DIabetes: 'smart insulin patch' could revolutionize glucose control

Patients with diabetes have to control their blood sugar by regularly pricking their finger and giving themselves insulin shots. The procedure is painful and imprecise - injecting the wrong amount of insulin can lead to serious complications, and in some cases, coma and death.

The researchers aim to develop a smart insulin patch that would only need to be changed every few days.
Image credit: Zhen Gu

Now, the development of a "smart insulin patch" could one day make such an ordeal a thing of the past for the millions of Americans who suffer from diabetes, according to the team behind the innovation, which includes members from the University of North Carolina (UNC) in Chapel Hill and NC State in Raleigh.

The smart patch - a square sliver of tape no larger than a penny - has more than a hundred microneedles, each about the size of an eyelash, containing tiny reservoirs of insulin and glucose-sensing enzymes.

The device - which can be placed anywhere on the body - senses when blood sugar levels get too high and rapidly discharges the right amount of insulin into the bloodstream.

In the Proceedings of the National Academy of Sciences, the diabetes doctors and biomedical engineers that invented the painless patch describe how they tested it in a mouse model of type 1 diabetes and showed it lowered blood glucose for several hours.

While it shows great promise, it is too early to say if and when the patch can be used in human patients - the team says more tests and then clinical trials are needed.

Patch mimics body's own system for generating insulin

The smart insulin patch works by mimicking the body's own system for generating insulin - the beta cells of the pancreas - which produce and store insulin in tiny sacs or vesicles. They also sense changes in blood sugar and signal insulin to be released from the vesicles as needed.

The team constructed artificial vesicles that perform in a similar way out of two natural materials - hyaluronic acid (HA) used in cosmetics and 2-nitroimidazole (NI), an organic compound used in diagnostics.

Together, the two compounds form a molecule that is water-loving at one end (the HA part) and water-repellent at the other (the NI part). Groups of the molecule self-assemble into vesicles - rather like oil droplets do in water - with the water repellent ends on the inside and the water-loving ends on the outside.

The researchers found they could insert a core of solid insulin and enzymes designed to detect glucose into the artificial vesicles, which in large numbers formed millions of bubble-like nanostructures, each 100 times smaller than the thickness of human hair.

When they tested the intelligent insulin nanoparticles in the lab, the team found they responded to raised blood sugar. The excess glucose molecules entered the artificial vesicles, using up oxygen as the enzymes on board converted them into gluconic acid. This reduction in oxygen or "hypoxia" makes the water-repellent NI end of the molecules that make up the vesicles become water-loving, and the vesicles dissolve and release insulin into the bloodstream.

Patch kept blood sugar normal in diabetic mice for hours

The next step for the researchers was to find a way to administer the artificial vesicles to diabetes patients. This is when they turned to the idea of tiny microneedles incorporated into a patch, rather than rely on the large needles or catheters of the "closed-loop systems" of other approaches to glucose-sensitive insulin delivery.

They eventually produced a silicon strip with over a hundred microneedles that pierce the skin and tap into the blood flowing in the underlying capillaries. Each microneedle contains a reservoir of the artificial vesicles.

The team tested the invention in a mouse model of type 1 diabetes. They gave one group of mice a standard insulin injection - the levels dropped to normal but then quickly rose to hyperglycemic levels.

But when they treated another group of diabetic mice with the patch, their blood sugar levels normalized within half an hour and stayed that way for several hours.

The researchers also found that by varying the dose of enzyme, they could fine-tune the patch to alter glucose levels within certain ranges.

A 'game changer' for diabetes patients

Mice are less sensitive to insulin than humans, so the researchers believe that the patches could last even longer in human patients. The researchers aim to develop a smart insulin patch that would only need to be changed every few days.

Such a prospect would be a "game changer" for diabetes patients, explains co-senior author John Buse, a professor of medicine and past president of the American Diabetes Association:

"The hard part of diabetes care is not the insulin shots, or the blood sugar checks, or the diet but the fact that you have to do them all several times a day every day for the rest of your life."

Co-senior author Zhen Gu, a professor in biomedical engineering, says:

"We have designed a patch for diabetes that works fast, is easy to use, and is made from nontoxic, biocompatible materials. The whole system can be personalized to account for a diabetic's weight and sensitivity to insulin, so we could make the smart patch even smarter."

There are more than 387 million people with diabetes worldwide, and the number is predicted to rise to 592 million by 2035.

Funds from the NC TraCS Institute and the American Diabetes Association helped finance the research.

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First Asia-Pacific vision-restoring "bionic eye" implant performed

Groundbreaking bionic retinal implant surgery has been performed in Honolulu by a team at the Eye Surgery Center of Hawaii. The procedure is the first of its kind in the Asia-Pacific region to help restore vision for the blind.

The Argus II "bionic eye implant has the potential to restore vision to patients, who have been in total or near total darkness."

The team of doctors, led by Dr. Gregg T. Kokame, completed the cutting-edge procedure on March 24, 2015. Dr. Mark Humayun, Prof. of Ophthalmology at the University of Southern California (USC) Eye Institute, Los Angeles, CA and the co-inventor of the Argus II implant was also present for this historic event.

The Eye Surgery Center of Hawaii is an ophthalmology specialty surgery center and a portfolio company of SKAI Ventures that is focused exclusively on the surgical treatment of the eye in Hawaii and the Asia-Pacific region. There are presently eighteen eye surgeons who perform ophthalmologic surgeries at the center.

Dr. Kokame, founder and president of Retina Consultants of Hawaii, and the president of the Eye Surgery Center of Hawaii says:

"Today is a historical day for many reasons. This 'bionic eye' implant has the potential to restore vision to patients, who have been in total or near total darkness. This can dramatically change the quality of life of these patients."

"I have been involved in the care of hereditary blindness since the beginning of my career in Ophthalmology at the UCLA Jules Stein Eye Institute," he adds. "I have watched patients progressively lose vision, but this new futuristic technology is now available to allow potential vision recovery to patients who are functionally blind."

World's first approved vision-restoring device

"We are excited to bring this life-changing technology to Hawaii residents and to the Asia-Pacific region," comments Dr. Hank Wuh, CEO of SKAI Ventures. "As the leading center of excellence for vision surgery, we hope to help people with retinal blindness throughout the region."

The "bionic eye," known officially as the Argus II Retinal Prosthesis System (Argus II), is the world's first approved device intended to restore some functional vision for people suffering from blindness. The Argus II, developed at USC, has shown dramatic clinical results to help patients with retinal blindness be able to utilize artificial vision to see.

Argus II is approved for use in the United States and the European Economic Area and is available in European countries and the Middle East.

The implantation of the Argus II novel vision-restoring device at the Eye Surgery Center of Hawaii is the first time the procedure has been performed in the Asia-Pacific region. The Eye Surgery Center of Hawaii is also only the second center in the western US to perform the procedure - the first being USC.

Argus II headband and Argus II glasses.
Image credit: Second Sight

The doctors have scheduled more artificial retinal bionic implant transplants at the Eye Surgery Center of Hawaii.

Patients with blindness from retinitis pigmentosa, who are interested in being evaluated for this procedure, should contact Dr. Gregg Kokame's office at 808-487-8928 or email inquiries to research@retinahi.com.

Patients from the Asia-Pacific region interested in bionic retina transplantation should contact SKAI Ventures Concierge Program at gulloa@skaiventures.com or 808-949-2208 ext. 129.

Medical News Today recently reported that a blind man affected by a degenerative condition known as retinitis pigmentosa is now able to see objects and people again with the help of a bionic eye implant.

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New rapid test could distinguish viral infections

A new blood test shows promise as a rapid way to help doctors determine whether a respiratory infection is viral or bacterial and thus reduce inappropriate use of antibiotics, which only work against bacteria.
The study is published in the journal Science Translational Medicine.
Study co-author Geoffrey Ginsburg, a professor at Duke University School of Medicine, says:
"Current tests require knowledge of the pathogen to confirm infection, because they are strain-specific. But our test could be used right away when a new, unknown pathogen emerges."
He explains the new test would be especially useful for spotting new viruses before they spread into outbreaks.
For example, in the case of pandemic flu or MERS, the new coronavirus that has erupted in the Middle East, it would be very important to diagnose new cases quickly, much faster than current diagnostic tests.
The new test uses a different approach to traditional diagnostics: instead of testing the pathogen, it tests the immune response in the infected person.

The new rapid test was able to detect viral infections with 90% accuracy by determining how strongly genes in immune cells and other blood cells were switched on.

Using an approach called "reverse transcription polymerase chain reaction (RT-PCR)," the test evaluates how strongly certain genes in immune cells and other cells in the blood are switched on.
Previous studies have shown these genes are more active in people with respiratory infections caused by viruses. They are not switched on in healthy people or those whose infection is caused by bacteria.
In their study, the team describes how they evaluated the test in a group of over 100 people and found it was able to identify, with nearly 90% accuracy, the ones with viral infections.
The group comprised patients (some with viral infection, the rest with bacterial infection) and healthy controls. The patients had attended a hospital emergency department complaining of fever.
The test positively identified viral infection in 89% of cases, and it correctly ruled out viral infection in 94% of cases.
The team concludes:

"These results show that RT-PCR-based detection of a host gene expression signature can classify individuals with respiratory viral infection and sets the stage for prospective evaluation of this diagnostic approach in a clinical setting."

Christopher W. Woods, co-author and an associate professor of medicine, pathology and global health at Duke and the Durham VA Medical Center, says bacterial resistance, which is largely driven by overuse of antibiotics, is a big global public health problem, causing infections that are increasingly difficult to manage:
"A tool that enables us to accurately identify viral infections could curb the indiscriminate use of antibiotics and reduce the development of resistant pathogens."
The US Centers for Disease Control and Prevention (CDC) says taking antibiotics for viral infections can do more harm than good, citing for instance, that where children are concerned, antibiotics are the most common cause of emergency department visits for adverse drug events in the US.
The team is now working to reduce the time it takes for the test to report results.
It currently takes 12 hours to analyze 30 genes, so Prof. Ginsburg says there is scope to reduce both the time and the number of genes.

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Super-Quick Test for Bacteria Thanks to Nano-Sized "Tuning Forks"

Some bacterial infections are so severe that if the right antibiotic is not given straight away, there is a high chance the patient will die. But unfortunately with current methods it can take days if not weeks to test a bacterium's response to treatment. Now researchers in Switzerland have developed a test based on nano-sized "tuning forks" that could cut this timescale to minutes and thereby save lives.
At present, to find out if a bacterium is responding to antibiotic treatment, clinicians have to wait and see what happens when they try to grow it in a culture. For some types of bacteria, such as the one that causes tuberculosis (TB), this can take up to a month.
The nano-sized "tuning forks" that the researchers in this new study have developed are tiny and extremely sensitive cantilevers, thinner than human hair, that can pick up almost imperceptible atomic-level vibrations emitted by live bacteria.
Researchers from Ecole Polytechnique Fédérale de Lausanne (EPFL) report how they developed and demonstrated the technology in a study published online in Nature Nanotechnology on 30 June.
"Here we show that the fluctuations of highly sensitive atomic force microscope cantilevers can be used to detect low concentrations of bacteria, characterize their metabolism and quantitatively screen (within minutes) their response to antibiotics," they write.

Tuning Forks Pick Up Bacterial Vibrations

Live bacteria are busy with metabolic activity, the set of life-sustaining chemical reactions that goes on in living cells. The researchers propose that it is this metabolic activity that sends out the tiny vibrations that their technology detects.
Placing the bacteria on or near the nano-sized tuning forks or cantilevers causes them to oscillate in response to the bacterial vibrations. The oscillations are very small, of the order of one millionth of a millimeter.

The measuring device © EPFL / Alain Herzog

By projecting a laser beam onto the cantilever and picking up how the light is reflected back, the researchers convert the oscillations into electrical signals that can be read easily.

Fast and Accurate Way to Find Out If Antibiotic Is Working

When the electrical signal is a flat line, it means there are no live bacteria. An effective way to find out very quickly whether treatment with an antibiotic has had the desired effect. This is especially useful for testing resistant strains.
Study author Giovanni Dietler, a physicist who investigates properties of living materials, says in a statement:
"This method is fast and accurate. And it can be a precious tool for both doctors looking for the right dosage of antibiotics and for researchers to determine which treatments are the most effective."
"We applied this methodology to Escherichia coli and Staphylococcus aureus, showing that live bacteria produced larger cantilever fluctuations than bacteria exposed to antibiotics," write the authors.

Technology Fits In a Matchbox

The researchers have miniaturized their technology so it fits in a device the size of matchbox, making it easily portable for clinical use.
Dietler says they could make it even smaller:
"By joining our tool with a piezoelectric device instead of a laser, we could further reduce its size to the size of a microchip," he explains.
And he also sees it may be possible to develop a version that can test a series of antibiotics on one strain in only a few minutes.

Nano-Sized Tuning Forks May Have Use In Cancer Treatment

The researchers suggest their nano-sized tuning forks could also be useful for testing response to chemotherapy treatment.
They are currently looking at a way to use their nano-sized tuning forks to measure the metabolism of tumor cells that have been exposed to chemotherapy.
Again, as with bacterial infections, the huge advantage would be to see within minutes instead of weeks, whether the cancer was responding to treatment.
Another way scientists are using nanotechnology in medicine is to target therapy at the cellular level. For example, one group at MIT in the US has developed an approach that could be used to create "nano-factories" that make protein-based drugs at tumor sites to fight cancer.

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Face Of Transplant Woman Has Complete Feeling And Better Speech

Five months after her partial face transplant, Isabelle Dinoire has complete feeling on her face again. According to an interview Dinoire had with Le Journal du Dimanche, the physical recovery has been easier than coming to terms with her new look.

When asked whether she had accepted her new look, she said 'It is too difficult to explain'. She says that every day she thinks of the donor who made it possible for her to be visible again. She says she is forever grateful. Sometimes she says she looks at her photo album, sees pictures of her old self - before she was mauled, and is still amazed at how different she looks now.

She is able to move her facial muscles again, Dinoire says her speech has improved significantly.

Dinoire has to have an injection each week to stop her body from rejecting the new tissue, she also takes 10 pills each day. On a daily basis she has to look at a patch of the donor's skin, which has been attached to her stomach. Any change in the skin would be an indication that her body may be rejecting the donor's tissue.

Dinoire was the first person to receive a face transplant. The operation took place in November, 2005. She received new lips, a chin and a nose.

In her first news conference last year it was not easy to understand her as she had difficulty in moving her mouth. She had a large scar around her face - this scar is healing well, she said. Her operation lasted over 15 hours.

In May last year Isabelle's face was severely disfigured when her dog mauled her while she was asleep as a result of a medication overdose. Apparently, the dog was trying to revive her - which it apparently managed to do. The dog was later put down, against the family's wishes.

This year a man received a face transplant at the Xijing Military Hospital, Xian, China. Li Guoxing received a new upper lip, cheek and nose. Surgeons worked for 14 hours on his face. Guoxing was a hunter who suffered a bear attack two years ago, leaving his face severely disfigured.

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Heart Attack Test Gives Diagnosis In 1 Hour

A more sensitive test for heart attack may cut the diagnosis time to one hour, removing the need for prolonged monitoring in 3 out of 4 patients who present to the Emergency Department (ED) with chest pains, according to a new US study published this week.

Writing about their work in a paper published online on 13 August in the Archives of Internal Medicine, the researchers suggest the test, which screens more sensitively for changes in a standard biochemical marker for myocardial infarction (heart attack), may help move patients more quickly through the ED, thus reducing congestion and saving time and money.

Around 10% of all emergency department consultation in the US are people with symptoms that might suggest acute myocardial infarction (AMI).

The Need for a Rapid Test

In an accompanying commentary, L. Kristin Newby, professor of medicine at Duke University Medical Center in North Carolina, explains there is a demand for new tools that can help rapid triage of patients with suspected heart attack, especially as EDs are getting more and more crowded.

When a patient presents to the ED with chest pains, the first thing doctors do is rule in or rule out for heart attack. The cornerstone for diagnosing the condition relies on clinical assessment, electrocardiography and measurement of a biochemical marker called cardiac troponin (or cTn). Without a rapid test for the marker, it can take 3 hours or more to check for increases in levels.

In their introduction, first author Tobias Reichlin, of University Hospital Basel, Switzerland, and colleagues, explain while there is evidence that high-sensitivity cardiac troponin (hs-cTn) assays appear to improve the early diagnosis of AMI, it is not clear how doctors should use them in practice, especially as there is a suggestion they may also increase positive results for other conditions.

So they developed and validated an algorithm designed to help doctors rapidly rule in and rule out AMI.

The Study

For their multicenter study Reichlin and colleagues recruited 872 patients who presented to the ED with acute chest pain. AMI was the final diagnosis in 147 (17%) of them.

They developed the algorithm in half of the patients and validated it in the remaining half. The algorithm used baseline hs-cTnT and absolute changes in levels of the biochemical marker within the first hour.

When they validated the test in the second group of patients, within one hour it classed 60% (259 patients) of them as rule-out, 17% (76) as rule-in, and 23% (101) as being in the observational zone.

They found the cumulative 30-day survival was nearly 100%, 98.6% and 95.3% for patients classed as rule-out, observational zone, and rule-in respectively. Reichlin and colleagues conclude:

"Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain."

"This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients," they add.

Comment on the Study

Newby writes that the study is an important step forward in the use of hsTn (high-sensitivity troponin) as a triage tool for ED patients with a possible heart attack, but there is still a lot of work to be done before there is sufficient evidence that hsTn and the algorithms Reichlin and colleagues have developed can be used in clinical practice.

She also points to a practical problem which is far from "simple" as the authors describe. And that is in practice, doctors would need different groups of algorithms for different groups of patients (for instance depending on age and other characteristics).

This added consideration will "challenge application by busy clinicians unlikely to remember or accurately process the proposed algorithm", says Newby.

Because of this, she suggests if the hsTn algorithms are validated, then they should form part of electronic health records so doctors have all the information, with interpretation and explanation of the algorithm to hand when conducting triage and treatment.

Research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, Abbott, Roche, Siemens and the Department of Internal Medicine, University Hospital Basel, financed the study. Roche also donated the blood assay the researchers used.

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What Is MRI? How Does MRI Work?

MRI is short for Magnetic Resonance Imaging. It is a procedure used in hospitals to scan patients and determine the severity of certain injuries. An MRI machine uses a magnetic field and radio waves to create detailed images of the body. Common reasons people go in to get an M.R.I. are for a sprained ankle or back pain.

What should I do to prepare for an MRI?

There is little to no preparation needed before getting an MRI. When you first arrive at the hospital, the doctors will ask you to change into a gown. You will also be asked to remove all accessories such as jewelry, credit cards, and any metallic objects. The reason for this is because MRIs involve magnets, which may interact with objects in your possession. This in turn may lead to bad results and/or poor image quality.

What does an MRI machine look like?

Most MRI machines look like a long tube, with a large magnet present in the circular area. When beginning the process of taking an MRI, the patient is laid down on a table. Then depending on where the MRI needs to be taken, the technician slides a coil to the specific area being imaged. The coil is the part of the machine that receives the MR signal.

Is an MRI going to hurt?

You can breathe a sigh of relief. It is not going to hurt one bit. The exam itself is a painless procedure that is noninvasive, meaning that the body is not tampered with in any way. Since humans are not able to feel any type of radio waves, patients will not feel a thing. A loud tapping noise will be experienced, however, as the magnets are turned on and off throughout the exam. No need to worry, though. If you think the noise will bother you, just ask the technician for a pair of earplugs to drown out the noise.

How long does the MRI test last?

The exam itself takes about 30 - 45 minutes. However, this may vary depending on the number of body parts being examined.

So how does MRI work?

A strong magnetic field is created by passing an electric current through the wire loops. While this is happening, other coils in the magnet send and receive radio waves. This triggers protons in the body to align themselves. Once aligned, radio waves are absorbed by the protons, which stimulate spinning. Energy is released after "exciting" the molecules, which in turn emits energy signals that are picked up by the coil. This information is then sent to a computer which processes all the signals and generates it into an image. The final product is a 3-D image representation of the area being examined.

Unlike CT scanning or general x-ray studies, no ionizing radiation is involved with an MRI.

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What Is Endoscopy? What Is An Endoscope?

An endoscopy involves examining the inside of a person's body using an endoscope. An endoscope is a medical device consisting of a long, thin, flexible (or rigid) tube which has a light and a video camera. Images of the inside of the patient's body can be seen on a screen. The whole endoscopy is recorded so that doctors can check it again. Endoscopy is a minimally invasive diagnostic medical procedure. It is used to examine the interior surfaces of an organ or tissue.

The endoscope can also be used for enabling biopsies and retrieving foreign objects.

Endoscopy is a noninvasive alternative to surgery for foreign object removal from the gastrointestinal tract.

When is an endoscopy used?

To confirm a diagnosis

An endoscopy is often used to confirm a diagnosis when other devices, such as an MRI, X-ray, or CT scan are considered inappropriate.

An endoscopy is often carried out to find out the degree of problems a known condition may have caused. The endoscopy, in these cases, may significantly contribute towards the doctor's decision on the best treatment for the patient.

The following conditions and illnesses are most commonly investigated or diagnosed with an endoscopy:

• Breathing disorders
• Chronic diarrhea
• Incontinence
• Internal bleeding
• Irritable bowel syndrome
• Stomach ulcers
• Urinary tract infections

Biopsies

Endoscopies are commonly used for the diagnosis of cancer. They are used for biopsies - taking samples of tissue to find out whether it is cancerous. Thanks to an endoscope, biopsies of the intestines or lungs can be done without the need for major surgery. This study explains that colonoscopy is the most effective screening option for colorectal cancer.

Surgery

Some surgical procedures can be carried out with a modified endoscope, such as the removal of the gallbladder, tying and sealing the fallopian tubes, and taking out small tumors and foreign objects from the lungs or digestive system. A study found that the removal through endoscopy of tumors that affect only the superficial layers of the esophagus can avoid complete extirpation of this part of the digestive tract.

A laparoscope is a type of endoscope which is used for keyhole surgery or laparoscopic surgery. Laparoscopic surgery requires only a small incision and is commonly used today for appendectomies, hysterectomies, and prostatectomies. Patients lose much less blood during and after surgery and recover much faster, compared to other surgical procedures.

Short history of endoscopy

Reports indicate that the first endoscope was devised in 1805. It consisted of a large tube and a candle. Because it was cumbersome and large it had very limited uses. Fiber optics, which appeared in the 1960s, was a major factor in the endoscopy revolution. With fiber optics it really became possible for the doctor to see and record the inside of the patient's body with a small and relatively painless device.

Endoscopy has many uses today

An endoscope can be fitted with surgical instruments; it can send pulses or heat and electricity and destroy small tumors or gallstones. Specialized endoscopes have their own names, such as:

• Bronchoscopes - they examine the air passages and the lungs.
• Colonoscopes - they examine the colon.
• Gastroscopes - they examine the small intestine, stomach and esophagus (throat).
• Arthroscopes - they examine the joints.
• Hysteroscopes - they examine a woman's uterus.
• Cystoscopes - they examine the urinary bladder.

Types of endoscopies

Here is a list of some types of endoscopies and their meanings:

• Amnioscopy - examination of the amniotic cavity and fetus.


• Arthroscopy - examination of the joints.


• Bronchoscopy - examination of the air passages and the lungs.


• Colonoscopy - examination of the colon.


• Colposcopy - examination of the cervix and the tissues of the vagina and vulva.


• Cystoscopy - examination of the urinary bladder.


• EGD (Esophageal Gastroduodenoscopy), also known as panendoscopy - examination of the esophagus, stomach and duodenum.


• ERCP (endoscopic retrograde cholangio-pancreatography) - examination of the liver, gallbladder, bile ducts, and pancreas.


• Fetoscopy - examination of the fetus.


• Laparoscopy - a small incision to examine the abdominal cavity.


• Laryngoscopy - examination of the back of the throat, including the voice box (larynx) and vocal cords.


• Proctoscopy - examination of the rectum and the end of the colon.


• Rhinoscopy - examination of the inside of the nose.


• Thoracoscopy - examination of the lungs or other structures in the chest cavity.

Endoscope the patient swallows - wireless capsule endoscopy

The patient swallows a capsule which wirelessly sends images of the inside of his/her stomach and digestive tract. Eventually the capsule will exit the patient when he/she has a bowel motion. Currently, capsule endoscopy is used to find out why a patient is bleeding in their digestive system, with no clear cause. It can also be used to diagnose GERD (Gastroesophageal reflux disease). A study indicated that capsule endoscopy is effective in diagnosing gastrointestinal bleeding and small bowel Crohn's disease in children. Another study showed how wireless capsule endoscopy is turning up Crohn's diseases diagnoses among patients whose illness had not been spotted for over a decade.

The capsule is about the size of a multi-vitamin and has a camera attached to it. As it moves through the digestive tract it takes pictures. The patient wears a small data recorder on his/her belt; this recorder receives the data from the capsule. The pictures are later downloaded and interpreted by a doctor.

Before swallowing the capsule the patient must have fasted overnight. The next day he/she will be fitted with the equipment, which includes a belt that contains a battery and a data recorder. Leads will be hooked up to the abdomen; this is painless and does not perforate the skin. As soon as the equipment is hooked up the patient swallows the capsule. Eight hours later he/she returns and the equipment is disconnected.

The main components of an endoscope

An endoscope consists of:

• A flexible or rigid tube.


• A light that illuminates what the doctor wants to examine. The light is delivered via an optical fiber system.


• A lens system that transmits an image to the viewer from the fiberscope.


• Another channel to allow the entry of medical instruments or manipulators.

What happens during an endoscopy?

The patient may be asked to fast (not eat) or drink for a period before the endoscopy if the instrument is going to go in through the anus. In some cases the patient may be given a laxative. Some patients are given antibiotics to prevent infection.

Patients on blood-thinning medications, such as warfarin, may be asked to stop taking them for a number of days before their endoscopy. There is a risk the blood thinner may cause excessive bleeding during the procedure. It is important the patient only does so if the doctor tells him/her. A study concluded that anti-inflammatory drugs, such as aspirin, do not increase the patient's risk of bleeding during an endoscopy.

In the UK most endoscopies are done in hospital, or some large GP (general practice) clinics.

The vast majority of endoscopies do not require a general anesthetic. Some patients may receive a local anesthetic. A study found that administering a lidocaine lollipop as a single-agent anesthetic to patients undergoing an upper gastrointestinal endoscopy procedure eliminated the need for sedation in the majority of patients. Patients describe the procedure as possibly 'uncomfortable', but hardly ever 'painful'. This study explains that the use of an evidence-based sedation protocol for endoscopic procedures improves the quality of practice and reduces the incidence of sedation-related adverse events.

Most endoscopes will enter the patient via the:

• Anus
• Throat
• Urethra (urine exits the body through the urethra)
• A small incision made in the skin

In most cases endoscopies will last from 15 to 60 minutes. The patient rarely has to spend the night in hospital. Some patients may notice some blood in their urine after a cystoscopy (bladder examination) or when they pass a stool after a prostate biopsy, for example - this is normal for a few days.

Most patients can get up within an hour of their endoscopy. It is advisable that the patient does not drive out of the hospital after an endoscopy.

What are the complications of an endoscopy?

According to the National Health Service (NHS), UK, less than 1% of endoscopies have complications. When they do occur, they may include:

• An infection, possibly somewhere along the path of the endoscope.


• Piercing or tearing of an organ. This may require subsequent surgery.


• Bleeding more than normally expected. This may require subsequent surgery.


• An allergy to the anesthetic. Antihistamines may be used to treat this.

The following signs may indicate an infection has developed after the endoscopy:

• Redness
• Swelling
• Fluid or pus discharge
• Pain
• Temperature (fever)

Any patient who experiences these signs after an endoscopy should contact their doctor. A course of antibiotics should clear up the infection.

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Recognition of Movement Disorders: Extrapyramidal Side Effects and Tardive Dyskinesia

Extrapyramidal Side Effects and Tardive Dyskinesia. Would You Recognize Them If You See Them?

Anti-emetic, anti-spasmodic and prokinetic medications commonly used in gastroenterology are neuroleptics, a class of drugs which includes anti-psychotics used for schizophrenia.

These medications are capable of causing serious and potentially permanent side effects. The manifestation of neuroleptic drug side effects may range from dramatic and debilitating to very subtle. It has been demonstrated repeatedly that these side effects often go unrecognized.

Doctors prescribing prokinetics, anti-emetics and anti-spasmodics need to be able to recognize these side effects. A full description of the most common movement side effects and the corresponding medical term is included as a resource list for professionals and patients.

BACKGROUND

Any drug capable of causing Extra Pyramidal Side effects (EPS) and Tardive Dyskinesia (TD) is by definition a neuroleptic, Latin for "seize the neuron." It is widely assumed that only patients who are being treated for psychiatric disorders such as schizophrenia are at risk for neuroleptic side effects, yet several gastroenterology drugs have the same side effect profile as Thorazine. Patients taking these medications need to be monitored carefully to prevent potentially irreversible side effects.

Psychiatrists have long been trained to recognize the signs and symptoms of EPS and TD and a great deal of physician education has been aimed at them, yet it has been well documented that they often miss the symptoms. In some studies, experts in the field pick up twice as many cases of tardive as newly trained psychiatrists.

Most other physicians have never been trained to recognize the many different manifestations of EPS and TD. These conditions can be particularly difficult to recognize in children, even for those with specific training.

The relationship between neuroleptic medications and movement disorders is extremely complex and confusing. A neuroleptic may cause movement symptoms in a patient, but the same drug can also temporarily suppress the symptoms or delay the onset of symptoms for the same patient. Symptoms often first appear during withdrawal of the medication. Movement symptoms can occur spontaneously, but they are often clearly induced by medication. The best way to avoid permanent movement disorders is to use neuroleptics very cautiously and to monitor patients closely for emerging symptoms.

TERMINOLOGY

There are two major classifications of movement disorders, dystonias and dyskinesias. There are also two time frames used to classify the onset of symptoms. Dystonias are spasms of individual muscles or groups of muscles. They can be sustained or intermittent, sudden or slow, painful or painless. They can affect any of the body's voluntary muscles including those of the vocal cords. The movements of dystonias can appear very bizarre and deliberate but are involuntary.
Dyskinesias are involuntary, often hyperkinetic movements of various types that have no purpose and are not fully controllable by the patient. Some are random, some rhythmic, most are very odd looking and socially stigmatizing.

They can affect the ability to initiate or stop a movement as in Parkinson's. They can affect the smooth movement of a joint resulting in a jerky articulation. Abrupt and seemingly violent movements of a limb are common as are gyrations of any body part. Tics and involuntary vocalizations are related to dyskinesias.

Extrapryramidal Side Effects (EPS) describes movement side effects that begin during the early phases of treatment with a neuroleptic drug. Early onset symptoms tend to resolve quickly and completely when the patient is weaned from the offending medication(s). The word refers to symptoms originating in a specific part of the brain that refines and modulates movement.

Tardive Dyskinesia/Dystonia (TD) simply means late onset of the same EPS movement side effects.

They can appear after months of trouble free treatment, or they can begin to appear as the dose is lowered or the drug is withdrawn. Symptoms generally appear shortly after drug withdrawal although they can appear months later. The previous cut off of three months post withdrawal is now being questioned.

Tardive reactions may resolve quickly, but these late reactions are more likely to be persistent or permanent.

Symptoms that persist for six to twelve months are considered to be permanent although they may diminish slightly over the course of several years. Masking is the term used to describe the ability of the drug to cover the toxic symptoms it is producing.

EPIDEMIOLOGY

Studies of movement symptoms in patients taking neuroleptics for schizophrenia show prevalence rates ranging from .5% to nearly 70%. Studies examining this wide range of published prevalence rates show the discrepancies are most likely due to the skill of the observer. Movement disorders caused by motility and antispasmodic medications in the treatment of gastrointestinal diseases are widely believed to be rare.

This assumption is probably dangerous and inaccurate. Small studies of metaclopramide in particular show EPS and TD in up to 30% of patients. Given the devastating and potentially permanent nature of TD, extreme care should be taken to use neuroleptic drugs only when absolutely necessary and in the lowest doses possible.

RISK FACTORS

Most risk assessment studies on EPS and TD have been conducted in patients with schizophrenia. In these patients, TD is associated with older age, higher medication doses and longer treatment periods; i.e. total exposure. Females also appear to be a higher risk.

Concomitant treatment with any additional drugs capable of causing neuroleptic side effects is likely to increase the risk of EPS and TD. This includes both traditional antipsychotics and the newer, "atypical" antipsychotics which still carry some risk. Substances as common as alcohol and cold medications have some risk of TD and EPS. Caution is needed as well with patients taking anticonvulsants, antihistamines, barbiturates or antidepressants as some drugs in these categories have a high risk of EPS and TD.

Underlying "soft neurological" factors or mental retardation are significant risk factors in the development of TD.

Many experts caution that tapering down to drug free periods a few times a year is necessary to ascertain whether a patient has "covert" symptoms that are being masked by the continuing use of the drug. Other experts believe that this cycling on and off for "drug holidays" can provoke a tardive reaction and is an additional risk factor.

RECOGNIZING SIDE EFFECTS OF NEUROLEPTICS

Movement symptoms may be so subtle that a psychiatrist or neurologist who specializes in movement disorders may be the only expert to pick them up. But in many unfortunate patients, the symptoms are visible from blocks away.

Movement symptoms are generally not present during sleep, can worsen with stress, and patients can often suppress these symptoms for a short period of time through intense concentration. Movement symptoms may be present uniformly throughout the day, or they may have a diurnal pattern.

Some specific movement symptoms are more troublesome during resting and abate during voluntary movement. Other specific symptoms are only problematic during voluntary movement.

Movement symptoms can wax and wane over time and deliberate provocation may be necessary to elicit the symptom in a clinical setting. This is typically done by distracting the patient with conversation or asking them to perform a mental task, such as math, that requires intense concentration.

Tongue and facial symptoms are often the first to appear and a thorough neurological exam involves careful observation of the tongue in the mouth and sticking out. EPS and TD can mimic disorders such as Parkinson's Disease, Tourette's Syndrome, Huntington's Chorea, tics, cerebral palsy, stroke and hyperactivity.

They are often mistaken for psychiatric disturbances and patients may be shunned. During episodes of dystonia, opposing muscles that should relax contract. This can result in a limb that appears distorted. One of the most common manifestations is an ankle that twists and won't bear weight. In some cases, muscle groups that should be uninvolved in the activity being attempted will get involved. The result can be shoulders that swing violently during walking or an entire arm and shoulder that cramp and contort while the hand is holding a pen. In some instances, the opposing hand/arm/shoulder may also contort in a perverse sympathy.

Some patients find quirky tricks that can short circuit a dystonia or dyskinesia. For example, a few patients with torticollis find that stroking their jaw or touching the back of the head can stop the muscle spasms. A case report describes one patient with a severe gait disturbance who found that tossing a small object from hand to hand allowed him to walk more normally. For this reason, patients should be asked about any odd mannerisms.

In addition to causing movement disorders, neuroleptics used in gastroenterology are capable of causing a host of other symptoms that may not be automatically connected with the drug: drooling, autonomic instability, depression, cognitive slowing, confusion, flat affect, agitation, restlessness, irritability, headaches, disordered thinking, memory changes, altered sensations or perceptions, word retrieval problems, and many others.

Localized Symptoms

Neck/spine symptoms
Associated movement symptoms
Muscle spasms of the neck (cervical) which pull the head to the side (torticollis), forward and down (antecollis), or up (retrocollis) are often painful. An extreme bending at the waist is rare (Pisa Syndrome or pleurothotonus). The most extreme form of back arching can bring the entire body off the bed except the back of the head and the heels (opisthotonus). Pelvic rocking or gyrations (axial hyperkinesia) may appear to be self stimulating or sexual in nature. Jacknifing refers to abrupt bending at the waist.

Gait/walking disorder
Associated movement symptoms
A disorganized walk (ataxia) may be as subtle as a foot rolling in occasionally, or as dramatic and absurd as a Monty Python routine. The patient may appear clumsy, stumbling, clomping or drunk. An inability to start walking as if glued to the floor and then an inability to stop, or a shuffling walk are characteristic of tardive Parkinsonism.

Oral facial symptoms
Associated movement symptoms
Oral-mandibular/buccal-lingual symptoms include chewing motions (sometimes called 'Wrigley Sign'), biting with nose wrinkling ('Rabbit Syndrome'), tongue probing in the cheek ('Bon Bon Sign'), grimacing, pouting and repetitive swallowing. The jaw may open or shut or lock (trismus/lockjaw) making eating difficult. The tongue may protrude rapidly ('Fly Catcher') or hang flaccidly (tonic). The patient may make sucking/kissing/smacking/clicking noises. The patient may bite their own cheeks or tongue. Eyebrows may raise ('Spock eyebrows') or lower making the person appear haughty or angry. Symptoms confined to the lower face may be called Miege's Syndrome. Tooth grinding (bruxism) may occur during sleep. Some symptoms can be aborted by touching the lips or other tricks. Some patients with tardive Parkinsonism lack facial expressions (mask-like facies) and they may drool.

Finger movements
Associated movement symptoms
Finger movements often resemble playing 'Air Guitar', 'Air Piano' or a particular movement called 'milkmaid grip'. Writer's cramp is a severe spasm of the entire hand or arm. The opposing arm may also cramp. This is more than fatigue and may be induced by fine motor activities other than writing. 'Pill rolling' finger movements (rubbing the thumb and fingers in a motion similar to the gesture meaning 'money') are more common in drug-induced Parkinsonism.

Limb symptoms
Associated movement symptoms
Flailing movements involving a whole limb may appear combative like a punch or karate kick (ballismus), or may appear like raising a hand to ask a question. This is one of the few movements that occur during sleep. Some patients with tardive Parkinsonism have limb movements that are jerky and have a ratchet-like quality (cog wheel rigidity).

Eye symptoms
Associated movement symptoms
Blinking of both eyelids (blepharospasms) may be so severe that the patient is legally blind. The eyes may be rolled in any direction (oculogyric crisis).

Vocalizations, breathing, swallowing
Associated movement symptoms
Vocal tics such as grunting, throat clearing, swearing (coprolalia), and echoing words or sounds (echolalia) are possible. The vocal cords may spasm (dysphonia) making the voice choppy, quavery, breathy or cause a hoarse sounding noise when breathing in (stridor). The vocal cords may clamp shut (Laryngospasm/obstructive apnea/dysepnea). The speech may be slurred (dysarthria) or have a quality normally associated with brain damage (bulbar). Swallowing may be uncoordinated (dysphagia).

MONITORING MOVEMENT SYMPTOMS

The Abnormal Involuntary Movement Scale, (AIMS) is available online and provides one quick and systematic way to assess a variety of common movement symptoms. This scale is not useful for distinguishing between the many types of movement disorders and it cannot distinguish drug induced symptoms from spontaneous ones. Several other scales are commonly used and a full discussion of their merits and proper uses can be found in "Assessment of drug-related movement disorders in schizophrenia." Since different clusters of symptoms can suggest different treatments, a full exam by a movement specialist may be desired.

TREATMENT

Treatment of movement side effects that appear early during treatment (EPS) is generally accomplished by slowly withdrawing the drug or lowering the dose.

When the drug is being used to treat a major psychiatric illness such as schizophrenia, withdrawal of the drug may not be feasible. Anticholinergic medications may be helpful in EPS, but generally are not. Beta blockers have also been tried.

Treatment of late onset (TD) movement symptoms and syndromes can be much more complex. Withdrawal of the drug may need to be undertaken very slowly and drugs to counteract the symptoms may be tried. Unfortunately, anticholiergic drugs are generally not as helpful with late onset symptoms and may occasionally cause paradoxical exacerbation. Consultation with a movement disorders specialist may be helpful and in complex cases referral may be necessary.

The long list of drugs that may be used to reduce TD symptoms attests to the difficulty in treating this iatrogenic disease. Many cases of TD do not respond well to currently available treatments and there are many new treatments being investigated including vitamins that act as free radical scavengers. Vitamin E and vitamin B6 have both shown benefit in preventing the development of TD although they have not been effective in treating the disorder once it has developed.

Research is being conducted on the use of branch chain amino acids.

PEDIATRIC CONSIDERATIONS:

Recognition of movement side effects in children is particularly problematic. Infants are more likely to have boxing arm movements, cycling leg movements or generalized hypertonia, all of which are uncommon in adults.

A gait disturbance may not be apparent in a child who is just learning to walk. Motor restlessness in a pre-schooler can look like urinary urgency. Early onset EPS or TD can look like cerebral palsy. How do you distinguish between biting due to a dystonia and a temper tantrum?

Back and neck arching in an infant may be due to pain, an infantile spasm, a seizure, acid reflux induced Sandifer Syndrome or dystonia. A pediatric movement disorders specialist may need to examine the child in order to make a definitive diagnosis.

Non-movement side effects of neuroleptics are also more difficult to recognize in children. Small children can't tell us that they have a headache, that they are having memory trouble, that their senses are not functioning correctly, or that they are suffering from a mood change. How do you distinguish hormonal changes of puberty from the hormonal changes (gyncomastia, amenorrhea) due to prolactin fluctuations caused by a neuroleptic? How do you distinguish druginduced muscle pain (arthralgia) from the pain of the disease you are treating? How do you recognize psychosis, dementia or even a sleep disorder in a baby?

There is a wide range of developmental levels within the range of "normal" making subtle deficits difficult to spot. One author (Anderson) recently met a toddler who was believed to be profoundly retarded while on metaclopramide. His "intractable seizures" stopped the day after withdrawal and he was walking and talking after several months of intense therapy (personal communications with parents and doctor).

To further complicate matters, children metabolize many drugs differently. Children have an undeveloped blood-brain barrier which can leave them more susceptible to CNS involvement where none would be expected in an adult. Children with acute illness or dehydration seem to be at additional risk for dystonias.

Many common medications can exacerbate neuroleptic side effects. In addition, pediatric formulations of some drugs contain alcohol which can exacerbate or precipitate movement symptoms and many other side effects.

Of particular concern is the alcohol in pediatric ranitidine. One of the side effects of ranitidine is an interference with the normal clearance of alcohol that can magnify the effects of the alcohol by a factor of ten.

Children and the elderly are recognized to be at additional risk of EPS and TD from neuroleptics used for psychiatric illnesses. It is reasonable to assume that they are at increased risk when using neuroleptics for gastrointestinal ailments. The lack of recognition means that any estimates about the rarity of side effects are suspect. A few pediatric gastroenterologists no longer use neuroleptics for just this reason.

LEGAL CONSIDERATIONS

There have been many lawsuits filed by patients experiencing TD. The Journal of the American Academy of Psychiatry and the Law and the Journal of Clinical Psychiatry have both printed review articles describing the many legal issues raised. Acording to "Tardive Dyskinesia: Tremors in Law and Medicine," most suits have alleged malpractice but there have also been suits alleging failure to obtain written informed consent, torts violations, failure to monitor, inappropriate reassurance that the TD/EPS symptoms were not drug related, failure to follow standards of care, failure to refer to a neurologist, product liability, etc.

Institutionalized psychiatric patients have filed suits alleging civil rights violations. This article is written jointly by a forensic psychiatrist and an attorney. It summarizes the circumstances, arguments and rulings from dozens of individual cases and is available online. "Update on Legal Issues Associated with Tardive Dyskinesia," a section of a the Journal of Clinical Psychiatry Supplement on TD, contains a history of the use of neuroleptics and is more medically oriented. It explains concepts such as determining when the statute of limitations clock is likely to start in language accessible to doctors.

It gives practical guidelines for physicans who want to avoid lawsuits. The author explains that, "In determining causation, the law is more interested in the straw that broke the camel's back than in all the straws already piled on its back." He includes a quote from a 1984 article; "The impending flood of tardive dyskinesia litigation has begun. I think that there is an enormous backlog of cases that is going to plague us for years." He also warns that the pendulum is swinging in the direction of trying to link all movement disorders to neuroleptics.

Indeed, there are now class action law suits for patients who took metaclopramide and were damaged.

General Symptoms

Akathisia
An inner feeling of restlessness, which compels the patient to pace, march, fidget or wiggle although some patients are able to sit still. In infants, this is more likely to look like air boxing or air cycling. Restlessness may manifest as insomnia. It may be perceived as an uncomfortable inner vibration. Patients may call akathisia anxiety.

Chorea/choreic
Dance-like movements of any body part or the whole body.

Myoclonus/ myoclonic
Involuntary movements that are sudden and violent in appearance as if struck by lightening or hit by an invisible assailant.

Tics
Gilles de la Tourette Syndrome may be drug induced.

Vermicular/ atheoid
Worm-like writhing movement of any body part or the entire body.

Bradykinesia
Slowing of voluntary movements (bradykinesia) can affect any body part or the whole body. In rare cases there can be a complete lack of movement (akinesia).

Resting Tremor
Shaking of a resting limb or tongue that tends to subside during deliberate movements. The opposite of alcohol induced tremors which are worse during intentional movement.

Neuroleptic Malignant Syndrome
The most dangerous side effect of anti-psychotics is Neuroleptic Malignant. This Syndrome potentially fatal reaction is characterized by "lead pipe rigidity," high fever, dehydration, sweating, elevated blood pressure, fast heart rate and respiration, agitation, elevated white blood cell count, difficulty swallowing and autonomic instability.

Paroxysmal
Very abrupt movements

RECOMMENDATIONS

To avoid EPS and potentially irreversible TD, neuroleptics must be used at the lowest possible doses, for the shortest possible duration, only when clearly indicated and when there is no safer alternative. Patients should be monitored closely and frequently for emerging symptoms using standardized movement rating scales. Possible side effects should be fully disclosed via written informed consent documents and the doctor should initiate an ongoing dialog about this topic with the patient. The doctor should consider alerting family members since they often become aware of movement disorders before the patient does.

Resources

Journal of Clinical Psychiatry, 2000, Volume 62, Supplement 4, "Update on Tardive Dyskinesia" contains 9 articles (57 pages) on aspects of TD. CME credit is available. This supplement includes the article, "Update on Legal Issues Associated with Tardive Dyskinesia." The supplement may be ordered on line at http://www.psychiatrist.com/order.htm

Psychotropic Drug Directory, 2001, Stephen Bazire and William Benfield Jr., Quay Books, Mark Allen Publishing. This book contains a full list of drugs capable of causing movement disorders, mood disorders, sleep disorders, etc., (Chapters 5.8-5.9) with citations for each entry. It also has a section on the treatment of movement disorders (Chapters 1.20-1.22) with citations to relevant articles for each entry. Order online at http://www.markallengroup,com/quaybooks

"Tardive Dyskinesia: Tremors in Law and Medicine," Neil S. Kaye, MD, FAPA, and Thomas J. Reed Esquire. Journal of the American Academy of Psychiatry and the Law, 1999; Volume 25, No 2. Viewable online at http://www.courtpsychiatrist.com/tardive.html

Details of pediatric hypertonia symptoms are available in "Classification and Definition of Disorders Causing Hypertonia in Childhood," Pediatrics, 2003: Vol 11, No 1. Available in PDF format online at http://pediatrics.aappublications.org/cgi/reprint/111/1/e89.pdf

"Assessment of drug-related movement disorders in schizophrenia," Maurice Gervin and R.E. Thomas Barnes Advances in Psychiatric Treatment, 2000; 6: 332-341. This article contains a discussion of several movement rating scales and reviews methods of conducting them that can reduce the variability of the results. Available online at http://apt.rcpsych.org/cgi/content/full/6/5/332

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Narcissism Victim Syndrome, A New Diagnosis?

Do you see a preponderance of middle aged women in your practices with no particular physical disease process, yet a variety of physical and/or emotional complaints, including: insomnia, weight loss or gain, depression, anxiety, phobias, broken bones, lacerations, or bruises? Some may report an overwhelming feeling of emptiness or doom. Others may talk about or attempt suicide.

These patients are frequently rather nervous, with a guilt-ridden, anxious look and effect. They may appear restless, worried, and/or demonstrate a fake laugh that seems to hide something else.

In extreme cases they may describe sudden outbursts of rage with accompanying violence. They may have even been arrested for assault on their spouse. A few of them are men.

Who are these patients and how did they get this way? While there may be many situations with similar symptoms, it is important to recognize these may be "Victims of Narcissists" and they need your help. While narcissism itself has been a diagnosis in the DSM - IV, psychiatry's complete reference, little to nothing has been written in the medical literature surrounding those who live with the narcissist - and the torturous lives they live. And there are many of them out there.

Narcissism is a broad spectrum of behaviors. On a scale of 1 - 10, Healthy Narcissism is a one, and Pathological Narcissism, or Narcissistic Personality Disorder, (NPD) is a 10.

Healthy Narcissism is something we all can use. It's having a healthy self-esteem. It's what makes us pick ourselves up after experiencing failure and going on towards the next goal. It's what gives us the ability to help each other, and to love someone - as we already know how to love ourselves.

Yet, Pathological Narcissism is an ironic twist of this healthy state. Outwardly, it appears that these people love themselves too much - to the exclusion of anyone else. It is as if they are God himself and those around them must recognize their omnipotence, supreme knowledge, and absolute entitlement and power. Rules don't apply to them. They have an unrealistic and overblown sense of self, often without the credentials to match, as well as fantasies of unlimited power, success, and/or brilliance. They are interpersonally exploitive and have absolutely no understanding of empathy or compassion.

They are neither kind nor benevolent gods. And those who live with them end up paying the price.

While there is a range of narcissistic behaviors lying between level 1 and 10 on this scale, one doesn't need to have full-blown NPD to do incredible damage to those in the inner circle.

While victims of Narcissists are generally codependents, most have no idea how they got in this situation, because in the early stages of the relationship the Narcissistic person can be the most charming, Academy Award winning actor or actress (according to the DSM-IV, 50-75% of narcissists are men), of the century.

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Hip Implants - Traditional Ones As Good As New Ones

According to new evidence published on bmj.com, new hip implants appear to have no advantage over traditional implants. Some evidence even suggests that new implants may be linked to higher rates of revision surgery.

Although hip replacement surgery is commonly successful, there are nevertheless a significant number of patients who require revision surgery within 10 years to replace implants due to dislocation, infection, wear, loosening, instability or other mechanical failures.

Traditional hip implants consist of metal on polyethylene or ceramic on polyethylene bearing surfaces and are linked to low revision rates, whereas newer alternatives are made from metal on metal or ceramic on ceramic bearings, however their benefits compared with traditional implants is still unclear.

BMJ has called for better regulation of medical advices after several incidents have been reported whereby it has been detected that patients with metal on metal hip implants displayed severe cases of accumulation of metal ions in their tissues. In light of this, the US Food and Drug Administration (FDA) initiated a comprehensive review of evidence for approved hip implants in 2009.

Professor Art Sedrakyan and his team collaborated with the FDA in comparing the safety and effectiveness of hip implants with different bearing surfaces. They evaluated results of 18 studies with 3,139 patients and more than 830,000 operations from data obtained in annual reports of registries and discovered that functional outcomes, such as the ability to carry out common daily activities, and general quality of life scores were equal between the new traditional metal on metal or ceramic on ceramic hip implants compared with traditional hip implants.

Although one study showed that metal on metal implants were linked to fewer dislocations, they found evidence in the three largest national registries that higher rates of implant revision was linked to metal on metal implants compared with traditional metal on polyethylene implants.

Even though one trial demonstrated fewer revisions with ceramic on ceramic compared with metal on polyethylene implants, researchers found that the finding was not supported by data from national registries.

They conclude their findings, saying:

"There is limited evidence regarding comparative effectiveness of various hip implant bearings, and the results do not indicate any advantage for metal on metal or ceramic on ceramic implants compared with traditional bearings."

The researchers strongly recommend a large randomized trial of bearing surfaces before claiming any benefits, saying that until that time, "national registries provide important real world data that are critical for the safety and future comparative safety and effectiveness evaluation."

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