syrupy liquid. The Fentanyl is in small plastic bags - think of a small IV bag - and then placed in a device known as a PCA or Patient Controlled Analgesic. These are the pumps that allow the patient to press a button for a demand dose of pain control.
When only one epidural was placed the number of times the button was pressed was relatively high - there is a lockout function on these pumps so that the patient does not accidentally overdose on the pain med by pressing the button too many times. Now, with the advent of the double epidural I have seen little to no usage of the pain button, pain seems to be under control.

Stiff as a board

2009-04-18T11:46:00.000-07:00

Hello once again. Well, time is winding down now. The scramble for me to get those last 70+ surveys is on. I have definitely learned a thing or two about public opinion based things. Additionally I have learned a thing or two about follow-up. It is not enough to trust that someone is doing what you asked them to do; you must follow-up and make sure that it has been done or is getting done. Also I need to stress the fact that multiple surveys are OK, in fact they are encouraged.
Overall though this has been a good experience, I am glad I did this thing.

So, on to the 'DotW' feature. Last night I sat with an adolescent male who needed constant attention - actually he was pretty stable, I sat and watched TV and studied organic chem for 12 hours - so that he would not yank out his g-tube. A g-tube or gastric tube is a tube that is placed in the stomach from the outside and held in it's location via an inflatable balloon. G-tubes are placed so that a patient who is not eating, or is at high risk for aspiration - putting fluid into your lungs by not swallowing properly - can still get the nutrition they need via a fortified liquid. Early yesterday it seems that he was able to completely yank the thing out on his own, that must HURT! It is also very surprising to me that he was able to pull the thing out because I have been on this watch assignment before, a lot in fact, and have yet to see one come all the way out despite the amount of times it gets yanked on.
Anyway, long story short, this kid was in the hospital this time for placement of a Baclofen pump.

This has got me thinking, and today's feature drug shall be: Baclofen!
Like always we will begin by looking at the organic molecule:

I think this is the first instance of where I have used the generic name first. The brand name of Baclofen is Lioresal. Baclofen is used to treat muscle spasticity and is basically a muscle relaxer. It is generally available as a white pill, but sometimes a pump is placed in the patient and a catheter is inserted into the spinal column, or intrathecal space.
(http://www.drugs.com/baclofen.html)

Personally I have seen both the oral dose and the pump version. The cool thing about the pump version is that because the drug is being delivered at the nerve site it can be administered in terms of micrograms instead of milligrams. The nurse who works in the clinic at my hospital is a friend of mine and she has explained all of this stuff to me. I have also held one of the pumps, they are solid metal - about the size and shape of a hockey puck - with a silicon part in the middle - sort of about where the hole of a donut might be - and one side there is a triangle shaped silicone piece that holds the catheter in place.
Here is a picture of one:
This webpage is full of interesting information about Baclofen pumps. They call them ITBs or intrathecal baclofen therapy.
Here is another picture showing the pump once inserted into a patient:
This particular picture is oriented so that the pump is slightly above the right hip of the patient.

The second image is an animation of how the pump is positioned in the body

There is a bump - once again about the size of a hockey puck - that is visible under the skin of the patient. Clicking on the color picture will show the curious person the actual procedural pictures of a spinal fusion and insertion of a baclofen pump. I think it's pretty cool, but the more squeamish should be spared my medical curiosity.
Baclofen is a very effective medication at treating spasticity or spasms. After severe head trauma or when a person has decreased neurological function is when I have typically seen these inserted. The reason why spasticity is an issue after trauma or with decreased function was explained to me this way; the muscles in the body want to be contracted all of the time; the brain basically blocks out those signals and filters them so they can be controlled for autonomous muscle use. When the brain is impaired it no longer is able to filter out those signals like it once did. Baclofen therapy is also useful for persons who are suffering from MS. My wife's cousin is suffering from complications of MS and is really hoping to get a pump inserted to help with her spasticity and spasm issues.

According to: http://www.southshoreneurologic.com/clinical/itb/itb-results1.html there is a statistical significance in the amount of persons on baclofen and a decrease in their spasticity and spasm levels. On one of the tables they state that 168 patients were included in the study and spasticity was abolished 97% of the time; muscle spasms were abolished 98% of the time; bladder function was restored or improved 78% of the time and overall function was improved 70% of the time.

In addition to it's use as a muscle relaxer it seems that baclofen can be used to block the addictive effects of cocaine usage; at least in female rat populations. This is interesting though because it might have future benefit in therapy as an agent to help individuals who are struggling with addiction. (http://www.drugabuse.gov/NIDA_notes/NNVol17N6/Animal.html)

I am sorry for the brevity of this post. Once again I have bit off a bit more than I can chew with this feature drug. I would love to discuss all of the information I have found and the incredible resources I have by knowing the staff who maintain and install these devices, but time is forever against me. If you are interested in learning more any of the links provided should be more than sufficient.
Personally I think this drug is unbelievably helpful in the lives of people who are dealing with anything from complications of severe head trauma to MS.

The Intractables

2009-04-11T11:23:00.000-07:00

Today I am unsure what to talk about. I have honestly not thought much about my blog this week. In weeks past I have attempted to blog several times during the week, but because I am now in the last few weeks of my semester at school time has been a bit of a luxury.

Surveys seem to be going well. I have posted a large amount of fliers on the second half of my school's campus and there seems to be a good response. The best way I have found to make sure surveys get done is to talk to people directly. If you are there with a computer they are a lot less likely to say they will do surveys and then never quite get around to it. Also I need to talk to my neighbors in my apartment complex. Direct communication there will also be helpful for making sure that surveys are being completed.

Like always a lot of thought has gone into picking the 'DotW' feature for this post. In the last few weeks at work we have had a large amount of kids who are sick with RSV or Bronchiolitis. Now it seems that those numbers are decreasing as the season for those illnesses is passing and we are getting our regular kids again.
Along with getting our regular patient load we have gotten patients who have severe headaches. One of the most common treatments that I have seen for intractable headaches is administration of a medication known as D.H.E. 45

So, this weeks feature shall be: D.H.E. 45, or dihydroergotamine mesylate
The organic molecule is:
Yes, that is a rather complicated molecule; lots of sights of possible action. For example the empirical formula, the most simple way of writing this thing down, is: C33H37N5O5·CH4O3S.

Needless to say the mechanism is a little complex. I would need about two years more neurological biology to fully understand it myself. There are two proposed ways in which this medication molecule functions to calm down headaches, or migraines - I know that migraines are different from normal headaches because I have suffered from them, but for the purposes of this blog we will just say they are the same as intractable headaches. The first is by neurological vaso-constriction - making the blood vessels in your brain smaller - and the second is by inhibiting the release of an inflammatory substance known as neuropeptide. D.H.E. 45 is administered through IV or through subcutaneous injections. There have been some heart complications and there have been no studies to determine what, if any, other long term effects this medication has on the body. For additional, and more complicated, explanations of this drug visit: http://www.drugs.com/pro/d-h-e-45.html

Personally, due to my experience with migraine headaches, I believe that this medication acts as a vaso-constrictor. Not for any medical reason, but because when I have taken drugs that act on that end of fixing the problem I have gotten better. Typically when I have seen D.H.E. 45 administered the child is in the hospital for about a week and they are kept in a dark quiet room over the length of their stay. Sometimes this is very successful, and sometimes it is not successful at all. Seems to be rather hit and miss in my opinion.

Do I look bloated to you?

2009-04-04T09:54:00.000-07:00

Hello. This past week has been an interesting one. I have not really done any homework since I got back from Spring Break. The laziness has been nice, but it has certainly increased my stress level.

This week I would like to make a departure once more. This past Tuesday I attended a funeral for my wife's grandfather. He died of natural causes after a long fight with heart failure. This forum is not appropriate to discuss the nature of my beliefs about the soul of man, but I do not believe that he is gone forever. When I too die I will no doubt be reunited with those who have preceded me to the next stage of existence. That is all I have to say about that.

Due to this experience I have chosen to focus on a medication that is often administered for the person who is enduring the complication of heart failure. This is especially relevant as I did a survey for this medication just yesterday as I spoke with a co-worker.
This weeks 'DotW' feature will be: Lasix, or Furosemide.
Here is a molecule of Lasix, also known as Furosemide. Using my limited understanding of chemistry, even though that is going to be my minor, I can see several sites where a possible reaction could occur. This molecule looks rather reactive.

Lasix is a form of Diruetic. Basically what this means is that it causes your body to loose fluid.
According to www.rateadrug.com:

Furosemide
Furosemide (INN) or frusemide (former BAN) is a loop diuretic used in the treatment of congestive heart failure and edema. It is most commonly marketed by Sanofi-Aventis under the brand name Lasix. It has also been used to prevent thoroughbred race horses from bleeding through the nose during races.Along with some other diuretics, furosemide is also included on the World Anti-Doping Agency's banned drug list due to its alleged use as a masking agent for other drugs.

That is a rather succinct summation of what Lasix is. Now, however, we must look at what a loop diuretic is.
This a graphic that explains the mechanism of absorption and action through which Lasix acts.

As you look through the mechanism you can see that Furosemide is labeled in the fifth group of actions going from left to right. There are a lot of ways that your body can have a diruetic agent act upon it.
Each type of medication works in a different part of the Nephron. The Nephron is the functional structure and basic unit of the Kydney (http://en.wikipedia.org/wiki/Nephron). The above picture is a simplified version of a Nephron.

Each class of diuretics has a distinct site of action in the nephron...Furosemide (Lasix), bumetanide (Bumex), ethacrynic acid (Edecrine) and torsemide (Demadex) work in the loop of Henle. (http://www.cmellc.com/geriatrictimes/g010327.html)

With the help of www.drugs.com we learn that a loop diruetic is essentially a 'water pill' that does not allow your body to absorb salt and instead passes that salt through your urine.

Diuretics are actually compounds that increase the urinary salt excretion, and water just happens to come along...Chemically, diuretics are organic anionic compounds.
-Christian W. Mende M.D. (http://www.cmellc.com/geriatrictimes/g010327.html)

Like most medications there are a number of cases in which it may be prescribed. I have chosen to discuss Lasix as they are used in the treatment of the heart failure patient, but the list of possible doses is, but is not limited to: congestive heart failure, kydney disorder, hypertension and liver disease (http://www.drugs.com/lasix.html). Additionally there are cases in which a medication such as Lasix is used to treat the symptoms of a different drug therapy. No specific instances come to mind, but a chain of drugs meant to relieve the symptoms of a first medication is not at all uncommon.

Now we have reached the end of our discussion on Lasix. Thank you for coming. As I ponder on the current status of medicine and pharmacology I find myself thinking that we have come a long way. The fact that my wife's grandfather was able to live as long as he did after he had his first surgery was nothing short of miraculous. That is due to prayers on his behalf and due to the advances in modern medicine that we all take for granted.
There is much more work to be done though.
I wish the best of luck to those who are working even now to improve the absorption pathways and better understand the human anatomy.

It hurts when I do this...'

2009-03-26T08:51:00.000-07:00

Hello. I know it has not even been 24 hours since I last posted, but I had a Spanish class unexpectedly cancel on me today, so I thought I should take advantage of the time.

It seems that things are going along ok. I am currently tied for 3rd place amongst the interns. I need to get some surveys going so that I can get above the rest. But, that is ok, because this weekend, as long as they don't call me into the hospital, I can get some more surveys. FINALLY the laptop battery I bought online showed up and is working just fine, so I can harrass people at work and be up another 100+ surveys in a few hours worth of effort.
That is the plan anyway. The hospital has been really busy the last few weeks, so I am hoping that Saturday it will be slow enough that I can get some of this stuff done.

Anyway, it is now time to unveil this weeks 'DotW' feature.
This week I have decided to focus on another neurological medication.

I am going to write about Tegretol today. This is another medication that I have had personal interaction with. In previous posts I have mentioned that I worked in a group home with the developmentally disabled and have personally administered some anti-convulsants and other medications. Tegretol was one of those medications that I would personally assist with.

However, I am not going to talk about it as a medication for seizures I am going to focus on it as a medication that is used for chronic nerve pain.
The Tegretol molecule looks like this
(Actually when I was looking up the information for this molecule I ran across a picture of someone who had tatooed a Seratonin molecule on their hip. Not relevant to this blog, but interesting nonetheless. It was a well done tatoo):

Tegretol is also known as Carbamazepine, in fact, like most of the drugs I have reviewed I knew them by their brand names and not their generic name. Tegretol works by blocking the sodium gateways in nerve channels. It halts or slows the rapid firing of neuron transmission. Basically it stops the nerves from being able to send signals. This makes Tegretol useful for both seizure activity and for neuropathic, or simply - nerve - pain.
(http://www.neuroskills.com/tbi/ac.shtml)

Personally I have only seen this medication prescribed for seizure activity. When I have dealt with neruopathic pain in a healthcare situation I have seen Neurontin prescribed. I spoke about Neurontin in a previous blog post, and I feel that that medication works fairly well.
In fact, I would say that there are 3 major medications that come to mind when dealing with both nerve pain and seizure activity. Those medications are, in no particular order: Topamax, Tegretol and Neurontin.
I have seen these medications in both of my past jobs in which I have worked with seizure disorders and neuropathic pain, and I think they work fairly well.

We just need to wait until those whom I have contacted about doing surveys for their neurological medications find time to fill out some surveys and we can see what they think!

Thinking a loud.

2009-03-25T21:12:00.000-07:00

Unfortunately due to time constraints I won't be able to do a full post tonight, but I hope to be able to just talk briefly about some cool things that are going on.

I recently spoke with Cathleen Marshall who is one of the people in charge of the internship. She told me a really good idea, which was to find and speak with people who are in online groups and communities that deal with the medications that I am looking into. I did this today and I am happy to report that there seems to already be some progress.
I was worried about doing this because the last thing that I wanted to do was come off as a 'slimy' guy who was trying to capitalize on someone's illness. Like those awful lawyers who do commercials on tv telling people how much money they can get by taking people to court over traffic accidents - disgusting. But, it seems that people thus far have felt that my attempts were genuine. Cathleen also sent me the code lines so that I can link directly to surveys that have been completed. That will be a cool resource too.

I sincerely hope that those who look at www.rateadrug.com can get some answers and maybe give some as well. Especially in regards to those who suffer from chronic nerve pain. That can be so frustrating. I have taken care of kids who have this condition and just to touch their skin can be really painful for them. There is a surprising lack of knowledge on RAD concerning neurological medications. That is something I aim to correct.

In medicine there is often a lack of communication. Teams do not communicate with each other, doctors do no communicate with patients and patients do not communicate with doctors. There are of course the usual questions and relay of basic information, but there needs to be something more. Finding the right diagnosis is not just a matter of getting the right answer it is often a matter of asking the right questions.

Anyway, thank you for coming and reading my thoughts aloud. Later this week I shall post my 'Drug of the Week' feature.
Stay tuned!
Same blogger address, same blogger channel.

Vide Alternam Partem.

2009-03-19T07:14:00.000-07:00

Before I begin I have one more personal note, yesterday while at work I overhead one of the nursing staff talking about using an oral dose of Vancomycin. If any of you have been following my earlier posts I spoke about how oral doses of Vancomycin are used only to treat GI issues. Come to find out that this patient was at high risk for an overgrowth of bacteria known as C dificile and the Vanco was being used to pre-treat the issue. But, thanks to my research and blog I knew the context and the generally prescribed way in which Vanco is used. Go me.

The last time I 'blogged' I spoke about a drug being used called Racemic-Epi. That is going to be the subject of today's DotW feature.

Ok, first off I need to define a bunch of terms. I am currently enrolled in an Organic Chemistry course, and I am really enjoying it. The terms that I am going to use are from Organic Chemistry, as Epi or Epinephrine is an organic molecule.

Epinephrine looks like this:
It is more commonly known as Adrenaline. It is commonly known as Epinephrine because it is produced by the adrenal glands which are above - epi - the kidneys and in Greek nephro means kidney. So, epinephrine means above the kidney.

Technically speaking, epinephrine is a sympathomimetic catecholamine. It causes quickening of the heart beat, strengthens the force of the heart's contraction, opens up the airways (bronchioles) in the lungs and has numerous other effects. The secretion of epinephrine by the adrenal is part of the fight-or-flight reaction. Adrenaline is a synonym of epinephrine and is the official name in the British Pharmacopoeia.
(http://www.medterms.com/script/main/art.asp?articlekey=3286)

We now have a basic understanding of Epinephrine, or, Adrenaline.
So, what makes it so special if it is called racemic?

We have to do a few definitions before we can define it completely. A racemic mixture is a 50/50 mixture of what are known as R and S enantiomers. An enantiomer is a mirror image of a molecule; when you have enantiomers they can not be placed directly on top of each other. To understand enantiomers think about your right and left hands. They look like mirror image of each other, but they can't be placed directly on top of each other with out rearranging things.
To say that an enantiomer is R or S means that it has bonds around a carbon that rotate in either a clockwise - R - direction or counter-clockwise - S - direction.
In other words, a racemic mixture is a mixture that has carbons with bonds that are counted in a clockwise direction and bonds that are counted in a counter-clockwise direction.
This is important because the way in which bonding occurs on a carbon atom can really affect the way in which the molecule is able to act.

Racemic-epinephrine is commonly used in an aerosol form to treat airway problems. There is, however no standard for treating a respiratory ailment with racemic-epi.
Several studies¹ have shown that nebulized racemic epinephrine, which stimulates both α-adrenergic and β-adrenergic receptors, is as effective or superior to albuterol in relieving airway obstruction in patients with viral bronchiolitis. Some studies²³ have shown no significant difference in the effectiveness of nebulized therapy with epinephrine and albuterol in a hospital setting. But short-term benefits in respiratory rate, oxygen saturation, and clinical score have been observed with the use of epinephrine. A single outpatient, placebo-controlled trial⁴ noted a statistically insignificant but potentially clinically meaningful 12% decrease in the hospitalization rate in the epinephrine group. One study⁵ in an ED showed that patients treated with epinephrine were discharged significantly earlier than patients who had been treated with albuterol.
(http://www.chestjournal.org/content/129/4/1114.2.full)

It is significant to note that it is commonly not the practice for medicinal chemists to use a racemic mixture of any drug. The idea is to isolate either the R or the S enantiomer and study those effects individually before you throw them together. Putting R and S together without a solid knowledge of what each will do is kind of like a box of chocolates. You don't know what you are going to get.
In this case, however, it seems that the benefits are high and the general outcomes positive.
I will continue to explain more stuff about organic chemistry as I myself learn more.

The Yellow Jersey

2009-03-14T11:18:00.000-07:00

Before I begin, I need to talk about some cool new things.

#1 I have picked up my efforts for surveys. Hopefully I will be hitting that 200+ mark in no time. I am also waiting on a new battery for my wife's laptop so that I can walk around and bug people that way. I think the person-to-person contact will prove to be much more successful.
#2 One of the people who helps and supports the interns - Cathleen Marshall - has shown me a way to put a graphic of www.rateadrug.com on the top of my page. That is kind of cool, if you look to the left of this sentence you will see it there, it looks kind of like a pill, but it says rateadrug on it. That is a neat feature and I like being able to customize the thing.
#3 I learned - in my last post - how to enter text boxes so that I can make the text that I quote look a little better and be a little more compelling.
#4 At work the other night one of the nurses that I work with told me that a patient had received a drug known as Racemic-Epi. I know what that means! I understood what the name of the medication was and what it would do! That is thanks to this blog and internship, and thanks also to my Organic Chemistry course at school. I like learning, it's cool.
I think that Racemic-Epi will probably be the next DotW (Drug of the Week) feature, I will explain what that name means, and why I thought that was neat.
Hopefully by the end of this internship I will have learned even more stuff!

I have been pondering over the 'Drug of the Week' feature for this week, and I must admit I was somewhat stumped. Generally I focus on Neurological medications and functions/abnormalities as this is what I usually see; but, recently my unit at the hospital got a girl who was in renal (kidney) failure and was on Dialysis for it. I have known people who were on Dialysis for kidney failure, but I had never before seen the machine or seen the procedure. That got me thinking, I wonder if there are any medications that are actively prescribed for people who are undergoing dialysis or if there are any renal medications for that condition? This was the first time I had ever thought about this, and I needed to do some research about what, if any, medications someone on Dialysis might be required to take.
Not knowing much about Dialysis, I decided to do some research about that first, there are several different kinds of Dialysis and several causes for renal failure. After searching for some time though I came across a medication known as: Erythropoietin.

Erythropoeitin does not directly treat the kidney failure, instead it is used to treat symptoms of being in kidney failure and being on Dialysis. One of the big concerns about having this condition is the complications that go with it, and Anemia (loss of red blood cells) is one of those complications.

If you're undergoing hemodialysis for kidney disease or chemotherapy for cancer, you may be familiar with erythropoietin drugs that treat anemia — low red blood cell count. These medications are called erythropoiesis-stimulating agents, or ESAs. ESAs are genetically engineered forms of the human protein erythropoietin (uh-rith-ro-POI-uh-tin), which is important in the production of red blood cells.
...Erythropoietin is a hormone produced by your kidneys that stimulates bone marrow to make healthy red blood cells, which carry oxygen. The hematocrit level in your blood is a measure of the level of healthy oxygen-carrying red blood cells in your body. Anemia occurs when your hematocrit falls below the normal range. Usually, that's prevented by the kidneys making extra erythropoietin and prompting your bone marrow to produce more red blood cells.

One consequence of kidney disease is decreased production of erythropoietin. Chemotherapy also can cause decreased erythropoietin production and may decrease erythropoietin's effectiveness. In both of these instances, giving erythropoietin can increase red blood cell production, eliminating the need for blood transfusions and improving your well-being.
(http://www.mayoclinic.com/health/erythropoietin/DA00137)

I have often wanted to put a graphic that shows the concerted mechanism for the medication that I was discussing, but could not find one, or find one that anyone would let me use for free, but I found one for Erythropoietin:
Obviously a simplified mechanism, but cool nonetheless for understanding how this thing works in your body.
This is the organic molecule:

I must admit, knowledge of this thing is way outside of my understanding, but it is cool looking!
The use of Erythropoietin has come under fire since the 1980's when it was used as a simple and effective form of blood-doping among athletes. It was not until the Australian Olympic games of 2000 that a test was developed to combat this problem. EPO is used as a doping agent because it produces more Red Blood Cells (RBCs) which allows the blood to carry more oxygen and give an athlete an edge over their competition. It is especially rampant in professional cycling, the riders are tested for EPO regularly, but its use is still a problem.
(http://www.pbs.org/wnet/secrets/doping-for-gold/the-dangers-of-doping)

That is also another interesting area of discussion for medications, that of abuse. For any number of legitimate uses for a medication there are the same number of abuses. Perhaps another feature, before I finish my internship will be to discuss some of the common abuses of medications. I find there is so much that I want to learn about that there is not enough time to get it done in.

But, that about wraps up our discussion on EPO. Thank you for coming.

Doctor! I got the shakes so bad!

2009-03-06T16:06:00.001-08:00

So, here we are again. I am certain that everyone who follows my internship blog with rapt attention is interested in learning what the new drug feature will be. I, myself, am also interested to learn what it will be.

On with the grand unveiling:
This week the featured drug belongs to a group of medicines known as anticonvulsants. Anticonvulsants are defined as, 'medications that are used to prevent seizures or stop a series of on-going seizures'. (http://www.medterms.com/script/main/art.asp?articlekey=20523)
This is in honor of a patient that I took care of not too long ago and I got to see again today. He is a cute little guy and he and I hit it off, but unfortunately we did not meet under good circumstances. This guy has a pretty severe seizure disorder and anticonvulsant medications are used to treat his seizures.
The anticonvulsant of choice shall be: Neurontin, or Gabapentin (we will just call it Neurontin for simplicity sake).

I also have another motive in discussing this medication as I have personal experience with it. In an old job of mine I worked with the developmentally disabled and one of my clients was on this particular medication. The rules in Utah are funny: if I were giving medication to an intellectually capable person it would have been far outside of my scope of practice, but as my clients were not fully capable of understanding what was going on, it was suddenly appropriate for me to give them the medicine, and they took it. The days when this client either neglected or was not able to take his medication he had a great deal more seizures, so at least in his case, it proved effective.

The Neurontin molecule looks like this:

This molecule is considerably less complex than some we have looked at before. I wanted to find a space-filling molecule, but information on this drug is surprisingly lean. I was able to find, though a series of graphs from a clinical trial of Neurontin on nerve pain,

'The proportion of responders (those patients reporting at least 50% improvement in endpoint pain score compared with baseline) was calculated for each study' (http://www.healthyplace.com/other-info/psychiatric-medications/gabapentin-neurontin-full-prescribing-information/menu-id-122/

I was also able to find this 'chart' which shows the side-effects of Neurontin as compared to a Placebo. Some points of clarification as to the chart:

'The most commonly observed adverse events associated with the use of Neurontin in adults, not seen at an equivalent frequency among placebo-treated patients, were dizziness, somnolence, and peripheral edema.

In the 2 controlled studies in postherpetic neuralgia, 16% of the 336 patients who received Neurontin and 9% of the 227 patients who received placebo discontinued treatment because of an adverse event. The adverse events that most frequently led to withdrawal in Neurontin-treated patients were dizziness, somnolence, and nausea.

Table 2 lists treatment-emergent signs and symptoms that occurred in at least 1% of Neurontin-treated patients with postherpetic neuralgia participating in placebo-controlled trials and that were numerically more frequent in the Neurontin group than in the placebo group. Adverse events were usually mild to moderate in intensity.'

'Body System/	Neurontin	Placebo
Preferred Term	N=336 %	N=227 %
* 'Reported as blurred vision'
Body as a Whole
Asthenia	5.7	4.8
Infection	5.1	3.5
Headache	3.3	3.1
Accidental injury	3.3	1.3
Abdominal pain	2.7	2.6
Digestive System
Diarrhea	5.7	3.1
Dry mouth	4.8	1.3
Constipation	3.9	1.8
Nausea	3.9	3.1
Vomiting	3.3	1.8
Flatulence	2.1	1.8
Metabolic and Nutritional Disorders
Peripheral edema	8.3	2.2
Weight gain	1.8	0.0
Hyperglycemia	1.2	0.4
Nervous System
Dizziness	28.0	7.5
Somnolence	21.4	5.3
Ataxia	3.3	0.0
Thinking abnormal	2.7	0.0
Abnormal gait	1.5	0.0
Incoordination	1.5	0.0
Amnesia	1.2	0.9
Hypesthesia	1.2	0.9
Respiratory System
Pharyngitis	1.2	0.4
Skin and Appendages
Rash	1.2	0.9
Special Senses
Amblyopia*	2.7	0.9
Conjunctivitis	1.2	0.0
Diplopia	1.2	0.0
Otitis media	1.2	0.0'

(http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?id=3943&type=display)
This webpage, if I am not mistaken, is where government drug trials are reported. This was a great resource in terms of finding other information about this drug. There were even data tables discussing the differences between adult reported side-effects and pediatric side-effects. But, my space is short, so I picked only one of the graphs. A further look at this drug and the information found on that page is definitely worth it.

Neurontin has wide ranging uses. Sometimes it is administered as an anti-migraine medicine, sometimes for control of neuropathic pain, seizure control or it has even been used as a therapy for pain control after a case of the shingles has developed (http://www.neurontingabapentin.com/information.shtml).
(I would love to be able to use the opinions found on www.rateadrug.com for other insight into this medication, but there have been no surveys completed about Neurontin specifically. This is something I will have to work on with my co-workers. The more information the better!)

According to information from Pfizer, the maker of Neurontin,
'The mechanism by which gabapentin exerts its anticonvulsant action is unknown...' And, 'The mechanism by which gabapentin exerts its analgesic action is unknown...' It is, however, suspected that Neuronton acts in the way that it does by mimicking a certain transmitter known as GABA (gamma-aminobutyric acid), but it is not converted into it, nor does it react in quite the same way.

'In vitro studies with radiolabeled gabapentin [Neurontin] have revealed a gabapentin binding site in areas of rat brain including neocortex and hippocampus. A high-affinity binding protein in animal brain tissue has been identified as an auxiliary subunit of voltage-activated calcium channels. However, functional correlates of gabapentin binding, if any, remain to be elucidated.'
(http://www.pfizer.com/files/products/uspi_neurontin.pdf)

So, after searching the internet for some time I have found that Pfizer, the maker of Neurontin, openly admits that they do not fully understand how this drug functions. On the outset that seems to be a little disconcerting, but from personal experience I can assure you this drug does work. I have seen it administered for seizure activity and for neuropathic pain and it has been effective in both cases.

Regulate

2009-03-05T20:42:00.000-08:00

I am coming to learn that it is difficult to get large groups of people to do things.

200 surveys does not seem to be a large number. In fact, if approached individually, 200 people is not that many people. The problem is one of how to reach the most people in the shortest amount of time.

My latest endeavor was to place fliers on people's cars telling them about www.rateadrug.com and all of the cool things that it has to offer the public. I know that these fliers are annoying to receive. I personally do not much like that this method has been used before, but it is a great way to reach people. I could contact 200 cars in less than 30 minutes and if only 25% of the people did surveys that would add another 50 surveys to my total. If nothing else the numbers are encouraging.

I have learned, however, that most places discourage this type of thing. After trying to go through the right channels so that I can contact people in this way it has come to my attention that most places don't like you doing that. In fact the university I attend will actually prosecute someone if they are caught doing this.

So, that plan was scrapped, but life goes on. I will also be contacting people in a more personal way by talking to the members of my science classes; I am not sure if I will extend this to my other non-science courses or not. I will also make some more fliers, those seem to have gotten a pretty good response. I should look for other areas of the community in which I can place those fliers though...
And I have finally gotten approval to be able to speak with my co-workers which I am very excited about.

So, the work continues despite minor set backs and I should be able to hit the 200 mark, if not a few more, by the time that May is winding down.

The Vanco Avenger

2009-02-28T11:00:00.000-08:00

Well, here we are. Another week has come and gone. Midterms have just begun/ended and the semester is now in full swing.
I have also upped my efforts at trying to get surveys done. For anyone reading this and wondering how best to reach a large amount of people in a short amount of time I suggest fliers. I have put up fliers all over the campus at school and that seems to be helping. I am also going to be putting things on cars, and doing a fairly aggressive mailing campaign to doctors and other health professionals. I also am planning on speaking with the nursing staff, pharmacists and doctors with whom I work. I am hoping all of that pays off. I want to be the top intern.

And I went running for the first time in about 3 months today. I enjoyed it, but man if you don't keep your endurance up, it goes downhill fast. I used to be able to skip-rope for about 15 minutes and run 2 miles in the same morning and it didn't really faze me, but now, not so much.

OK, now to the subject I am sure we have all been waiting for, the 'Drug of the Week'.
This week's drug shall be :
Vancomycin Hydrochloride.

Vancomycin, or Vanco as it is commonly called, is the heavy hitter when it comes to preventing infection. Often, Vanco is administered post-operatively as a pre-medication against infection. Vanco does not absorb well through the digestive tract. In fact pill form Vanco is used to treat infections of the intestinal system. For Vanco to be effective at preventing infection it must be administered through IV or placed directly on the operation site.
This drug has one large molecule:
Once again the finer points of this molecule are outside the scope of this blog, but that is one complicated molecule. Recently in an Organic Chemistry course I was supposed to label and recognize certain aspects of this molecule, needless to say, it took awhile.
Vanco is also one of the only drugs on the market right now that is capable of attacking MRSA or Methicillin Resistant Staphylococcus Aureus.
Normal antibiotics attack bacterium by inhibiting growth of the cell wall. MRSA is a so called 'super-bug' because it has developed a way in which it can go around the cell wall inhibiting agent of a antibiotic drugs.
In times past western medicine has been too quick to administer any form of antibiotic agent and that, combined with patients who have not taken the full dose of their medications, has caused/allowed bacterium to develop methods for combating the way that common antibiotic agents work; or have worked in the past.

This shows an animation of how Vanco is able to inhibit cell wall growth even in MRSA infections:
http://student.ccbcmd.edu/courses/bio141/lecguide/unit2/control/vanres.html
Unfortunately I was unable to get the animation to post, so the link will have to suffice. The animation shows, basically, the way in which Vanco molecules bind to sites on the cell wall and keep the bacterium cell from forming which causes cell lysis or simply put; it splits the cell.

There are, however, complications to using this medication. According to:
http://findarticles.com/p/articles/mi_m3230/is_1_37/ai_n9770627

'Because vancomycin-resistant staphylococci are very rare, vancomycin has long been considered the gold standard for treating MRSA infections. Unfortunately, despite its in vitro activity, when vancomycin is used as single-drug therapy to treat MRSA infections, cure rates in serious infections have been very disappointing....44% failures in treating bacteremia...40% failures in treating lower respiratory-tract infections.
In treating nonserious MRSA infections, such as wounds, skin, and urinary-tract infections (UTIs), in addition to slow cure rates and failures, vancomycin is practically and economically burdensome. Because there is no oral form, a patient for whom vancomycin is prescribed must wear an infusaport [an intravenous system placed into the chest, often used for chemotherapy treatment, a.k.a. a Broviac] around the clock. Additionally, he must visit daily an infusion center or have home infusion service. To avoid toxicity, blood levels must be monitored. Vancomycin drug acquisition, administration, and laboratory costs are approximately $100 per day.'

There is current research attempting to find better alternatives to Vanco and to create new medicines to combat resistant bacteria. This is one of the major focuses of medicinal chemists today.

IBUPROFEN TO THE RESCUE!

2009-02-19T17:46:00.000-08:00

Strep throat update day 7. So, I am now feeling much better. When I wrote the last blog I was shivering due to fever complications, but now I feel pretty good. After a brief and fairly convenient trip to the doctor we came home with Amoxicillin and some throat spray. That combined with the Ibuprofen I was taking in mass quantities got me through the next few days.

So, as previously mentioned, I have decided to discuss a medication that I used a great deal while sick. After thinking on this for awhile I have decided to focus on Ibuprofen. I used it a lot to keep my fever down and keep me functioning and I have also seen it used post-operatively for pain control.

Here is an organic model of an Ibuprofen molecule:
Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). Because of it's non-steroidal effects it does not upset the hormonal balance of the body. Ibuprofen works by inhibiting an enzyme called cyclooxygenase, which in turn inhibits the transformation of fatty acids into products known as prostaglandins. This is what allows the drug to act as an analgesic and anti-inflammatory agent.
Ibuprofen is comparable to aspirin and is usually taken to relieve mild to moderate pain and has even been shown to be effective in slowing the pulmonary decline of those who suffer from Cystic Fibrosis.
(http://www.3dchem.com/molecules.asp?ID=14)

Ibuprofen is an over-the-counter medication and, unlike my previous 'Drug of the Week' feature widely known and used for both adult and pediatric patients.
Despite it's common use though, it is interesting to look at just what it is, and how it works. Even the common stuff has some pretty cool mechanism and history.
Ibuprofen definitely came to my rescue this past weekend.

Thanks Ibuprofen. Thibuprofen

Can you spare an antibiotic?

2009-02-15T11:49:00.000-08:00

The life of a student is not an easy one. Especially if you are working and trying to fulfill Pre-Med classes with a good enough score to actually be considered.

Things get considerably worse when you are sick. It seems that I get ill about this same time every year. I can count at least 3 years in a row when I was sick in the beginning/middle of February. When I lived in Ireland both of my ears got really plugged up with wax for some reason. I have always been able to fight the infection off before, this is pretty much the only time of year when I get sick. After working in a childrens hospital for nearly 2 years I can count the sick days I have taken with one finger.

But, according to www.webmd.com I have strep throat. This one I know I can kick myself, but that will sure not be fun. I am looking forward to later today when I can get to a doctors office and they can give me some of that sweet antibiotic therapy.

It is times like this when I see the true value of medications. This illness will also give me an opportunity to fill out some surveys myself about drugs that I have taken - or will be taking.
I am also grateful for programs like the PPREP program which spread the word about medications and for things like webmd.com.
I had always steered away from those institutions because of the dangers of self-diagnosis, but they can be valuable tools to help the medical professional narrow down your condition.

It is often not just about asking the right questions, but giving the right answers too.

Perhaps my next drug feature will take a change of course and I will discuss antibiotics - they seem to have a bit more timeliness to me right now.

Um...Sir...? Are you aware you are leaking CSF at an alarming rate?

2009-02-12T13:44:00.001-08:00

Well, here we are again. Has it really been a week? In some ways it feels much shorter, but in many other ways it feels A LOT LONGER.

This is the first installment in the 'Drug of the Week' feature. And we will begin by tackling a big one, Diamox or acetazolamide. Here is a skeletal structure of the organic molecule:And here is a space filling model:
Diamox is used mostly to treat edemas, seizure disorders, glaucoma or altitude sickness.
As I work primarily with Hydrocephalic children, this drug is of particular interest to me because of its effectiveness in pharmaceutically treating Hydrocephalus.
'...medical treatment with a medication which decreases the production of the cerebrospinal fluid may be tried to improve some of the symptoms of hydrocephalus.'
(http://www.nervous-system-diseases.com/obstructive-hydrocephalus.html)

'Hydrocephalus is an excess accumulation of cerebrospinal fluid in or around the brain that can be produced by a broad spectrum of disorders. It can develop at any age and its incidence is increasing, both in infants and adults. Although the standard treatment of hydrocephalus is cerebrospinal fluid shunting, there are certain circumstances in which medical treatment, alone or in combination with shunting, has been suggested as an alternative. Carbonic anhydrase inhibitors, loop diuretic agents, osmotic agents and fibrinolytic therapy are discussed. The most suitable drug seems to be acetazolamide [Diamox], alone or in combination...'
(http://www.ncbi.nlm.nih.gov/sites/entrez)

Diamox works as as an inhibitor of the enzyme carbonic anhydrase. Essentially, it acts as a diuretic and causes the body to lose water. This loss of water also affects the production of cerbrospinal fluid causing a decrease and therefore a decrease in intercranial pressure.

'Diamox blocks an enzyme in the kidney and makes the blood acidic which is interpreted by the brain as a signal to breathe more. Diamox therefore, enhances the physiological response to altitude by increasing the rate and depth of breathing and it ... acts as a mild diuretic...'
(http://www.lycos.com/info/diamox--drugs.html)

It appears at this time, however that, 'The safety and effectiveness of acetazolamide [Diamox] in pediatric patients has not been established.'
(http://www.rxlist.com/acetazolamide-drug.htm)

There are, however, studies which show the effectiveness of this drug for children, some dating all the way back to 1958 and some - such as the abstract quoted just above this line - as recent as 2005.

Quoting from PEDIATRICS Vol. 22 No. 5 November 1958, pp. 875: 'Observations in a Case of Hydrocephalus Treated with Diamox®

The effect of Diamox® on the formation of cerebrospinalfluid was studied in a patient with noncommunicating internalhydrocephalus over a period of 1 year. During the administrationof Diamox® the frequency of ventricular aspiration wasmarkedly reduced, with long periods when no aspirations werenecessary. Percutaneous aspiration of the shunt tube was performedonly after signs of increased intracranial pressure developed.Each time the drug was discontinued, signs of increased intracranialpressure soon became evident.' 'Confirmation of this observationwould be desirable since satisfactory management of this pediatricproblem is usually difficult or impossible.'
(http://pediatrics.aappublications.org/cgi/content/abstract/22/5/875-a)

The finer points of these articles are outside the scope of this discussion, but prove to make the point rather well. These are only two of the abstracts from medical journals I chose to include, other date exists; further enhancing the idea and proof of clinical effectiveness in the pediatric patient.

So, why did I spend the last several hours of my life discussing and compiling data on Diamox? And why does this matter to you, my reader? With all of the trial data and information that shows that this drug can have a postive effect on adults with Hydrocephalus I think that more consideration should be taken towards using it in the pediatric patient as well. I have shown several instances in which it has had a beneficial effect, and I think that more people should become aware of this disorder, and alternative treatments to surgery.

...in medias res

2009-02-05T16:00:00.000-08:00

It is only the beginning, and yet, there is so much to talk about. After finding out that I was going to be part of the premed internship with www.rateadrug.com I had a lot of work to do. The title of this blog alone took me about an hour to come up with. And, this is about the fourth draft I have written for this first blog entry.

I have been racking my brains trying to come up with a specific area of focus. My main interest is in gathering medications that relate to neurological studies as this is my area of focus at my job with Primary Children's Hospital and I have a large amount of experienced health care workers from which I can gather information.
However, this is too small of a segment of the population.

So, I have decided that I will focus on two things. I will collect general information surveys from the population at large: friends, family, students, patients etc. And starting next week I will be doing a drug of the week feature. This will be based upon medications that I deal with at my work. The drug of the week feature will be largely my own research and the opinion of medical professionals with whom I work. This should help me to fulfill my two major goals and gather a great deal of information.

And if you are stumbling upon this blog and feel like contributing you can go to www.rateadrug.com and do a survey on any medication you are currently taking or have been on in the past including over the counter stuff. When the survey asks you where you heard about the webpage put PPREP in the first dropdown menu and TB927 in the second.

Cheers, and look forward to next week's feature drug!