Monthly Archives: May 2011

Mental Health Mittwoch: Is Ketamine Going to Revolutionize the Treatment of Depression?

Ketamine is well-known to veterinarians. It is hard to imagine a veterinary drug cabinet without it. Developed originally in 1962 as a battlefield anesthetic for wounded soldiers, it was quickly adopted by veterinarians for use in their patients, and unlike many anesthetic agents, whose day comes and goes, ketamine has been part of the  basic tool kit for veterinarians for the entire time.

It has also moved beyond it’s original use as a balm for injured soldiers, and is found in all hospitals .  Indications for use  in humans include (from Wikipedia):

  • Pediatric anesthesia (as the sole anesthetic for minor procedures or as an induction agent followed by muscle relaxant and endotracheal intubation)
  • Asthmatics or patients with chronic obstructive airway disease
  • As part of a cream, gel, or liquid for topical application for nerve pain—the most common mixture is 10% ketoprofen, 5% Lidocaine, and 10% ketamine. Other ingredients found useful by pain specialists and their patients as well as the compounding pharmacists who make the topical mixtures include amitriptyline, cyclobenzaprine, clonidine, tramadol, and mepivicaine and other longer-acting local anaesthetics.
  • In emergency medicine in entrapped patients suffering severe trauma
  • Emergency surgery in field conditions in war zones
  • To supplement spinal / epidural anesthesia / analgesia utilizing low doses

THE KETAMINE EXPERIENCE

Using ketamine in a clinic, a new veterinarian learns quickly that at as a sole agent, ketamine is not very good. The animals tend to become rigid during their sedation, their eyes remain open, and they don’t exhibit the floppy type of sedation that we prefer when working with a sedated or anesthetized animal. Furthermore, recoveries from ketamine look rather bizarre and uncomfortable, with the animal swinging his head back and forth as if he’s watching a marathon game of tennis.  Therefore, when used in a veterinary clinic, ketamine is virtually always combined with another drug, generally one that provides relaxation. A historically common ‘cocktail’ is s 50:50 volume mixture of ketamine and valium.

This looks like a cat on ketamine.Note the unrelaxed posture and the open eyes.

Humans, likewise, report hallucinations when using the drug as a sole agent, and physicians will often combine it with other drugs to minimize this effect. The hallucinogenic potential  has made ketamine a popular ‘club’ drug, like MDMA (Ecstasy) or Rohypnol. Until 1999, Ketamine was unscheduled, meaning that it wasn’t a controlled substance. We could use the drug without having to log every single dose used, and without fear of scrutiny from the FDA. Alas, because of ketamine’s growing popularity as a recreational drug, the Feds moved and made ketamine a controlled substance.

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I’m not quite sure how this was discovered, but ketamine has a rapid and profound effect on depression. Unlike Prozac and the other selective serotonin reuptake inhibitors (SSRIs) which usually take 3-6 weeks to “kick-in”, ketamine takes effect within 24 hours, and often within 2 or 3 hours of administration.

And here is the strange part. Although ketamine’s half-life  is only 3  hours, the anti-depressive effect seems to last at least a week. (A half life is the time it takes for half of the substance to be cleared, so, for example after 4 half-lives [1/2->1/4->1/8->]1/16th of the substance will remain.)

THE FUTURE OF DEPRESSION THERAPY?

So, imagine this. You are in the midst of a depressive episode. Instead of taking a several week regimen of pills, you go to the doctor’s office in the morning, and by lunchtime you are feeling like yourself again.

Fortunately, instead of burying this because of fears of abuse, studies are going forward. The National Institute of Mental Health is conducting clinical trials of the effect of ketamine on major depression and bipolar disorder. The Department of Defense is collaborating with Mt. Sinai School of Medicine on a clinical trial testing ketamine as a rapid treatment for Post-Traumatic Stress Disorder.

There are doctors who are already using ketamine to treat depression. At UCSD, the psych department  offers treatment-resistant depressives intravenous ketamine as a treatment. Because it is not an approved use of ketamine, insurance will not cover it. Ketamine is not an expensive drug. Perhaps in the future depressives will be able to dose themselves with intramuscular shots, much the same as diabetics treat themselves with insulin.

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What To Do with the Leftover Raw Egg Yolks after You’ve Made a Pisco Sour: The Vaina

A letter from Apoteoso: You remember Apoteoso, the kid from Whitefish Bay who got jailed in the Andes sometime in the past? Apparently, he got wind of us using his story here at the Assassin Bug, and was none too happy about it. His parents threatened to have us sued in Milwaukee District Court. (I can tell you we were quaking in our mukluks, notwithstanding their superior insulating qualities.) One of our editors had the brilliant idea of letting Apoteoso write a post or two for us. It seems that being in the spotlight has soothed whatever anger the Arco-Balena family may have had (not that we would ever call writing for the Assassin Bug being in the spotlight).

And what better subject for Apoteoso than mind-altering substances? In deference to alcohol being the drug of choice world-wide, and in trying to keep with the blog’s theme of pairing  South American Cocktail recipes with public health writing, we present you with following recipe. Note also that Apoteoso truly entered the spirit of the blog, finding a way to use public health in his post. He thought he would catch us being hypocritical. We do promise to follow up (yeah, right, just like you promised to follow up on the Zappa post) with a report on egg safety.

Hard time looking tough drinking this one.

 

Back when you plagiarizing sods gave a recipe for the classic Peruvian cocktail, the Pisco Sour, right?  You oh so cavalierly gave the formula, knowing that your readers would probably rush right out and make their libations from raw egg whites, pasteurized egg whites not being something what readers got on they’re shelves. (They do carry them at the Prospect Avenue Whole Foods in Milwaukee, so I bet they have them elsewhere.) And then as divine karmic comeuppance, the Wright County Egg Salmonella outbreak occurred last summers, and half a billion eggs we’re recalled. Really. I know that I am given to hyperbolly, but this was realllly a half a billion eggs. I don’t know if you guys got sick, but you really should feel responsible if anyone got sick drinking Pisco Sours. anyways, there is always the problem of what to do with the yolks if youve been making stuff with the whites, so here you go (from Andrea’s Recipes):

Ingredients

1-1/2 ounces (45 ml) ruby red port
1 ounce (30 ml) cognac or brandy
1 ounce (30 ml) crème de cacao
3 teaspoons confectioner’s sugar
1 raw egg yolk, very fresh
1/3 cup crushed ice
pinch of cinnamon

Preparation

In the blender, mix the port, cognac, crème de cacao, confectioner’s sugar, and egg yolk with the ice until foamy. Pour into the flute or mini cocktail glasses and garnish with a pinch of cinnamon.

Note from the editors: Of course, use only pasteurized egg yolks.

Found this one in españolo:

No debes usar vino tinto normal, sino vino añejo. No es lo mismo. Con vino tinto corriente debe quedar horrible.
El vermuth no corresponde. Falta la canela molida
Está mal tu receta. No sé qué hiciste, pero no es vaina.

Trata con la siguiente:
Ingredientes
50 cc Vino Añejo
30 cc Cognac
30 cc Licor de Cacao
2-3 Cucharaditas de Azúcar Flor
1 Yema de Huevo
Canela en polvo

Preparación
Mezclar todos los ingredientes (excepto la canela) en una coctelera con hielo. Batir y servir en una copa de sour. Espolvorear canela sobre el trago

Ooohhh SAS-sy! or Why I was gone so long is partially due to what’s wrong with Public Health Education: SAS, and the rest of the lot

I apologize to my very few readers for my lengthy absence. (I’ve been busy, and my cats ate my last post just after I finished writing it.It was my best post ever.) Realizing that this will be a post of limited interest to the general public, I have included the usual gratuitous pictures of dishes from the 60s. Please read the text in between them, folks.

And there will be a quiz at the end. Winners will be acknowledged.

CAJOLING AND CARESSING THE DATA

As part of a real MPH (the concentrations where you actually learn to do something, such as epidemiology, biostatistics, environmental health, health law, etc, as opposed to the amorphous field of international health) most students are required to take a semester of biostatistical computing. This should probably be at least 2 semesters, especially for epidemiology concentrators, but that’s a topic for another time. At the august Boston University School of Public Health, that means a semester of SAS.

SAS (formerly Statistical Analysis Systems), is the software produced by the SAS Institute , based in North Carolina. SAS software, currently in version 9.2.  It is used for not only statistical analysis, but data mining, IT management, business intelligence, etc.  They are clearly doing something right. For two years in a row, the SAS Institute has been named Fortune magazine’s best company to work for, and their software  could easily be considered the industry standard in its particular area.

Fine and dandy. There is a hitch of course, and the hitch is that SAS licenses are expensive. Really expensive. For those of us in Public Health, they are Ferrari and Audemars-Piguet expensive. I called to see what it would cost me to get a 1-year license for a single user to use SAS (are you sitting down?)

About $10,000.

For the projects that I work on, that’s way too expensive . Last year I did some work on Ehrlichia in Peru, where the whole budget, including paying the staff, was less than $3000.  I just completed working on a data set regarding the behavior of cats in shelters for a non-profit organization. Using SAS on this would have been like chartering a luxury yacht to go commercial fishing–it just can’t pay off.

Clearly, SAS is  worth it for some users, but I can’t speak to that. What I do know is that if the biostatisticians continue to teach SAS in public health schools, they will be instructing their students in a technology that could easily be out of their reach.

WHAT ARE THE ALTERNATIVES?

I just finished crunching data for the ASPCA. I used a free 30-day trail of Minitab 16 that I downloaded from the internets. It was more than sufficient for my project. The data set, though,  was rather small, consisting of 40 or so variables on 253 cats, taken at 5 different points in time. The downside was I had to take out a mothballed PC, and I am a Mac person. (BTW, both SAS and Minitab used to make versions that could be used on a Mac. I really  like using my Mac. It is far more stable than any PC I have ever used. ) One of the other things that I like about Minitab is that while it uses a menu-driven, point-and-click user-friendly interface, one can enable the command editor and the code will be recorded in the session window.

What’s the best endorsement for Minitab? The PhD in statistics who helped me, Al Kabong (not his real name), prefers Minitab over the other statistical packages available to him. He admits that for monstrous data sets he is going to need SAS, but he is an emeritus prof and has the resources of a large research university behind him.

Is the system rigged against small projects?

Now for the quiz: Who are the sassy chickadees in the pictures?

Next issue: JMP , R, and the answers to the quiz