)? It’s Facebook’s addition to the geolocation landscape of many, many other social networking applications already in existence, such as Gowalla (

You can’t get too far using any application on your iPhone without a screen coming up and asking you if you want to allow that application to use your location. If you hit “allow,” your location will then get tagged to whatever it is you are doing…posting, tweeting, or geolocating.

I typically hit “Don’t Allow.” And, to date, I haven’t tried any of the prior geolocation networks, although I see that many of my friends have. There are a few reasons I’ve resisted so far:

1. Privacy: I desire a clear boundary between my online and offline lives. If I wish for my friends and followers to know where I am for a specific reason, I’ll post that in my status update. I often do this if I’m attending a conference to let others in that city know I’m in town, for example. Plus, announcing your offline whereabouts to your online world could have physical dangers if your privacy settings are not set appropriately. This could be a major concern for teens and young adults.

2. Value: I have yet to see the value in knowing the location of my friends and followers when they post their locations from services such as Gowalla, so I don’t feel that others knowing my location will add value to their ability to know me, either personally or professionally. The connections we have are via our content, not our locations.

3. TMI: I’m sure you’ve noticed this yourself. There is most definitely a trend toward over-sharing online that can be interesting to observe. Sharing locations for the sake of sharing locations falls into that category, in my opinion. We all have busy lives. Do we really need to know that you drank a coffee at Starbucks or browsed books at Borders? That’s what’s happening via these services. These three items add up to the perfect storm for why to not use any geolocating service. I’m just not feeling it!

Kara Swisher of All Things Digital summarized all these issues in her Boom Town Blog recently,when she wrote, “Viral Video: Nobody’s Listening” (

“There’s been a bit of bloggery agonizing of late about the possibility that no one is listening to the endless stream of sharing via status updates and other social networking tools. 

As in, if a check-in falls in the forest, does it make a sound? It’s a good question to answer, given all the effort being put into the social medium.”

You likely have a sizable cohort of patients quite swept up in the social media craze. With Facebook leading the charge, many will be tempted to test drive Facebook Places and geolocate their every move. It’s important that we help them understand that these programs exist so that they can make sure their privacy and safety is what they think it is.

Also take the time to remind our families to unplug and reconnect the old-fashioned way: offline and without technology. Having some private time with friends and family is the only way to help the patients we care for remember why boundaries and privacy are so important…and why technology, while tempting and alluring, places our very humanity at risk of being drummed out of us.

Gwenn Schurgin O’Keeffe, MD, FAAP (aka “Dr. Gwenn”) is a pediatrician, health journalist, parenting and social media expert, and CEO and Editor-In-Chief of Pediatrics Now (

), an online health and communications company dedicated to providing reliable information for today’s busy families. She also writes the blog Dr. Gwenn Is In (

Articles

Columns

Social Media Notebook - Oh, the online places you'll go...or not!

Patrick J. Sweeney, MD, Department of Neurology, Cleveland Clinic, authored the extensive information located here. He covers the definition of Parkinson’s disease, its prevalence, pathophysiology, signs and symptoms, diagnosis, therapy, and outcomes in a fully referenced review, complete with five helpful tables and a link to an algorithm for the management of Parkinson’s disease, which originally appeared in 

www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/parkinsons-disease/

National Parkinson Foundation — Professionals

In keeping with its goal to “improve the quality of Parkinson's care through research, education and outreach” and belief that “by working together, we can improve the quality of care for every person diagnosed with Parkinson's disease,” NPF provides this collection of resources and tools to help keep you and your patients informed. Here, you can read the most recent white papers from NPF, learn about educational opportunities, and read the latest blog posts in the field of neurology and Parkinson’s disease. Be sure to check out the resources section, which houses conference information, diagnostic and referral guides, screening instruments, and downloadable posters from the 2009 annual Center Leadership Conference.

NINDS Deep Brain Stimulation for Parkinson's Disease Information Page

Find a detailed description ofdeep brain stimulation (DBS), a “surgical procedure used to treat a variety of disabling neurological symptoms-most commonly the debilitating symptoms of Parkinson's disease (PD), such as tremor, rigidity, stiffness, slowed movement, and walking problems” at this site from the National Institute of Neurological Disorders and Stroke. Offered in outlined format are a description of the procedure, treatment, prognosis of patients who’ve received it, and research being conducted. Links to clinical trials currently recruiting patients with this and similar disorders, journal abstracts, and press releases dealing with this condition can be found on the left sidebar of this site.

www.ninds.nih.gov/disorders/deep_brain_stimulation/deep_brain_stimulation.htm

Direct patients to this site to access recent news articles about Parkinson’s disease (PD), in addition to a resource directory, forums, and chats to connect with patients who also suffer from PD; to post comments, registration is required (no charge). Patients who visit the site will be able to access a variety of videos reviewing PD topics, from current treatments and overcoming disabilities to device therapy and caregiving.

The Impact of Left Prefrontal Repetitive Transcranial Magnetic Stimulation on Depression in Parkinson's Disease: A Randomized, Double-blind, Placebo-controlled Study

To confirm the hypothesis that “repetitive transcranial magnetic stimulation (rTMS) seems to have an antidepressive effect on patients with Parkinson's disease (PD).”

Although the authors suggest their results should be confirmed in studies looking at patients with PD who also have severe depression, they found that left dorsolateral prefrontal cortex rTMS had beneficial effects on depression in patients with PD for at least 30 days after treatment.

Deep Brain Stimulation for Camptocormia in Dystonia and Parkinson's Disease

To determine the effects of deep brain stimulation on camptocormia (bent spine syndrome), comparing primary dystonia to idiopathic Parkinson’s disease.

Although GPi (globus pallidus pars interna) deep brain stimulation is effective in treating camptocormia in dystonia, “response of camptocormia to chronic STN [subthalamic nucleus] or GPi DBS in PD is more heterogenous. The latter may be due to a variety of causes and needs further clarification.”

http://dx.doi.org/10.1007/s00415-010-5695-0

Transcranial Doppler Monitoring in Parkinson's Disease: Cerebrovascular Compensation of Orthostatic Hypotension

To determine if “cerebral blood flow regulation explain[s] why orthostatic hypotension (OH) has often no accompanying symptoms” in patients with Parkinson’s disease.

“Results showed a normal autoregulatory response to downward blood pressure shifts in PD. Moreover, orthostatic blood pressure instability is compensated equally sufficient in anterior and posterior parts of cerebral circulation. Whether in PD patients, OH becomes symptomatic rather seems to depend on blood pressure falling below the autoregulated range.”

http://dx.doi.org/10.1016/j.ultrasmedbio.2010.06.016

Research: The Organized Genetics Initiative (PROGENI)

To “study genetic and other risk factors that may be important in the development of Parkinson's disease.”

http://clinicaltrials.gov/ct2/show/NCT00086073?term=parkinson%27s&recr=Open&rank=19

To use in vivo PET scans to compare regional cerebral dopamine neurochemistry and blood flow between people with both familial and sporadic Parkinson’s disease, people with schizophrenia spectrum disorders, and “normal” volunteers.

http://clinicaltrials.gov/ct2/show/NCT00024622?term=parkinson%27s&recr=Open&rank=40

Transcranial Magnetic Stimulation in Parkinson's Disease

To determine if motor and mood symptoms can be improved with repetitive transcranial magnetic stimulation in patients with Parkinson’s disease.

http://clinicaltrials.gov/ct2/show/NCT01080794?term=parkinson%27s&recr=Open&rank=3

The Future of Parkinson’s Disease: Diagnosis and Management

Complete this program to review neuroprotective treatment strategies for Parkinson’s disease, the neuroprotective effects of dopaminergic therapies that are currently available, emerging therapies for treating both motor and non-motor symptoms of Parkinson’s disease, drug delivery advances, the “unmet need for valid rating scales to identify early nonmotor symptoms of PD,” and potential biomarkers for aiding in early Parkinson’s disease diagnosis.

www.parkinsonsdiseasecme.com/cme-modules/future-of-parkinsons-disease

Strategies for Parkinson’s Disease Care: Evolving Approaches to Initial and Combination Therapy with Monoamine Oxidase Inhibitors

The mechanism of action of MAO-B inhibitors and why these agents are a good choice for initial monotherapy in patients with Parkinson’s disease; their role as adjunct therapy with levodopa in patients with advanced disease who experience motor fluctuations and dyskinesia; the differences in efficacy, safety, and tolerability profiles of rasagiline and selegiline; and the “potential neuroprotective effect of MAO-B inhibitors in animal models of PD” form the foci of this course.

www.parkinsonsdiseasecme.com/cme-modules/parkinsons-disease-care

Net Guide

Parkinson's Disease

Addiction Resource Guide: Resources for Professionals

This site from the Addiction Resource Guide contains 30 links to sites in four categories: Associations, Research Centers/Foundations/Education, Government Resources, Accrediting Bodies. Sites linked to include the home of the American Academy of Addiction Psychiatry, the National Center on Addiction and Substance Abuse at Columbia University, the National Institute on Alcohol Abuse and Alcoholism, and The Rehabilitation Accreditation Commission. The list should serve as a great spring board to your online search for information on alcoholism.

http://www.addictionresourceguide.com/profresources1.html

American Society of Addiction Medicine — Resource Links

A variety of resources await psychiatrists at this site. Among the most relevant are practice guidelines on the role of phenytoin in alcohol withdrawal syndrome, pharmacologic management of alcohol withdrawal, and medical treatment of opiate addiction. A comprehensive collection of lists to sites covering treatment and recovery will prove to be a great starting point for a search on addiction medicine topics. Site visitors will also find advocacy information, postings for jobs in addiction medicine, and links to the sites of related professional organizations.

http://www.asam.org/PracticeGuidlines.html

The homepage for NAADAC, “the association for addiction professionals” hosts information on how to obtain any of three different certifications for both member and non-member addiction professionals. Under “Resources,” you’ll find a career center, NAADAC position statements on issues that include nicotine dependence and adolescent drug testing, and publications that include the NAADAC newsletter and the 

Written for teens, this physician-reviewed site from the Nemours Foundation answers the question “What are substance abuse and addiction?” and addresses signs of addiction, obtaining help for those who think they’re addicted to drugs or alcohol, and staying clean. Site visitors can also find contact information for a number of resources that provide help and test their knowledge about drugs and alcohol by completing the Substance Abuse Quiz; explanations for corrects answers are provided, with links to further information.

This website is intended for the families, friends, and other loved ones of individuals suffering from some form of drug addiction: the specific addictions covered here include heroin, alcohol, cocaine, methamphetamines, “club drugs,” and prescription drugs. Visitors can access information about each type of addiction, including the physical effects of the drug and what to expect during withdrawal. Those concerned with a loved one’s addiction can also fill out a confidential online information form to receive a referral to a rehabilitation program in their area.

Beyond providing the basics on sexual addiction (types, consequences, and recovery), this site from The Society for the Advancement of Sexual Health provides patients with contact information for specialist professionals and treatment facilities, as well as for groups and meetings designed for the addict, partners and family members, and sexual abuse survivors. Of most use to site visitors are a collection of four sex addiction checklists covering cyber sex, gay men, heterosexual males, and women.

Computer-delivered Interventions for Alcohol and Tobacco Use: A Meta-analysis

Rooke S, THorsteinsson E, Karpin A, et al.

“To quantify the overall effectiveness of computer-delivered interventions for alcohol and tobacco use.”

After performing a meta-analysis, the researchers determined that Internet-accessed, computer-delivered treatments with minimal contact could provide a cost-effective way of treating substance use that is uncomplicated, as well as related issues.

http://dx.doi.org/10.1111/j.1360-0443.2010.02975.x

Efficacy of Virtual Reality in Triggering the Craving to Smoke: Its Relation to Level of Presence and Nicotine Dependence

Studies in Health Technology and Informatics

Ferrer-Garcia M, Garcia-Rodriguez O, Gutierrez-Maldonado J, et al.

To “assess the capacity of eight environments to produce the craving to smoke and determine the relation of craving to nicotine dependence and level of presence.”

With a direct relation seen between craving and one’s sense of presence, each of the eight virtual environments were able to generate the desire to smoke.

http://dx.doi.org/10.3233/978-1-60750-561-7-123

[Internet- and Computer Game Addiction: Phenomenology, Comorbidity, Etiology, Diagnostics and Therapeutic Implications for the Addictives and Their Relatives]

To “give an overview about the current scientific discussion of the overuse and addiction of internet and computer game playing.”

With addicted people rarely showing any desire to make a behavioral change, the authors suggest training relatives on how to increase motivation for a behavioral change in the addicted person as a promising approach.

“To examine the promise of a new computer based approach to use in usual drug counseling when treating crack cocaine addiction.”

http://clinicaltrials.gov/ct2/show/NCT00586534?term=addiction&recr=Open&rank=1

Post-traumatic Stress Disorder (PTSD), Addiction, and Virtual Reality

Department of Defense Telemedicine and Advanced Technology Research Center

To test the hypothesis that veterans with post-traumatic stress disorder and problems with addiction who receive exposure therapy plus virtual reality-based exposure to cues for marijuana, cocaine, heroin, cigarette, and/or alcohol use, as well as cell phone-based reminders of learning to virtual reality exposure to high-risk contexts for drug use will experience less substance use and lower PTSD symptoms during and after treatment than those who receive only exposure therapy.

http://clinicaltrials.gov/ct2/show/NCT01186315?term=addiction&recr=Open&rank=6

Transcranial Magnetic Stimulation in Nicotine Addiction

National Institutes of Health Clinical Center

To test whether single-pulse transcranial magnetic stimulation is effective in reducing cue-induced nicotine cravings and use in people who smoke cigarettes.

http://clinicaltrials.gov/ct2/show/NCT01031693?term=addiction&recr=Open&rank=9

Opioid Dependence: Managing the High Cost of Treatment Failure

Complete this program for a review of the epidemiology and burden related to the treatment of opioid dependence; how opioid treatment impacts managed care; strategies for managing opioid dependence that take clinical, economic, and humanistic factors into consideration; and “communication methods and techniques for dialogue with treating physicians and other treatment providers to ensure the optimal care of patients undergoing opioid dependence treatment.” Enter the link code below at hcplive.com, link to the hosting site for this activity, enter the title in the search box, and chose your profession to access the program.

Addiction

Do You Know Who I Am? A Look at the Devastating Effects of Alzheimer's Disease - Strategies for Early Recognition and Treatment

With the goal of providing “clinicians with an overview of emerging therapies, strategies for early recognition, and effective management of patients with Alzheimer’s disease (AD),” this program thoroughly reviews risk factors associated with AD onset, and strategies for disease prevention and brain health maintenance. Participants will also learn about clinical tools for identifying and assessing AD so that patients can receive early intervention and treatment, as well as available guidelines and quality measure that can be incorporated into one’s practice.

www.neurosciencecme.com/cecity/cmea.asp?ID=468

Exploring the Potential of Novel Mechanisms in the Treatment of Alzheimer's and Huntington's Diseases

This two-part activity features neurodegenerative disorder experts who discuss the latest happenings in Alzheimer’s disease and Huntington’s disease management. The experts review the pathophysiology and available therapeutic options for both diseases, the role played by altered energy metabolism in Alzheimer’s disease progression, recent trial data, and potential cellular targets for developing new treatments.

www.peerviewpress.com/exploring-potential-novel-mechanisms-treatment-alzheimers-and-huntingtons-diseases

Improving the Quality of Patient Screening, Timely Diagnosis, and Institution of Therapy for Alzheimer’s Disease Among Minority Populations in the Community and Long-term Care Settings

Complete this two-part program for a greater understanding of the various factors that can increase the risk of developing Alzheimer’s among minority patient populations. Delays in screening, diagnosis, and treatment of the disease due to sociocultural and professional barriers; tactics for improving the rate of diagnoses in minority populations who are at risk for developing Alzheimer’s disease; and the application of recent date from pharmacologic studies in developing treatment plans for the disease in minority patients are all explored.

www.peerviewpress.com/improving-quality-patient-screening-timely-diagnosis-and-institution-therapy-alzheimer%E2%80%99s-disease-among-minority-populations-comm

Mitochondria: An Emerging Therapeutic Focus in Alzheimer’s Disease Therapy

With mitochondira representing an emerging therapeutic focus in Alzheimer’s disease research, as more and more evidence shows the cell components might play a key role in aging and neurodegenerative disease, this course reviews current Alzheimer’s disease treatments and their mechanisms of action; provides and overview of the suggested role played by mitochondria in aging and neurodegenerative diseases; and explores “recent evidence regarding the efficacy of an agent targeting the mitochondria in the treatment of Alzheimer's disease.”

Alzheimer’s Disease Education & Referral Center (ADEAR)

This site from the National Institute on Aging is meant to help patients and caregivers “find current, comprehensive Alzheimer's disease (AD) information and resources.” Here, they will find extensive information on causes, symptoms, diagnosis, and treatment, all provided in and easy-to-understand, question-and-answer format. Family members will also find tips, advice, information, and links to more resources, directed specifically for them as caregivers or in regards to obtaining professional caregiving. Site visitors will also find the latest news, information on and links to clinical trials, and the opportunity to sign up for the 

newsletter in the “Research Information” section.

The AFA mission is to “provide optimal care and services to individuals confronting dementia, and to their caregivers and families—through member organizations dedicated to improving quality of life.” With that in mind, this site provides both an introduction to Alzhemier’s and to caregiving. Links throughout the site direct visitors to such helpful resources as expert insights, financial help information, and other sites that are a part of the AFA network.

National Association of Professional Geriatric Care Managers

Direct caregivers to this site to learn more about professional geriatric care manager (PGCMs), how families can decide whether the time is right to engage their services, and questions to ask when evaluating candidates. Visitors can also access a “consumer library” that provides information about Alzheimer’s disease, family caregiver agreements, hiring in-home caregivers, and housing options for older adults. Patients and family members can use the “Find a Caregiver” search engine to find PGCMs based on name or geographic location. Patients and their families can also download a copy of the National Association of Professional Geriatric Care Managers Standards of Practice for Professional Geriatric Care Managers.

's Disease Neuroimaging Initiative Grand Opportunity

To “build upon the information obtained in the original Alzheimer's Disease Neuroimaging Initiative (ADNI1), to examine how brain imaging technology can be used with other tests to measure the progression of mild cognitive impairment (MCI) and early Alzheimer's disease (AD),” and “to define and characterize the mildest symptomatic phase of AD, referred to in this study as early amnestic MCI (EMCI),” as this “information will aid in the early detection of AD, and in measuring the effectiveness of treatments in future clinical trials.”

http://clinicaltrials.gov/ct2/show/NCT01078636?term=alzheimer&recr=Open&rank=36

Effect of Repetitive Transcranial Magnetic Stimulation on Language in Patients with Alzheimer's Disease

The researchers conducting this study aim “to investigate the efficacy of targeted repetitive transcranial magnetic stimulation (rTMS) on expressive language in patients with Alzheimer's disease.”

http://clinicaltrials.gov/ct2/show/NCT00814697?term=alzheimer&recr=Open&rank=12

Alzheimer’s Association Resources for Physicians

A number of key resources are presented in this section of Alzheimer’s Association (AA) website that make it one of the most useful Alzheimer’s sites for physicians, including references for diagnostic criteria, guidelines for disease management, and links to resources from other professional organizations. Site visitors can download the 40-page Tools for Early Identification, Assessment and Treatment document, which the AA created with the National Care Consortium; link to information on treatment, counseling families, coordinated care, and educational and outreach materials for African Americans and Spanish-speaking, Chinese, and Korean populations; and view the Alzheimer’s Research Center website. External resources that are linked to include “Early Alzheimer’s Disease: Patient and Family Guide,” from the Agency for Health C are Policy and Research Guidelines; “Guideline Summary for Point of Care: Detection, Diagnosis and Management of Dementia,” from the American Academy of Neurology; and “Position Statement: Principles of Care for Patients with Dementia Resulting from Alzheimer’s Disease,” from the American Association of Geriatric Psychiatry.”

http://www.alz.org/professionals_and_researchers_14899.asp#physicians

“Dementia Care Mapping is a tool developed by the late Professor Tom Kitwood, and Kathleen Bredin in the late 1980s and was designed to assess quality of care from the perspective of the person with dementia,” explains this site, which adds, “In 1992 the Bradford Dementia Group began delivering training courses in use of the method and since then undertaking training in the method has become increasingly popular with those working with people with dementia from many professional backgrounds.” Access this site to learn more about dementia care mapping, what information is provided in the courses, and when and where the courses are held. Don’t be discouraged by the UK basing of the site and training group; courses are provided for US physicians.

http://dev-zone.cen.brad.ac.uk/acad/health/dementia/dcm/index.php

Regional Differences in MRI Detection of Amyloid Plaques in AD Transgenic Mouse Brain

To use “five-way anatomic spatial co-registration of MR images with three different histological techniques” to reveal “properties of amyloid plaques in AD transgenic mouse brain… that may explain their variable visibility in gradient- and spin-echo MR images,” as most MRI studies that attempt to detect plaques in AD transgenic mouse brains have “ployed techniques that exploit the paramagnetic effect of iron and have had mixed results.”

In the MR imaging of human AD plaque, MRI methods might eventually be more successful if they rely less on iron magnetic susceptibility effect. This is especially believed by the authors because “human AD plaques more closely resemble the cortical and hippocampal plaques of AD transgenic mice than thalamic plaques.

http://dx.doi.org/10.1016/j.neuroimage.2010.08.033

Relative Capability of MR Imaging and FDG PET to Depict Changes Associated with Prodromal and Early Alzheimer Disease

Alzheimer's Disease

This Physicians’ Information and Education Resource from the American College of Physicians reviews screening, diagnosis, consultation for diagnosis, hospitalization, non-drug and drug therapy, patient education, consultation for management, and follow-up for insomnia. The fully reference, and incredibly thorough text is expert written and provided in bullet-point format for easy referencing. Enter the link code below in the search window at HCPLive.com, and enter “insomnia” in the search window at the site to which you are directed, and then select “physician” as your profession to access this activity.

Restless Legs Syndrome: A Case-based Review

The prevalence and impact of restless legs syndrome, associated risk factors and conditions, both behavioral and pharmacologic treatments for restless legs syndrome, and the differences in looking at the syndrome from the points of view of a primary care physician, psychiatrist, or neurologist form the foci of this interactive case study-based course from Johns Hopkins University School of Medicine.

Evolving Sleep-Wake Research: Implications for Improved Patient Outcomes, Part 3

With ongoing research in the area of sleep-wake medicine offering insights into the link between sleep disturbances and adverse effects on performance, mood, behavior, and medical illness, an understanding of the implications this data has on clinical practice is necessary. With that in mind, this activity thoroughly reviews the link between the neuronal process of electrical coupling and sleep-wake control. The physiology of electrical coupling and the impact medication may have on electrical coupling and the ability to modulate arousal are also discussed.

Obstructive Sleep Apnea — Sleep Channel

This frequently physician-reviewed site covers all the bases for patients in regards to obstructive sleep apnea (OSA), from causes and risk factors to complications and treatment. Beyond this information, the site provides a lengthy list of questions for patients to ask their physician, the story of another patient with OSA who was able to see the light of the tunnel (site visitors can submit their own stories), a doctor finder, and the chance to participate in any number of related forums that offer guidance and support.

www.sleepdisorderchannel.com/osa/index.shtml

Quite possibly the most extensive sleep resource online, this site provides patients and caregivers/family members comprehensive reviews on more than 25 conditions, from bed wetting and hypersomnia to night sweats and narcolepsy. Many sleep-related topics are also covered in equal depth, including sleep aids and devices, sleep tests, and sleep-related breathing disorders. Patients who are just beginning their search for online information on sleep are encourage to check out he “Sleep Basics” section, which answers such questions as “What does sleep do for you?”, “What happens when we dream?”, and “What disrupts sleep?”

www.sleepdisordersguide.com/sleep-center.html

Keep with its 30-year tradition of “equipping health care professionals with the tools needed to excel in the field of sleep medicine,” the American Academy of Sleep Medicine provides a collection of links to educational opportunities, professional training, and quality resources through this section of its online home. Through the resources here, physicians can obtain and prepare for board certification in sleep medicine; browse current job openings; take advantage of continuing education opportunities; and review recommendations for quality patient care.

Cognitive-Behavioural Therapy (CBT) for Insomnia Via Internet or Telehealth

Though your patients won’t be eligible for this trial—only residents of rural Manitoba, Canada, are eligible&mdash;the study is worth keeping an eye on, as the results will certainly have implications on telehealth practices in the US in regards to patients with insomnia. The study will “compare the effectiveness of two brief (6 week) psychological interventions delivered to residents of rural Manitoba using Telehealth or an interactive Internet-based platform” with the hypotheses “that a) participants in the Telehealth condition will report significantly greater improvements in sleep parameters (e.g., sleep efficiency, time awake in bed, sleep-onset latency), insomnia severity, and daytime fatigue than those in the Internet condition, and that b) participants in the Telehealth condition will show better adherence to treatment and greater satisfaction with treatment than those in the Internet condition.”

www.clinicaltrials.gov/ct2/show/NCT01162655?term=insomnia&recr=Open&rank=4

Cognitive Benefits of Treating Sleep Apnea in Parkinson's Disease (TAP)

To “test the effects of treating [sleep disordered breathing (SDB)] among patients with Parkinson's disease and SDB. Specifically, the study will test the effect of [continuous positive airway pressure (CPAP)] treatment on SDB and sleep; the effect of CPAP treatment on daytime sleepiness, cognition, overall quality of life and mood; the effect of CPAP treatment on the frequency of symptoms of REM behavior disorder and restless legs syndrome; the effect of continued CPAP use (beyond the six weeks of the study) on SDB, sleep, cognition, mood and quality of life; whether the study-partner feels that CPAP improves the patient's sleep, mood and overall functioning; [and] whether study-partners feel that their own sleep, mood and overall functioning improve as the patient's sleep improves both during the 6-week protocol and at follow-up for those opting to continue using CPAP.”

www.clinicaltrials.gov/ct2/show/NCT00492115?term=restless leg syndrome&recr=Open&rank=19

Transoral Robotic Surgery for Sleep Apnea

To determine if the da Vinci Robotic Surgical system “allows for ‘adequate exposure’ for transoral resection of hypertrophic lingual tonsils in patients with obstructive sleep apnea.”

www.clinicaltrials.gov/ct2/show/NCT01187160?term=sleep&recr=Open&rank=43

Development of the Pediatric Restless Legs Syndrome Severity Scale (P-RLS-SS)

: A Patient-reported Outcome Measure of Pediatric RLS Symptoms and Impact

“To develop a questionnaire to measure Pediatric Restless Legs Syndrome (P-RLS) symptoms and impact for use in clinical research.”

Although it is recommended that the scale be recommended, detailed input from both children and adolescents suffering from RLS, their parents, and clinical experts was used to create the P-RLS-SS. Therefore, the scale has “strong content validity that is intended to be comprehensive, clinically relevant, and important to patients.”

http://dx.doi.org/10.1016/j.sleep.2010.03.016

Relationship Between Insomnia and Pain in Major Depressive Disorder: A Sleep Diary and Actigraphy Study

To analyze “the association between insomnia and pain symptoms using subjective and objective sleep measures.”

The authors concluded that their “study supports specific role of subjective sleep disturbances and actigraphic measures in predicting pain symptoms in major depressive disorder. Further studies using a micro-longitudinal design are necessary to find out the causal relationship between sleep and pain in depressed patients.”

www.sleep-journal.com/article/S1389-9457%2810%2900008-0/abstract

AASM-endorsed Insomnia GUIDELINES Pocketcard

1.9MB (Android)/0.5MB (BlackBerry, Symbian s60)/2.5MB (iPhone, iPod Touch, iPad)/2.2MB (Palm OS)/2.9MB (Pocket PC, Windows Mobile Smartphone)

Use this practical, quick-reference tool to obtain all you need to make accurate decisions at the point of care in regards to insomnia, through algorithms on diagnosis and treatment and information that covers screening, drug therapy, dosing, patient monitoring, and counseling.

Sleep Disorders

When deciding whether to buy a new gadget, especially one with a somewhat hefty price tag, one usually looks for indispensable features not available with current technology as a justification for the purchase. Well, look no further. When I saw this program available, I knew that no further exotic features would be needed to more than justify my iPad purchase. Clearly, there is no more essential diagnostic maneuver than performing the test for the Opticokinetic Reflex. Countless imaging studies could undoubtedly be avoided if only this reflex was more routinely and expertly utilized. So, when I saw the iPad app that could facilitate checking for OKN, I knew I could not put off my iPad purchase any longer. My patients deserved no less. So, instead of investing in a piece of cloth (about 50 cents) and then lugging that object all over kingdom come, there was now the option to just carry my iPad around instead. The ingenious principle behind this app entails the animation of lines or shapes on the iPad screen, which is held stationary. No longer is the tiresome pulling of the cloth through the hands required. The stripes come in Red and Black (though I don’t know the anatomical-pathological-physiological implications of the difference). In addition, an entirely red screen can be presented to check for red desaturation. Who needs swinging flashlights or VER tests with this technology available?

     As it turns out, this is such a valuable technology that two other software companies have introduced their own versions of a similar application, and who could blame them? There is OptoDrum (

), which provide the same functionality. I predict there will be more entries in the almost limitless market for more sophisticated OKN testing.

This program was apparently written by a vascular neurologist and contains several very useful  neurology scales. Of course, the NIH Stroke Scale is included, with a very simple user interface for conveniently determining the score. tPA contrainidications and dosing regimens are also included. I liked the interface for the ABCD2 scale as well (helpful in predicting the risk of stroke within 48 hours after TIAs). This scale assists in determining who should be admitted to the hospital after a TIA and seems to be increasing in its popularity. Another very useful scale is the Anoxic Encephalopathy Prognosis based on the AAN Guidelines for predicting which patients have a very poor prognosis after a cardiac arrest. Finally, there is an algorithm for the treatment of Status Epilepticus. All in all, the very practical information is presented in a clear-cut and usable fashion.

This app is the digital version of the standard tap test (hence the name) which counts the number of times the patient can tap the screen of your device in a given amount of time.  A pretty simple concept, but I think not currently utilized to its full potential.  The program enables you to test  sequential tapping and  even test the tapping abilities of  toes (though I’m not too enthusiastic about patients stepping on the iPad screen). Even in the absence of rigorous studies demonstrating the validity of this test for diagnosis specific application, using tap rapidity as a motor evaluation has a  commonsense appeal .  I would think that in Parkinson’s Disease there would be a particular interest in using this test to follow a patient longitudinally, or even optimizing their dosing regimens.  I even wonder if there would be a correlation between results of this tap test and the general motor skills required to safely operate a motor vehicle.  Maybe there is a study or two that could be done?

MDNG: Neurology/Psychiatry Edition Physician Editor-in-Chief, Steven Zuckerman, MD

Nerve Whiz is a free neuromuscular education application developed by a neuromuscular neurologist at the University of Michigan. Features of the application include: charts organized by muscle, nerve, root, action, or plexus; a weak muscle localizer; adaptive diagrams of the brachial and lumbosacral plexuses that show which muscles and nerves are involved for each segment selected; and an interactive sensory localizer that allows users to touch a picture of an arm or leg to determine the origin of sensory loss. The interface is simple, intuitive, and beautifully rendered. Charts and diagrams load seamlessly, and the sensory localizer is downright fun to use. Combining this wealth of information with skilled clinical knowledge makes the complex and often intimidating realm of diagnosing neuromuscular complaints a little less difficult. If you are a medical student or a physician who deals with patients experiencing frequent nerve-related musculoskeletal problems, Nerve Whiz is a “must have” application for your electronic medical bag.

This app is for the doc who often searches for medical information on Medline, Medscape, or even Google. Simply speak your search term/s and the voice recognition software searches for you in all the databases at once, but divided into sources. Simply spin the source tab at the top to change the data source; I really like that feature! Explore the IMO database as a convenient way to find an ICD9 or CPT code—this may be it's most useful feature. The Drugs.mobi database is also available, and suddenly you also have a quick way to look up a medication and find pharmacology, indications, and dosing easily. I would give this app five stars but took it down one star for collecting my name and contact information before being able to be used.  Enhancements I would like to see include the ability to set a default database or disable the ones you don't want, and add access to other online databases, such as Up-to-date if you already subscribe.

Feature Articles

Our app reviewers have taken over, providing all of this month's reviews. See what they had to say.

App Wrap

Patients are empowering themselves to become more involved drivers in their healthcare journey, many times turning to the Internet to obtain health information. And although the right information can be decidedly useful, plenty of information online can be out of date and plain wrong, and it’s what the patient does with that information that counts. So, how can you help?

In the spirit of e-mail, e-commerce, e-books, and e-prescribing, it’s time to get familiar with the term “e-patients.” Only this time, the “e” doesn’t mean electronic. It stands for patients who are “equipped,” “enabled,” “empowered,” and “engaged” with information. The term comes from the late Tom Ferguson, MD (www.doctom.com), who had written and lectured about empowered consumers of healthcare from 1975 until his death in 2006. Ferguson’s legacy lives in part through the Society for Participatory Medicine (

), incorporated in 2009 to serve empowered, engaged patients and encourage others to take more control over their own health and healthcare.

Ferguson saw healthcare as a partnership between healthcare professionals, patients, and support systems. According to the society, “Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.”

Many patients are carrying the torch for the movement these days, but few as zestfully as a New Hampshire cancer-survivor-turned-patient-advocate named Dave deBronkart, aka “e-Patient Dave” (

DeBronkart wrote a book about his experience battling kidney cancer that had metastasized to his lung, Laugh, Sing and Eat Like a Pig: How an Empowered Patient Beat Stage IV Cancer (and what healthcare can learn from it), and now has made it his job to preach the word of patient empowerment.

Initially after his 2007 cancer diagnosis, deBronkart acted like anyone who had to confront his own mortality. He turned to the Internet and started asking questions of his doctor, who happened to be pretty tech-savvy himself. Soon, Daniel Z. Sands, MD, director of medical informatics at Cisco Systems (

), primary care physician at Beth Israel Deaconess Medical Center in Boston (BIDMC; 

), and MDNG editorial board member, became deBronkart’s physician and partner in care.

“At no point did I decide that I was going to take this all into my own hands,” deBronkart says. “I needed expert help.”

A marketing consultant with good computer skills, deBronkart already was a user of BIDMC’s PatientSite portal (

)—which Sands helped create&mdash;before the cancer diagnosis. “It’s not something that all of a sudden came along when I got sick,” he notes.

DeBronkart found some reassurance and a community of other oncology patients from the public website of the Association of Cancer Online Resources (www.acor.org): “It’s the best source of information on the Internet about what to do about kidney cancer,” deBronkart says. He took the information he gathered and started asking a lot of questions. “If I find something, I ask, ‘What do you think about that?’” deBronkart says. His engagement in his own care helped deBronkart through multiple rounds of treatment, and now his cancer is in remission. deBronkart quit his job last year to become a full-time advocate for e-patients as co-chair of the Society for Participatory Medicine. “Much to my surprise, I went from almost dead from cancer in two years to chairman of a medical society,” he says.

As deBronkart can attest to simply by being alive, patient engagement often pays off. A 2009 study from the AARP (

) found that the 30-day hospital readmission rate for patients with chronic diseases who were not much engaged in their care was twice that of those who did take a more active role. The researchers found similar trends with medical errors, care coordination, and communication between the patients’ healthcare providers.

The Internet, of course, has changed the dynamic of the physician-patient relationship and of disease care in that information is more accessible than ever before and that patients can more readily find others with similar conditions. A Harris Interactive poll (

) published in August found that 88% of adult Internet users in the U.S. searched for health information at least once in the last year, and 53% said they discussed their online findings with a health professional.

The wide availability of information works two ways, though. “Doctors use Google just like patients,” notes Ronald Epstein, MD, professor of family medicine and director, Center for Communication and Disparities Research, University of Rochester (

). “In a way, we’ve got a shared resource. As physicians, we no longer have claim to secret knowledge.”

While that can be good for patients, it’s often hard to figure out which information is helpful and which is inappropriate, out of date, or just plain wrong.

), producer of electronic medical reference databases, found that more than 60% of primary care physicians like it when patients bring in information they printed from the Internet and believe it helps them communicate with their patients. Yet only 5% of the doctors completely agreed with the statement that such information is useful to treatment.

A decade ago, Charles M. Kilo, MD, now chief medical officer of Oregon Health & Science University (

), a Portland, Oregon practice set up as a new approach to primary care. Among other things, the practice focuses on empowering patients with information and building strong patient-physician relationships.

“Engaging patients is an evidence-based intervention to try to improve care,” according to Kilo. “Just having access to information doesn’t necessarily mean you are more empowered, but it’s a good start.”

Sure, Kilo does have some reservations. “The Internet is not a great tool for patients in an unadulterated form,” he says. People do get a lot of misconceptions from reading online health information, such as having a fever and believing that they have five symptoms indicating malaria.

But the Internet still can be helpful as an adjunct to physician advice. “We shouldn’t throw out the baby with the bathwater,” says Kilo. “I find it really simple to re-correct their course.”

Kilo would like to see patients take the attitude that they are engaged in prevention and/or care of a chronic disease. “There’s no reason to be put off by this,” he says. “We want people to ask questions.”

One physician who thinks patients can, and do, go too far with Internet search is Scott Haig, MD, assistant clinical professor, orthopedic surgery, Columbia University College of Physicians and Surgeons (

), and occasional contributor to Time magazine (

). Haig penned a controversial commentary in Time in 2007 (

) about “brainsuckers,” a common physician term for patients who spend lots of time researching minutiae about their doctors’ personal lives and waste their doctors’ time with irrelevant, confrontational questions.

“There’s so much information (as well as misinformation) in medicine—and, yes, a lot of it can be Googled&mdash;that one major responsibility of an expert is to know what to ignore,” Haig wrote in that article.

Haig says it’s exceedingly easy to get a paper published these days and that pharmaceutical and medical device makers spend big bucks marketing their expensive new products, so there’s a lot of questionable scientific information floating around. For example, some recent medical literature suggests operating on broken clavicles, something Haig has never done in nearly 30 years of practice. “I think it’s malpractice. I think it’s unethical. I think it’s immoral,” Haig says.

But it’s also very profitable. “How do you tell people this?” Haig wonders.

The Harris Interactive poll specifically used the term “cyberchondriacs” to refer to the 32% of U.S. adults who frequently used the Internet to search for information about health and healthcare—up from 22% a year ago. (Sands personally finds the word “pejorative,” noting, “There were people on the lunatic fringe before the Internet.”)

September 2010

Social Media Notebook - Oh, the online places you'll go...or not!

Parkinson's Disease

Addiction

Alzheimer's Disease

Sleep Disorders

App Wrap

E-patients: What You Need to Know

Regional Extension Centers: Helping You Achieve Meaningful Use

Latest News