Motor vehicle collision is a common cause of blunt renal trauma. There is usually a sudden acceleration/deceleration that can damage the kidney. Renal trauma is graded from Level 1-5. Most Grade I-IV blunt renal injuries are managed conservatively, but the indications for surgical intervention include vascular injury to the renal pedicle, shattered kidney, expanding or pulsatile hematoma, and hemodynamic instability. Conservative treatment entails bedrest until bloody urine clears, monitoring vital signs and hematocrit, monitoring hematocrit or blood level. A staging CT scan is also ordered to fully image the damage and rule out higher grade renal injury. In scenarios with conservative management, there is concern that nonviable renal tissue will still be perfused, which may lead to hypertension. Research has demonstrated only isolated instances of hypertension; therefore, such a low risk of hypertension does not warrant surgical intervention for nonviable renal segments. However, it is possible that a patient could still develop hypertension. For this reason, standard protocol is for post-injury blood pressure to be followed and treated with antihypertensive medications first followed by surgical intervention only in refractory cases. Points of contention in this case should include a review of the details of nonoperative management. "Nothing was done" implies absence of surgical intervention; however, the inpatient stay should be assessed for the steps taken to minimize morbidity and prevent complications (i.e. Was a CT scan ordered and reviewed? Was the patient surgically explored for other reasons with still no renal intervention? Was there a nonviable renal segment on imagining? If a nonviable segment was seen, was serial radiological imaging performed during inpatient stay to document injury resolution. Was follow-up imaging performed at 3 months to document renal function?). That being said, importantly, this patient's development of renal failure could very well be attributed to various causes independent of the renal trauma, such as a family history of kidney disease or comorbidities such as diabetes and hypertension – and those are also issues that must be investigated.

I am an attorney representing two parents whose teenage son recently committed suicide after having begun antidepressant treatment with a psychiatrist. The question that has been raised is whether the antidepressant should not have been prescribed as I have seen several news reports about the FDA warning about antidepressants causing suicide.

Although specific assessment and opinion regarding possible violation of standard of care would require more information, I can address your question regarding the reports about antidepressants and suicide in adolescents. As you may suspect, suicide is the most frequent trigger for lawsuits against mental health professionals. This is not surprising given that suicide is the third leading cause of death for persons aged 15-24 years, even more than homicide. The FDA warnings were based on pooled analysis of trials indicating an increase in suicidal behaviors in adolescents with major depressive disorder (clinical depression) from about 2% with placebo to 4% with antidepressants. Note, however, that in none of the trials was there one completed suicide and most of the suicidal behaviors were having suicide related thoughts. Since the FDA black box warnings occurred, prescriptions of SSRI’s (a family of antidepressants that drugs like Prozac or Zoloft belong to) decreased. Concurrently, and in a significant reversal of the trend in previous years, the death rate from suicide in youth increased. Many speculate this reversal is due to the decrease in antidepressant usage as untreated major depressive disorder carries a high rate of suicide and several more recent analyses have indicated higher rates of antidepressant prescriptions are associated with less suicides. More recent trials and data, both international and in the U.S., have failed to show an increase in suicide with antidepressants. In the adult psychiatry literature, some believed that a depressed individual's risk of suicide increased after antidepressant treatment began due to certain symptoms of depression (in this case, energy) improved before other symptoms improved such as sad mood, hopelessness, or negative thinking. This has not seemed to fit more recent data showing that risk for suicide in adolescents was highest the month before starting treatment and dropped sharply after beginning treatment. So, it does not seem that antidepressants "cause" suicide, but have a small chance of exacerbating suicidality in certain situations. Given some of the mixed findings, prudent usage should occur i.e. in deciding if antidepressant treatment is begun, the risks and benefits of initiation of antidepressant treatment (or any treatment) should be weighed against risks and benefits of no treatment and alternative treatments and discussed with the patient. Standard of care includes proper diagnostic assessment/formulation (misdiagnosed bipolar disorder may be exacerbated by antidepressants) as well as follow-up monitoring of treatment (frequent weekly to biweekly check-in's for the first several weeks of antidepressant treatment). I would recommend investigating these areas to evaluate for negligence.

My client's husband is a 55 year old man who recently underwent coronary artery bypass surgery and developed a right-sided stroke on post-operative day one. We are concerned because he underwent this operation without going on a bypass machine. Is there a significant difference in complication rates for undergoing this surgery with or without a bypass machine?

Coronary bypass surgery is one of the most frequently performed heart surgeries and can be performed either with or without the use of a bypass machine (or even as a combination of both approaches). In general, though complication rates are comparable between both approaches, it is less complicated (and preferred) to perform the surgery without a bypass machine - and in the majority of cases, this operation is indeed performed without using a bypass machine. There are clinical situations (i.e. patient with abnormal coronary artery anatomy), however, where coronary bypass is the preferred aproach. In order to anticipate any problems that might occur, patients are required to undergo thorough pre-operative clinical evaluation that influences the surgeon's choices. Like any other major surgery, however, there is an expected rate of complications (which the patient should be informed of and consents to), including: postoperative cardiac rhythm problems requiring prolonged hospital stay (15-20%), renal failure (2-4%), postoperative heart attack (1%), postoperative bleeding problems (2-3%), respiratory failure requiring prolonged ventilation by a machine (8%), and neurological complications such as stroke (1-2%). In summary, complications associated with performing the surgery without bypass machine should be considered comparable to those on bypass. Remember that this is a major surgery - so one should always choose a Cardiac Surgeon who performs many (at least one hundred) of these operations every year (without using the bypass machine). As for points of contention, you may wish to investigate the thoroughness of the surgeon’s pre-operative evaluation of the patient? Were there pre-operative medical conditions that should have required this surgery being performed on bypass machine? Also, what is the Cardiac Surgeon's prior track record? Does it fall in line with acceptable complication rates?

I am looking to hire a psychiatrist to aid in a divorce case involving a child custody dispute. What should I be looking for in hiring a psychiatric expert witness?

An expert witness should be an individual who will be considered professionally credible. Although there are competent psychiatrists who are not members of professional organizations or Board-certified, in a forensic setting, these attributes may be associated with peer and community acceptance of competence, standards of ethical conduct, expertise, and professionalism. Since the child custody process and evaluation is quite complex, an expert should have full training in child and adolescent work and significant forensic experience (if not certification and experience). Typically (with rare exceptions), general psychiatrists do not have the level of training, experience, and ongoing clinical responsibilities necessary for the child custody process. The witness should not be a “hired gun” and should be active in clinical activities. You must be able to rely on the witness to give honest answers, as this will help you better identify and plan for the strengths and liabilities of your case. It may help if the psychiatrist actively participates in continuing education and/or teaches other medical professionals. Frequent lawsuits or license restrictions may impede an expert’s credibility. The expert witness should not have been a treating physician (have any prior relationship with any of the parties) as this would introduce significant and unavoidable bias. A well-performed evaluation can be a lengthy process, requiring review of several sources of information and interviewing of several parties, and can be quite costly but can also be invaluable in assisting with your case.

My client's husband was a 58 year old male who had a lung nodule described on a non-contrast CT as "concerning" and subsequently underwent a repeat CT with contrast. During the procedure, my client's husband went into shock and died. Could the allergic reaction and its consequences have been avoided?

Reactions to iodinated contrast are not uncommon and range from the annoying (hives and itching) to the catastrophic as in your client's case. Informed consent should have been obtained prior to the CT, which includes explaining these risks and allowing the patient to ask questions. A prior history of allergic response to contrast should also have been asked. The facility where the scan was performed should also have the staff and equipment prepared to deal with such a situation, including an appropriately stocked crash cart and personnel certified in BLS (basic life support). These are the relevant issues of concern that you should investigate to find any grounds for liability in this case.

My client is a 16 year old female who was recently diagnosed with Non Hodgkin’s Lymphoma Stage IIA, for which she is receiving 6 cycles of chemotherapy. Several months earlier (prior to diagnosis), my client saw her primary care physician, a Pediatrician, who prescribed her antibiotics for the enlarged lymph nodes in her neck. When these lymph nodes grew larger, the Pediatrician simply changed the antibiotics but again there was no improvement. After several months, the Pediatrician finally referred her to a Pediatric Hematologist-Oncologist, who ordered several CT scans, and then sent her to a surgeon for a biopsy, which showed cancer. The concern of my client is that her primary care physician delayed diagnosis for 6 months, causing the disease to spread from an earlier stage to a later stage. My client feels that if this was diagnosed earlier, at an earlier stage, then her prognosis would be improved. We feel this is ground for medical malpractice on the part of her Pediatrician. In your opinion, do you feel that this was an excessive delay in diagnosis? Additionally, do you agree that this delay has worsened her prognosis?

Given the limited information provided regarding her diagnosis, it is impossible to say with any certainty if 1) the disease progressed from Stage I to II, or 2) whether a few months would make any impact on her management or prognosis. If and only if the disease could have been caught in stage I and was a low grade “indolent” NHL like “follicular small cell lymphoma subtype” (you did not specify grade as this is of CRUCIAL importance), then it is possible that the management would be different and the prognosis different – but not that much more different – we’re talking a few percentage points in disease free survival and overall survival. Secondly, you did not specify which nodal regions this tumor is involving, as this also effects the management and the side effects of treatment. I can only assume that the nodes involved are in the neck and mediastinum (chest region). So bottom line, if the primary care physician was a little more attentive - and note that it is totally in line to give antibiotics for 6 weeks or more before considering something else (as kids tend to get infections) – sure it could have been diagnosed a few months earlier, and would it have affected outcome – small chance, but can you prove that it would have – not likely because the change in prognosis is so small. However, the important issue you did not bring up was if diagnosing it earlier would have changed the morbidity (or side effects) associated with the different management strategy that may have resulted (i.e. treating with radiation alone instead of chemotherapy or chemotherapy + radiation) from treating Stage 1 vs. Stage 2 NHL. This is a legitimate concern as there are long term consequences from radiation to the mediastinum for a young girl – the risk of secondary breast cancer rises… Hope this helps, but next time, you need to be much more specific in the details you provide so I can help you better – but I think there is enough ground here for you to get a more extensive review and opinion from a Pediatric Hematologist-Oncologist to make a decision on proceeding forward with this case.

A client was thought to be both paralyzed and to have polymyositis. Now, however, he is walking and therefore was not paralyzed. If somone with polymyositis degenerates to the point of being effectively paralyzed from polymyositis (and is that possible), what is the prognosis for later reaching the point of being able walk, and what kind/how much/and what duration of therapy (if any) would be required? Also, what is the chance of the polymyositis subsequently degenerating to the point where use of a wheelchair would again be required?

Assuming your client has no co-morbid conditions further exacerbating his weakness, it is possible for someone with polymyositis, in the absence of appropriate and effective treatment, to develop severely debilitating weakness to the point of near-paralysis. This deterioration would not be permanent, as effective therapies target the inflammation that characterizes the disease and causes the patient's weakness. It is uncommon for such an outcome (near-paralysis), having effective treatments, such as first-line corticosteroids and, if necessary, immunosuppressants. The strategy for treatment is to start a patient on a corticosteroid (i.e. prednisone) for 4-6 months initially. If at that point, the patient has significantly improved, the corticosteroid dose is tapered over the next couple of months, as tolerated, to a maintenance dose level to keep the patient's condition stable. However, if the patient's condition is not significantly improved or even worsened, then an immunosuppressant (i.e. cyclophosphamide) is added. The route and amount of immunosuppressant is variable (oral therapy or intermittent IV therapy can be used) and the required duration indefinite. It is difficult to answer whether the client in your scenario (who was previously nearly paralyzed) would be able to walk again. The prognosis of polymyositis is very good with current therapies. Nevertheless, the patients who do NOT respond to current therapies (mentioned above) often deteriorate and develop respiratory insufficiency (respiratory muscles are involved) and subsequently die. Therefore, unless a patient who previously did not receive appropriate prior management (or did not receive management at all) received a new medication to which he responded, it would be highly unlikely for a previously appropriately managed patient to improve spontaneously, again, in the absence of another medical condition. Finally, if a patient were to improve after being severely debilitated, it would indeed be possible to require a wheelchair in the future if the patient stopped the effective medications or the medication's effect ceased. I should note that it is possible to develop tolerance to these medications, especially corticosteroids. However, in this setting, one would see common toxicities associated with these medications, such as central (around the waist) obesity, ruddy cheeks, easy bruising, weak bones and subsequent fractures, increased susceptibility to infections, etc. If you need any clarification or additional information, please feel free to contact me.

Glaxo-Smith-Kline has a popular B-blocker med Coreg (Carvedilol) that is used to treat high blood pressure. The drug is administered twice-a-day, but recently, an enhancement in the delivery characteristics led to the creation of a CR (continuous release) once-a-day formulation Coreg CR, which is not only more convenient for the patient, but has been shown to have more consistent pharmakokinetics (therapeutic dose levels). Coreg is about to go generic. FDA recently approved Coreg CR so Glaxo is preparing to take it to market. The standard release twice-a-day Coreg (Carvedilol) is about to go generic. While M.D.s would naturally prefer their patients to use the more effective Coreg CR, patients may prefer the use of the generic Carvedilol because of economic incentives (full insurance coverage or lower copay versus Coreg CR). The specific question is: Will Glaxo stock drop or rise? But this leads to a more general overlying question (not just for this specific case study but in general) is - what drives the market? Will the fact that a drug (Coreg CR) is more effective drive insurance companies to cover the drug even though it is more expensive)? Does efficacy drive the market? If so, insurance will cover Coreg CR to the extent that Coreg CR will dominate over generic forms of Carvedilol - and ultimately, Glaxo stock will not fall... Is this correct??

Glaxo is a huge company. I am not sure how big the impact of one drug will be on the company. This is your area of expertise. I cannot even venture to answer your question with any certainty. Relating to reimbursement for medications by insurance companies, I am not the person to be asking this question. You should consider asking someone with drug regulatory expertise, but from what I know, it is a complicated process. I do know that the level of efficacy of a drug plays a huge part in determining the reimbursement rates. Relating to the drug, Coreg CR efficacy is improved because of a novel delivery system utilizing encapsulated microtubules to carry and deliver the drug in a more sustained release form, which contributes to the “steadier” dose levels, and hence the increased efficacy of the drug. However, other drugs of the same class are being tested in Phase III trials using similar encapsulated drug delivery technologies through various companies (Psivida is such an Australian company). I would say that while Coreg CR is a breakthrough drug, it’s lifespan of dominating the market is limited, as the new drug delivery system is going to come out in force onto the market in the next year through various other drugs of the same class, many of which will likely be cheaper and equally effective. You would benefit from more research into all of these areas.

NOT: We are considering investing in a medical company with a drug that is entering phase III clinical trials as a hair loss treatment. This drug looks like it is showing increased efficacy compared to the existing hair loss drug Propecia, but has increased side effects relating to increased impotence and decreased libido. From your experience, do your hair loss patients express significant concern regarding side effects in making their decision to go on Propecia. We are trying to assess the impact of the new drug on the marketplace considering the increased sexual side effects. [NOTE: MORE DETAILS ON SIDE EFFECTS SHOULD HAVE BEEN PROVIDED.]

INSTEAD: We are considering investing in a medical company with a drug that is entering phase III clinical trials as a hair loss treatment. This drug looks like it is showing increased efficacy compared to the existing hair loss drug Propecia, but has increased side effects relating to increased impotence and decreased libido. From your experience, do your hair loss patients express significant concern regarding side effects in making their decision to go on Propecia. We are trying to assess the impact of the new drug on the marketplace considering the increased sexual side effects.

I understand your question. However, I would need to know more details on the rate and severity of the sexual side effects to accurately express my opinion. But given the information that you have provided me, I would start out by saying that the sexual side effects relating to Propecia are quite low, of the < 2% range, and are limited to decreased volume of ejaculate. Decreased libido is even lower, so much so that that has not really proven a concern in any of my patients to deter them from trying Propecia. Other concerns are the risk of gynecomastia (enlargement of the breast), though this side effect is also very low. Regarding the new drug, I would say the key factors to consider are the rate and degree of these sexual side effects (in addition to any other side effects which you have not mentioned to me), as well as the degree of impact on preventing hair loss or causing hair regrowth. Propecia is more effective in preventing hair loss if the hair loss is caught early, but the rate of significant regrowth is not significant, so if the new drug is significantly better in either or both areas, I think that patients would be more willing to take the medication even if there are more potential side effects. After all, if they experience side effects, they can opt to discontinue the medication. So to answer you question given the limited information you have provided, I believe this new medication could have a tremendous market IF the drug is significantly more effective than Propecia without an associated side effect profile that is significant. Most men experience hair loss to varying degrees. While some are not effected by their hair loss, most men are, especially in our media and advertising influenced modern society. It is fashionable to have a full head of hair and anything that will help men significantly in this cosmetic area has the potential to make a splash in a big way.

I am a financial analyst following a pharmaceutical company whose primary drug is an antidepressant medication. Recently, the FDA extended previous warnings of SSRI (selective serotonin reuptake inhibitor) antidepressants leading to increased incidence of suicides to all antidepressant medications. As these FDA warnings may create a major detrimental impact to antidepressant drug sales, I would like to ask your expert clinical opinion on antidepressants relating to these suicides and the likely impact on clinical practice?

As you may suspect, suicide is the most frequent trigger for lawsuits against mental health professionals, which is not surprising given that suicide is the third leading cause of death for persons aged 15-24 years. The FDA warnings were based on pooled analysis of trials indicating an increase in suicidal behaviors in adolescents with major depressive disorder (clinical depression) from about 2% with placebo to 4% with antidepressants. Note, however, that in none of the trials was there even one suicide death and most of the suicidal behaviors were having suicide related thoughts. After the FDA warnings were issued, prescriptions of SSRI’s decreased. Concurrently, and in a significant reversal of the trend for several years, the death rate from suicide in youth increased. Many speculate this reversal is due to the decrease in antidepressant usage as untreated major depressive disorder carries a high rate of suicide and several more recent analyses have indicated higher rates of antidepressant prescriptions are associated with less suicides. More recent trials and data, both international and in the U.S., have failed to show an increase in suicide with antidepressants. In the adult psychiatry literature, some believed that a depressed individual's risk of suicide increased after antidepressant treatment began due to certain symptoms of depression (in this case, energy) improved before other symptoms improved such as sad mood, hopelessness, or negative thinking. This has not seemed to fit data showing that risk for suicide in adolescents was highest the month before starting treatment and dropped sharply after beginning treatment. There seems to a "buzz" or "backlash" in the psychiatric community, which is spreading to the broader medical community, regarding the dangers (previously known and ones being newly discovered) of inadequately treated depression, including suicide, especially in the context of the reversal of decline in youth suicide rates. Given the above, I suspect that prescriptions of antidepressants will increase (and at the very least, reverse the decline post-FDA warnings).

We have developed DRUG X that cleared clinical trials and was recently FDA approved for use as a normal tissue radioprotectant in head and neck radiation treatments. DRUG X showed a significant reduction in both mucositis and xerostomia without compromising the affect of radiation on cancerous cells. DRUG X has been approved to be administered either IV or subcutaneously 1 hour prior to RT delivery. While IV administration proves slightly more efficacious (~33%) than subcutaneous administration, it is associated with a higher likelihood (50% greater) of toxicities including nausea, vomiting, and hypotension than subcutaneous administration. In your opinion, would the inconveniences associated with IV administration in either a hospital or private radiation center setting negatively affect the likelihood of IV administration being integrated over the subcutaneous delivery form of DRUG X into clinical practice?

I would say that IV delivery will not find a place in common clinical practice. However, given increased availability of nursing and medical staff in the hospital setting as opposed to the ambulatory setting, IV use may have a limited use in this hospital based Radiation Oncology setting - but in more renowned hospitals where there is a higher commitment (despite inconvenience) to offer the highest quality of care. However, I would say that from the marketing standpoint, you must market the subcutaneous form as a convenient approach that both ambulatory and hospital based Radiation Oncologists can use without significant disruption of patient care continuity and flow, with IV administration being an alternative if staff and resources are available. Note that about ~2/3 of Radiation Oncology is delivered in the hospital setting, and about 1/3 in the ambulatory/free-standing center setting.

I’m just changed positions as a pharmaceutical sales regional manager. Relating to a chemotherapeutic drug we are planning to market, I have been doing research on the management of esophageal cancer but would appreciate your perspective. What is the thinking now on optimal management in terms of the sequencing of chemo and radiation as well as the use of surgery? [NOTE: THIS QUESTION IS TOO BROAD A QUESTION. ESOPHAGEAL CANCER MANAGEMENT IS A HUGE SUBJECT MATTER. THE CONSULTANT SIMPLY DOES NOT HAVE TIME OR ROOM TO RESPOND IN DETAIL TO THE ENTIRE SPECTRUM OF MANAGEMENT STRATEGIES GIVEN THE DIVERSE SCOPE THAT THE QUESTION ENTAILS, HENCE WHY THE RESPONSE IS BROAD STROKED.]

Since you did not specify in terms of early stage, late stage, nodal status, surgical status, etc., I will respond in broad strokes the best I can given my space limitations. The management of resectable esophageal cancer has evolved significantly in the last 15 years. The current preferred approach is trimodality therapy with neoadjuvant chemoradiation (50 Gy RT combined with concurrent 5-FU and cisplatin) followed by surgery. The trimodality approach provides a survival advantage compared to surgery alone as per the data from 3 trials (Walsh, EORTC, and Urba). Another option is definitive chemoradiation and 2 trials have looked at comparing definitive chemo-RT to neoadjuvant chemo-RT followed surgery. Both of these trials have shown no difference in survival between the two therapeutic options, however adding surgery did significantly increase locoregional control. Finally, induction chemo without RT also provides a significant survival benefit compared to surgery alone based on the MRC and MAGIC trials. However, no trials compare pre-op chemo to pre-op chemo-RT followed by surgery, and there is some data suggesting that local control is better with pre-op chemo-RT followed by surgery. Therefore typically the trimodality therapeutic approach is preferred. The optimal type, dose, combination and schedule of chemotherapy drugs is still evolving and unclear. However, at Columbia we use concurrent treatment with 2 cycles of cisplatin and 5-FU along with 50Gy RT as per the RTOG 85-01 trial. The one exception to these recommendations is the case of cancer in the cervical esophagus, which is preferentially treated with definitive chemo-RT as survival is the same as surgery and major morbidity is avoided using this approach.

We are developing a novel radiation delivery device for use in the intraoperative settings to deliver a single fraction of kilovoltage radiation to the tumor bed. The beauty of this device is that it is a self contained radiation delivery “box” that can be placed directly over the patient’s resection site to deliver a few Gray of radiation remotely while the surgeon and the remainder of the O.R. staff have left the room for the short period of a few minutes over which the radiation is delivered. The patient can be monitored remotely from outside the O.R. with a video camera. As we are dealing with kilovoltage radiation, no special O.R. shielding requirements would be required. It is our hope that this device would find rapid integration into community setting O.R. settings once the device is FDA approved for use. In your opinion, what do you anticipate would be the greatest barrier to its integration into practice, and what could we as the device manufacturer do to improve its integration into the marketplace?.

This sounds like a wonderful device with incredible potential. The fact that no O.R. shielding would be required is a huge selling point for this device, as expensive O.R. reconstruction requirements would be eliminated and this device could potentially be accessible to both academic and private hospital based Radiation Oncology practices. Given my limited knowledge of further details, and relying strictly on what you have mentioned, I believe that the single most important factor that you must pursue is setting this device up in clinical trials at major academic centers such as ours. Proving safety will not be enough for this device. A statistically significant decrease in local recurrence needs to be proven, which could take varying amounts of time depending on the cancer type. But once this is shown, then you will be taken very seriously, as the data will quickly be presented in major publications and conferences. Once all of this happens, I think you can aggressively market it throughout the community. Very importantly, at this point, I think you need to focus on partnering with major academic institutes to set up trials. Another issue, physicians use products that make them money. Radiation Oncologists in private practice who normally treat a rectal cancer with 6 weeks of external beam radiation will not be happy if the new technology will cut the number of fractions of external beam radiation required without an equal or greater amount of compensation in insurance reimbursement for use of this device. Though you might not have control of service pricing and insurance reimbursement, you must factor in all of this in designing the clinical trials (i.e. setting up trials where you do not eliminate significantly the external beam radiation therapy fractions, etc.).

I'm a freelance writer for a NYC newspaper contributing to a story about the possibility of terrorists bringing a nuclear weapon into Manhattan. Based on your expertise on radiation, please help me understand the big picture. What happens if someone detonates a nuclear device in the city? What can I do to protect myself? I hear that there are pills that can protect me from radiation?

The chance of a nuclear catastrophe in Manhattan is very small. NYC has highly sensitive radiation detection devices at all imaginable access points into the city – bridges, tunnels, airports, seaports. Additionally, there are unmarked vans with highly sensitive radiation detecting equipment that cruise the city streets. The only way a nuclear weapon could enter the city or be detonated in the city would be through an airstrike. If this were to happen, the nuclear epicenter could be approximately 2 kilometers in circumference. If you are in this epicenter, it is instant painless incineration from the heat. If you are outside of this area, the shock wave will likely kill you through the physical destruction of the city infrastructure, but if you survive the shock wave, you may have a chance. You must avoid the radioactive fallout (exposure). You must go “into the wind” such that the debris falls behind you – so leave town as fast as you can in the direction opposite to which the wind is blowing. Note that any exposure, however, to radiation, even if you survived, might result in radiation sickness (depending on the amount of exposure) and would also result in some increased risk of cancer many years down the line. The Potassium Iodide (KI) pills that you are referring to will not protect you from a major nuclear catastrophe as these pills are absorbed by the thyroid gland and prevent radioactive iodine-131 from being absorbed by the thyroid gland. I-131 is not a relevant part of a catastrophic nuclear device. It is more likely to be part of a “dirty bomb” – a radioactive “bomb” that someone could more likely bring into the city – but one that is most likely too ineffective to cause any significant harm. Rather, the media hysteria surrounding a dirty bomb is what will cause the most damage to the city – the “fear” factor – when in fact it is essentially harmless and clean up crews should be able to dispose of any dangerous elements in a relatively short period of time. Now if radiation or a biological agent gets into the water supply, then we have a more serious issue. Hope this helps.

Hello, I’m an entertainment writer covering the high profile story of XXXXX XXXXXX recently serving 60 days jail time for a DUI but who was released for “medical” reasons. Basically, I need some insight from the psychiatrist’s perspective on the medical reasons why someone would be released for “psychiatric reasons” relating to a “nervous breakdown” in an individual believed to have prior Attention Deficit Disorder and claustrophobia?

Since I am not privy to all of the relevant medical information surrounding the release of this individual from jail, it is difficult to speculate on the possible diagnoses and impacts they had on the release. I am not aware of any psychiatric diagnosis of “nervous breakdown” used clinically or listed in the major psychiatric diagnostic classification system (i.e. DSM-IV-TR or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision). ADD is now known as Attention Deficit-Hyperactivity Disorder, which is an illness with several symptoms broadly categorized under areas of difficulties with attention, impulsivity, or hyperactivity. None of these symptom areas would be direct reasons an individual could not be jailed. An individual with severe claustrophobia would likely have significant anxiety when placed in the situation that is irrationally feared and therefore avoided. However, with the inability to avoid restriction, the level of fear would likely peak (possibly to the point of feeling traumatic) but decline over time with essentially continual and constant exposure (this phenomenon is sometimes used clinically as patient’s are gradually exposed and desensitized to their fears). A diagnosis of claustrophobia by a psychiatrist may be grounds for release from a claustrophobic jailed condition to a less claustrophobic type of jail sentence. Lastly, it is important to note that there is psychiatric and other medical care available in jails, although it may have been with less frequency as what this individual likely experienced with a private community provider.

I am reviewing a disability claim case for a 60 year male who recently completed radiation treatment for cancer contained to the prostate gland. He has undergone 8 weeks of external beam radiation therapy to the prostate gland. He states that he is having severe sweats that interfere with his function as a truck driver and has filed for disability. Upon initial research, we found no correlation between sweats and radiation treatment. Please shed some legitimacy to his claim if any exists.

Radiation therapy side effects are always localized to the region that is treated (as opposed to systemic like hormones or chemotherapy). The types of side effects that would be expected from external beam radiation therapy would be urinary frequency, urgency, burning, and possibly some gastrointestinal side effect such as loose stools or irritation with bowel movements. The only systemic side effect associated with radiation therapy is generalized tiredness (which we do not have a clear explanation for). The sweats that he is undergoing are not a side effect of radiation, however, are a common side effect of management of prostate cancers that include hormonal therapy (or androgen ablation). Hormonal therapies include Lupron, Zolodex, and Casodex to name a few and are given either as injections, pills, or implants, and cause systemic side effects. Hormonal therapy are commonly given to localized prostate cancer patients for various reasons – to shrink the prostate gland or to decrease the risk of metastases in the future. Anyway, hormonal therapy is commonly associated with severe hot flashes and sweats (drenching at times) – similarly to a woman undergoing menopause. There are other systemic side effects but the hot flashes and sweats can be extremely severe in some men and could certainly be grounds for interference with job performance in occupations where lapses of concentration (such as driving) could result in accidents or other dangers to self or others. However, it’s important to note that this disability would not be permanent – but rather only over the course of hormonal therapy administration – which typically ranges between 3 months to 3 years for most cases of localized prostate cancer. The mentioned symptoms should resolve a few months after hormonal therapy is terminated.

I am a health insurance professional with a difficult case to determine if a customer should be covered under our insurance policy for recent onset kidney failure that may have resulted from a previous accident that he failed to report in our pre-insurance survey. The gentleman is a 60 year old male who failed to report that he was in a major car accident seven years ago and airlifted to the hospital, where he was found to have blood in his urine and diagnosed with a kidney laceration. According to hospital reports, nothing was done at that time. However, he recently developed kidney failure. We are trying to assess if his kidney failure is related to his prior kidney laceration?

Motor vehicle collision is a common cause of blunt renal trauma. There is usually a sudden acceleration/deceleration that can damage the kidney. Renal trauma is graded from Level 1-5. Most Grade I-IV blunt renal injuries are managed conservatively, but the indications for surgical intervention include vascular injury to the renal pedicle, shattered kidney, expanding or pulsatile hematoma, and hemodynamic instability. Conservative treatment entails bedrest until bloody urine clears, monitoring vital signs and hematocrit, monitoring hematocrit or blood level. A staging CT scan is also ordered to fully image the damage and rule out higher grade renal injury. In scenarios with conservative management, there is concern that nonviable renal tissue will still be perfused, which may lead to hypertension. Research has demonstrated only isolated instances of hypertension; therefore, such a low risk of hypertension does not warrant surgical intervention for nonviable renal segments. However, it is possible that a patient could still develop hypertension. For this reason, standard protocol is for post-injury blood pressure to be followed and treated with antihypertensive medications first followed by surgical intervention only in refractory cases. Points of contention in this case should include a review of the details of nonoperative management. "Nothing was done" implies absence of surgical intervention; however, the inpatient stay should be assessed for the steps taken to minimize morbidity and prevent complications (i.e. Was a CT scan ordered and reviewed? Was the patient surgically explored for other reasons with still no renal intervention? Was there a nonviable renal segment on imagining? If a nonviable segment was seen, was serial radiological imaging performed during inpatient stay to document injury resolution. Was follow-up imaging performed at 3 months to document renal function?). That being said, importantly, this patient's development of renal failure could very well be attributed to various causes independent of the renal trauma, such as a family history of kidney disease or comorbidities such as diabetes and hypertension – and those are also issues that must be investigated.

I am a case manager evaluating a life insurance claim relating to a 20 year old man who recently committed suicide after having begun antidepressant treatment with a Psychiatrist. As the terms of the insurance policy are quite “sensitive” in these situations, the question that has been raised is whether the antidepressant may have in fact contributed to his suicide – as we have encountered several news reports about the FDA warning about antidepressants causing suicide.

So, it does not seem that antidepressants "cause" suicide. I should mention as well that in deciding if antidepressant treatment should be begun, Psychiatrists are trained to weigh the risks and benefits of initiation of antidepressant treatment (or any treatment) against risks and benefits of no treatment and alternative treatments. Although specific assessment and opinion would require more information, I can address your question regarding the reports about antidepressants and suicide in adolescents. As you may suspect, suicide is the most frequent trigger for lawsuits against mental health professionals. This is not surprising given that suicide is the third leading cause of death for persons aged 15-24 years, even more than homicide. The FDA warnings were based on pooled analysis of trials indicating an increase in suicidal behaviors in adolescents with major depressive disorder (clinical depression) from about 2% with placebo to 4% with antidepressants. Note, however, that in none of the trials was there one completed suicide and most of the suicidal behaviors were having suicide related thoughts. Since the FDA black box warnings occurred, prescriptions of SSRI’s (a family of antidepressants that drugs like Prozac or Zoloft belong to) decreased. Concurrently, and in a significant reversal of the trend in previous years, the death rate from suicide in youth increased. Many speculate this reversal is due to the decrease in antidepressant usage as untreated major depressive disorder carries a high rate of suicide and several more recent analyses have indicated higher rates of antidepressant prescriptions are associated with less suicides. More recent trials and data, both international and in the U.S., have failed to show an increase in suicide with antidepressants. In the adult psychiatry literature, some believed that a depressed individual's risk of suicide increased after antidepressant treatment began due to certain symptoms of depression (in this case, energy) improved before other symptoms improved such as sad mood, hopelessness, or negative thinking. This has not seemed to fit more recent data showing that risk for suicide in adolescents was highest the month before starting treatment and dropped sharply after beginning treatment. So, it does not seem that antidepressants "cause" suicide, but have a small chance of exacerbating suicidality in certain situations. Given some of the mixed findings, prudent usage should occur i.e. in deciding if antidepressant treatment is begun, the risks and benefits of initiation of antidepressant treatment should be weighed against risks and benefits of no treatment and alternative treatments and discussed with the patient. Standard of care includes proper diagnostic assessment/formulation (misdiagnosed bipolar disorder may be exacerbated by antidepressants) as well as follow-up monitoring of treatment (frequent weekly to biweekly check-in's for the first several weeks of antidepressant treatment).

NOT: : I’m a health insurance administrator reviewing several similar claim disputes. Over the last two months, several subscribers were denied approval for an initial MRI ordered by primary care physicians for a knee injury because we felt that sufficient diagnostic workup including x-ray of the knee had not been performed. The PCPs have been contesting our decisions. What’s your opinion on this? [NOTE: THE QUESTION IS TOO VAGUE – THE CONSULTANT NEEDS MORE DETAILS TO RESPOND EFFECTIVELY.]

INSTEAD: I’m a health insurance administrator reviewing several similar insurance coverage disputes regarding our policy on allowing MRIs. Over the last two months, several primary care physicians (Family Physicians) were denied approval to order an MRI prior to sufficient diagnostic workup including x-ray of the injured knee. Our current policy requires that first line management include an initial trial of pain medications and/or initial diagnostic testing with an initial radiological study being an x-ray of the knee? Let me provide you with one specific example from our files to help relay the type of situation that we have encountered repeatedly. This particular subscriber is a 34 year old woman previously healthy and without prior medical history who reportedly was out dancing and heard a pop and felt excruciating pain in her knee. Since then, her knee has been swollen and she claims that she cannot straighten it completely nor bend it much because of the pain. Is an immediate MRI really justified as an initial test based on the information provided prior to any other less expensive diagnostic tests? Should medical management and watchful waiting be advised prior to more aggressive diagnostic measures and intervention? We are investigating these issues in considering a policy change for our company.

Based on the scenario that you have presented, I believe that there is a real possibility that the patient may indeed have torn a ligament in her knee, as opposed to a simple sprain. It could be the anterior cruciate ligament (ACL) or a tear in the medial meniscus. It is very difficult for a primary care physician to accurately assess the injury simply by physical exam as the swelling and pain will likely prevent adequate physical examination to help diagnose the nature of the injury. An x-ray of the knee will not show soft tissue (ligament) injury, and the likelihood of a bony injury given the history you have provided (without mention of a fall or other collisional trauma) is less likely. I believe that the most appropriate course of action would be for the primary care physician to place the patient on anti-inflammatory medications, order crutches to prevent weight bearing, and refer the patient ASAP to an Orthopedic Surgeon, who may be better qualified to assess the injury based on history and physical examination, but likely order an immediate MRI of the knee based on clinical insight and experience. If I suspect that it is a ligament tear, as opposed to a bony injury, an MRI is required not only for diagnosis but also to determine appropriate management. If it is a ligament tear, depending on the severity, the patient may simply need to have the knee braced for a few weeks (and take high dose anti-inflammatory medications), or if the tear were more severe, surgery would be required once the swelling diminishes. Following laparoscopic procedure, the patient would require physical therapy. The problem with not ordering an MRI initially would be a failure to accurately diagnose the pathology, and continued weight bearing could worsen a ligament tear, necessitating more significant surgery and resulting impairment of function with prolonged physical therapy. While policies may be important in managed care cost control, any policy must have a mechanism to allow the physician to break policy if the individual case requires it. Regardless, hope my clinical insight helps.

We have developed DRUG X that cleared clinical trials and was recently FDA approved for use as a normal tissue radioprotectant in head and neck radiation treatments. DRUG X showed a significant reduction in both mucositis and xerostomia without compromising the affect of radiation on cancerous cells. DRUG X has been approved to be administered either IV or subcutaneously 1 hour prior to RT delivery. While IV administration proves slightly more efficacious (~33%) than subcutaneous administration, it is associated with a higher likelihood (50% greater) of toxicities including nausea, vomiting, and hypotension than subcutaneous administration. In your opinion, would the inconveniences associated with IV administration in either a hospital or private radiation center setting negatively affect the likelihood of IV administration being integrated over the subcutaneous delivery form of DRUG X into clinical practice?

As IV administration associated side effects (as opposed to the subcutaneous approach) would require daily IV placement and nurse monitoring of the patient’s vital signs, it would likely prove enough of an insignificance despite it’s superior efficacy to prevent any significant integration of this IV administration into clinical practice. However, subcutaneous use would likely integrate well into clinical practice provided the evidence of a reduction of radiation morbidity is marketed to Radiation Oncologists.

Based on the limited information provided, it is my opinion that IV delivery will not find a place in common clinical practice. However, given increased availability of nursing and medical staff in the hospital setting as opposed to the ambulatory setting, IV use may have a limited use in this hospital based Radiation Oncology setting - but in more renowned hospitals where there is a higher commitment (despite inconvenience) to offer the highest quality of care. However, I would say that from the marketing standpoint, you must market the subcutaneous form as a convenient approach that both ambulatory and hospital based Radiation Oncologists can use without significant disruption of patient care continuity and flow, with IV administration being an alternative if staff and resources are available. Note that about ~2/3 of Radiation Oncology is delivered in the hospital setting, and about 1/3 in the ambulatory/free-standing center setting

My client is a 16 year old girl who was recently diagnosed with Non Hodgkin’s Lymphoma Stage IIA, for which she is receiving 6 cycles of chemotherapy. Several months earlier (prior to diagnosis), my client saw her primary care physician, a Pediatrician, who prescribed her antibiotics for the enlarged lymph nodes in her neck. When these lymph nodes grew larger, the pediatrician simply changed the antibiotics but again there was no improvement. After several months, the Pediatrician finally referred her to a Pediatric Hematologist-Oncologist, who ordered several CT scans, and then sent her to a surgeon for a biopsy. This showed cancer. The concern of my client is that her primary care physician delayed diagnosis for 6 months, causing the disease to spread from an earlier stage to a later stage. My client feels that if this was diagnosed earlier, at an earlier stage, then her prognosis would be improved. We feel this is ground for medical malpractice on the part of her Pediatrician. In your opinion, do you feel that this was an excessive delay in diagnosis? If a CT (or any other scan) of the head was ordered earlier, could a Radiologist have helped differentiate between infection and cancer? Importantly, do you agree that this delay has worsened her prognosis?

An ultrasound of the neck (to avoid radiation) or CT could have been performed to evaluate the lymph nodes, if not at the outset when clinical symptoms may have favored infection, certainly when the nodes continued to enlarge. Lymph nodes which are concerning for malignancy are enlarged and lose their fatty hila (a reactive lymph node may be large, but it will maintain its fatty hila). Additionally, the pattern of lymphadenopathy in lymphoma is fairly characteristic and would not be confused with infection once the entire body was imaged: additional scans would likely have been ordered based on the initial findings. Based on the limited information that has been provided to me about this case, I believe that a Radiologist indeed would have been able to differentiate between the two distinct processes. As for worsening prognosis? As a Radiologist, I cannot answer that question but a Pediatric Hematologist-Oncologist might be able to offer further clinical insight.

My client is a 16 year old girl who was recently diagnosed with Non Hodgkin’s Lymphoma Stage IIA, for which she is receiving 6 cycles of chemotherapy. Several months earlier (prior to diagnosis), my client saw her primary care physician, a Pediatrician, who prescribed her antibiotics for the enlarged lymph nodes in her neck. When these lymph nodes grew larger, the Pediatrician simply changed the antibiotics but again there was no improvement. After several months, the Pediatrician finally referred her to a Pediatric Hematologist-Oncologist, who ordered several CT scans, and then sent her to a surgeon for a biopsy, which showed cancer. The concern of my client is that her primary care physician delayed diagnosis for 6 months, causing the disease to spread from an earlier stage to a later stage. My client feels that if this were diagnosed earlier, at an earlier stage, then her prognosis would be improved. We feel this is ground for medical malpractice on the part of her Pediatrician. In your opinion, do you feel that this was an excessive delay in diagnosis? If a CT (or any other scan) of the head was ordered earlier, could a Radiologist have helped differentiate between infection and cancer? Importantly, do you agree that this delay has worsened her prognosis? [NOTE: THE SAME QUESTION FROM ABOVE HAS BEEN ADDRESSED TO A DIFFERENT MEDICAL SPECIALTY.

Given the limited information provided regarding her diagnosis, it is impossible to say with any certainty if 1) the disease progressed from Stage I to II, or 2) whether a few months would make any impact on her management or prognosis. If and only if the disease could have been caught in stage I and was a low grade “indolent” NHL like “follicular small cell lymphoma subtype” (you did not specify grade as this is of CRUCIAL importance), then it is possible that the management would be different and the prognosis different – but not that much more different – we’re talking a few percentage points in disease free survival and overall survival. Secondly, you did not specify which nodal regions this tumor is involving, as this also effects the management and the side effects of treatment. I can only assume that the nodes involved are in the neck and mediastinum (chest region). So bottom line, if the primary care physician was a little more attentive - and note that it is totally in line to give antibiotics for 6 weeks or more before considering something else (as kids tend to get infections) – sure it could have been diagnosed a few months earlier, and would it have affected outcome – small chance, but can you prove that it would have – not likely because the change in prognosis is so small. However, the important issue you did not bring up was if diagnosing it earlier would have changed the morbidity (or side effects) associated with the different management strategy that may have resulted (i.e. treating with radiation alone instead of chemotherapy or chemotherapy + radiation) from treating Stage 1 vs. Stage 2 NHL. This is a legitimate concern as there are long term consequences from radiation to the mediastinum for a young girl – the risk of secondary breast cancer rises… Hope this helps, but next time, you need to be much more specific in the details you provide so I can help you better – but I think there is enough ground here for you to get a more extensive review and opinion from a Pediatric Hematologist-Oncologist to make a decision on proceeding forward with this case.

My client is a 16 year old girl who was recently diagnosed with Non Hodgkin’s Lymphoma Stage IIA, for which she is receiving 6 cycles of chemotherapy. Several months earlier (prior to diagnosis), my client saw her primary care physician, a Pediatrician, who prescribed her antibiotics for the enlarged lymph nodes in her neck. When these lymph nodes grew larger, the Pediatrician simply changed the antibiotics but again there was no improvement. After several months, the Pediatrician finally referred her to a Pediatric Hematologist-Oncologist, who ordered several CT scans, and then sent her to a surgeon for a biopsy, which showed cancer. The concern of my client is that her primary care physician delayed diagnosis for 6 months, causing the disease to spread from an earlier stage to a later stage. My client feels that if this were diagnosed earlier, at an earlier stage, then her prognosis would be improved. We feel this is ground for medical malpractice on the part of her Pediatrician. In your opinion, do you feel that this was an excessive delay in diagnosis? If a CT (or any other scan) of the head was ordered earlier, could a Radiologist have helped differentiate between infection and cancer? Importantly, do you agree that this delay has worsened her prognosis? [NOTE: MORE CLINICAL DETAILS SHOULD HAVE BEEN PROVIDED.]

Given the limited information provided regarding her diagnosis, it is impossible to say with any certainty if 1) the disease progressed from Stage I to II, or 2) whether a few months would make any impact on her management or prognosis. If and only if the disease could have been caught in stage I and was a low grade “indolent” NHL like “follicular small cell lymphoma subtype” (you did not specify grade as this is of CRUCIAL importance), then it is possible that the management would be different and the prognosis different – but not that much more different – we’re talking a few percentage points in disease free survival and overall survival. Secondly, you did not specify which nodal regions this tumor is involving, as this also effects the management and the side effects of treatment. I can only assume that the nodes involved are in the neck and mediastinum (chest region). So bottom line, if the primary care physician was a little more attentive - and note that it is totally in line to give antibiotics for 6 weeks or more before considering something else (as kids tend to get infections) – sure it could have been diagnosed a few months earlier, and would it have affected outcome – small chance, but can you prove that it would have – not likely because the change in prognosis is so small. However, the important issue you did not bring up was if diagnosing it earlier would have changed the morbidity (or side effects) associated with the different management strategy that may have resulted (i.e. treating with radiation alone instead of chemotherapy or chemotherapy + radiation) from treating Stage 1 vs. Stage 2 NHL. This is a legitimate concern as there are long term consequences from radiation to the mediastinum for a young girl – the risk of secondary breast cancer rises… Hope this helps, but next time, you need to be much more specific in the details you provide so I can help you better – but I think there is enough ground here for you to get a more extensive review and opinion from a Pediatric Medical Oncologist to make a decision on proceeding forward with this case.

I reviewed the case to ascertain more details. My client had follicular small cell Non-Hodgkin’s Lymphoma “involving the Level 2 and 3 lymph nodes on the left side of the neck” as well as “involvement of the mediastinal lymph nodes.” There was no disease elsewhere as per full radiological work-up that included CT scans and PET scan. The patient was staged as Stage IIA. Now my client is receiving 6 cycles of CHOP chemotherapy for several months but is not scheduled to receive radiation therapy. The Pediatric Hematologist-Oncologist treating her feels that he would not have treated her any differently if she were caught 6 months earlier, but we feel he is protecting the Pediatrician. We would like a second opinion on whether this could have been diagnosed earlier and if so, if it would have changed matters significantly in terms of type of treatment, side effects, and prognosis. I hope these details help

Yes, the details shed more light on the matter. This is an unusual presentation, but in my opinion, I agree that the delay in diagnosis by 6 months does not change the prognosis or management strategy on this patient because of the particular histological subtype of the Non-Hodgkin’s Lymphoma. The follicular small cell subtype is very slow growing and very difficult to treat. While in older patients, many Medical Oncologists would have watched the patient if no symptoms existed, since it is a young patient, I think chemotherapy is a reasonable upfront strategy for her if she were caught earlier (and it may or may not have been Stage I because these cancers are so slow growing) or at the time she was diagnosed. So in summary, for this case, given the information you have provided, and given that I do not have the full details, I can say that earlier diagnosis probably would not have changed the management strategy if you had seen the same Pediatric Hematologist-Oncologist, nor would it have changed the amount of chemotherapy (number of cycles and dose), nor would it have changed the side effects, nor would it have changed the prognosis. Given what I know about this case, that is my expert opinion. Medicine is an art and a science, and there are no concrete rules, so there is always room for various interpretations, but in this case, I do think that it is pretty cut and dry. If it were a different histological site or in a different area of the body, then management may have been different (i.e. using radiation therapy instead or in combination) and side effect different – but not with this particular presentation.