<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_369"
                     title="Administration Issues Mental Health Parity Rule"
                     score="0.008"
                     href="http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/18258?impressionId=1265769841625"
                     
      &lt;p&gt;WASHINGTON  --  Under a proposed rule released by the Obama administration, patients in a group insurance plan who are being treated for mental illness or substance abuse may no longer be charged more than if they were receiving medical or surgical care.&lt;/p&gt;
&lt;p&gt;The Department of Health and Human Service (HHS), the Department of Labor, and the Internal Revenue Service issued an interim rule last week containing specific language necessary to enforce the bipartisan &lt;a href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/11169&quot; mce_href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/11169&quot; target=&quot;_blank&quot; title=&quot;Financial&amp;#8200;Bailout&amp;#8200;Carries&amp;#8200;Mental&amp;#8200;Health&amp;#8200;Parity&amp;#8200;Bill&amp;#8200;Through&amp;#8200;Congress&quot;&gt;mental health parity law passed by Congress in 2008&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;The law  --  called the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act  --  states that if a group health plan covers the treatment of mental illness or drug or alcohol abuse, the limits and financial requirements for these services can be &quot;no more restrictive&quot; than those that apply to medical and surgical benefits.&lt;/p&gt;
&lt;p&gt;That means an insurance plan cannot charge higher copayments, deductibles, and out-of-pocket expenses for mental health services than for treatment of physical illnesses.&lt;/p&gt;
&lt;p&gt;Companies with fewer than 50 employees in their group insurance plans are excluded from the law.&lt;/p&gt;
&lt;p&gt;&quot;The rules we are issuing today will, for the first time, help assure that those diagnosed with these debilitating and sometimes life-threatening disorders will not suffer needless or arbitrary limits on their care,&quot; said Kathleen Sebelius, secretary of HHS.&lt;/p&gt;

&lt;p&gt;The American Psychiatric Association (APA) issued a statement applauding the regulations.&lt;/p&gt;
    &lt;p&gt;&quot;Mental health parity was a major advance for the APA and for our patients living with mental illnesses,&quot; according to the group&apos;s president, Alan F. Schatzberg, MD. &quot;The APA will continue to work hard and submit the important feedback to the administration that is necessary to make sure our patients receive the care they need.&quot;&lt;/p&gt;
    &lt;p&gt;The statement also drew attention to some shortcomings in the regulations, which did not address provider networks and formulary development.&lt;/p&gt;
    &lt;p&gt;The APA intends to submit recommendations for these and other topics during the 90-day comment period.&lt;/p&gt;
    &lt;p&gt;The American Psychological Association also welcomed the regulations.&lt;/p&gt;
    &lt;p&gt;&quot;We are delighted that under these regulations consumers are protected from insurance discrimination to the greatest extent possible,&quot; according to its executive director for professional practice, Katherine Nordal, PhD, in a prepared statement.&lt;/p&gt;
    &lt;p&gt;The rule also requires a single deductible for mental health and medical/surgical coverage. Patients who are being treated for a mental condition at the same time as somatic condition often have to pay separate deductibles which can &quot;prevent access to mental health treatment,&quot; according to the psychologists&apos; group.&lt;/p&gt;
    &lt;p&gt;&quot;It is particularly significant that the regulation will ban health plans from imposing separate deductibles or setting separate out-of-pocket caps for mental health and medical/surgical services,&quot; the statement said. &quot;This is a big win for anyone seeking mental health treatment.&quot;&lt;/p&gt;
    &lt;p&gt;The 2008 law expanded greatly on the Mental Health Parity Act of 1996, which required parity only in lifetime and annual dollar limits. In practice, crtics say, insurers got around that prohibition by charging higher copayments for mental health services and by &quot;cherry-picking&quot; services that would and would not be covered.&lt;/p&gt;
    &lt;p&gt;The 1996 law also specifically excluded coverage parity for substance abuse treatment.&lt;/p&gt;
    &lt;p&gt;The new rule will take effect April 5, 2010.

    </recommendedItem>
    <recommendedItem id="20100101_19_341"
                     title="Doctor&apos;s Orders: Brain&apos;s Wiring Makes Change Hard"
                     score="0.007"
                     href="http://www.medpagetoday.com/Psychiatry/Addictions/tb/18207?impressionId=1265769841625"
                     
      &lt;p&gt;Doctor&apos;s Orders&lt;em&gt; is a feature in the collaboration between &lt;/em&gt;MedPage Today &lt;em&gt;and&lt;/em&gt; ABC News&lt;em&gt;. In this monthly segment we explore medical issues of interest to physicians and their patients alike. This month, we look at addiction and addictive behaviors, and what neuroimaging studies have revealed about why it&apos;s so hard to break bad habits. &lt;/em&gt;&lt;/p&gt;&lt;hr&gt;

&lt;p&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;&lt;/p&gt;

&lt;p&gt;By the end of January, many New Year&apos;s resolutions have been tossed out with the leftover holiday cookies. That&apos;s because change is hard  --  and neuroscientists are learning why.&lt;br&gt;
&lt;br&gt;Advances in neuroimaging have enabled researchers to peer inside the brains of addicts and patients with addictive behaviors. They can see in real-time what gets patients hooked: how the brain&apos;s reward system  --  based largely on the neurotransmitter dopamine  --  thirsts for more, while inhibitory control centers experience a system failure.&lt;br&gt;
&lt;br&gt;The pattern is similar across all kinds of behaviors  --  from cocaine and tobacco addiction to overeating. That&apos;s why changing your mind may be the first step toward breaking a habit, but altering the brain&apos;s neural machinery is the real challenge.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Hijacked Pathways&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;Drug-taking and other addictive behaviors &quot;hijack&quot; the brain&apos;s reward system, says Petros Levounis, MD, director of the Addiction Institute of New York at St. Luke&apos;s and Roosevelt Hospitals in Manhattan.&lt;/p&gt;
&lt;p&gt;In normal patients, dopamine plays a major role in motivation and reward, surging before and during a pleasurable activity  --  say, eating or sex  --  to make patients want to repeat a behavior that&apos;s crucial to the survival of the species.&lt;/p&gt;
&lt;p&gt;Dopaminergic pathways connect the limbic system, responsible for emotion, with the hippocampus, etching rewarding behaviors into the brain by creating strong, salient memories.&lt;/p&gt;
&lt;p&gt;The problem arises when the memory and the craving to recapture it takes over a person&apos;s life.&lt;/p&gt;
&lt;p&gt;&quot;Imagine what a strong hold these hijacked reward pathways take on our brains and our whole existence when they&apos;re so closely connected, geographically and anatomically speaking, with our memories and our emotions,&quot; Levounis says.&lt;/p&gt;
&lt;p&gt;As the dopamine surge repeats and repeats, it gains speed, but the brakes begin to fail: Normal function in the brain&apos;s frontal lobes, responsible for inhibitory control and executive functioning (read: willpower), tends to decrease in addicts.&lt;/p&gt;
&lt;p&gt;&quot;Ultimately,&quot; Levounis says, &quot;the war on drugs is a war between the hijacked reward pathways that push the person to want to use, and the frontal lobes, which try to keep the beast at bay. That is the essence of addiction.&quot;&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Similar Patterns&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;These neural pathways have been well studied in the brains of hardcore addicts. Now, researchers say they see similar pathways involved in other bad behaviors.&lt;/p&gt;
&lt;p&gt;Gene-Jack Wang, MD, of Brookhaven National Laboratory on New York&apos;s Long Island, has conducted several brain imaging studies of obese patients using PET-CT scans.&lt;/p&gt;
&lt;p&gt;The scans have revealed similarities in brain activity  --  or a lack thereof  --  between patients addicted to cocaine or alcohol, and those &quot;addicted&quot; to eating. Normally, the PET scan lights up when a contrast of radioactive glucose is metabolized, revealing an area of red activity in the center of the brain.&lt;/p&gt;
&lt;p&gt;But in both drug-addicted and obese patients, the scans show very little red activity, because there aren&apos;t enough receptors to which the radioactive glucose can bind. Wang says the decreased availability of dopamine receptors is the brain&apos;s way of coping with a constant dopamine overload.&lt;/p&gt;
&lt;p&gt;&quot;If a person constantly has an excess of dopamine, the brain will down-regulate,&quot; Wang says, explaining the principle commonly referred to as tolerance. &quot;Once the system is down-regulated, we have to do more in order to get the same amount of feeling in our normal state.&quot;&lt;/p&gt;
&lt;p&gt;Thus, obese patients &quot;will want to eat more in order to compensate for their down-regulated system.&quot;&lt;/p&gt;
&lt;p&gt;In other experiments, Wang and his colleagues have also found that a higher body mass index (BMI) correlated with lower prefrontal cortex function  --  the area associated with inhibitory control.&lt;/p&gt;
&lt;p&gt;&quot;If they&apos;re obese,&quot; Wang said, &quot;they have a problem controlling their eating behaviors.&quot;&lt;/p&gt;
&lt;p&gt;Those studies also revealed that a higher BMI was linked to a decrease in memory and executive functioning.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Out of Control&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;Ed Susman was 293 pounds when he decided to join a clinical trial for an investigational weight-loss drug and chronicle his year-long experience for &lt;em&gt;MedPage Today&lt;/em&gt;. (See &lt;a href=&quot;http://www.medpagetoday.com/PrimaryCare/Diabetes/8125&quot; mce_href=&quot;http://www.medpagetoday.com/PrimaryCare/Diabetes/8125&quot; target=&quot;_blank&quot;&gt;Journalist Participant to Present Insider View of Weight-Loss Trial&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Eating, to him, was a &quot;compulsion&quot;  --  as was biting his nails, a habit he picked up at age 4.&lt;/p&gt;
&lt;p&gt;Over the course of the trial, not only did Susman lose 52 pounds, he also stopped his nail-biting.&lt;/p&gt;
&lt;p&gt;He doesn&apos;t yet know if he was in the drug arm of the trial, but he strongly suspects he wasn&apos;t experiencing a placebo effect.&lt;/p&gt;
&lt;p&gt;&quot;I believe I was on the drug because it controlled a compulsion that I had had for 50 years,&quot; Susman says of the nail-biting. &quot;This stopped it cold.&quot;&lt;/p&gt;
&lt;p&gt;Unfortunately, he says, the same didn&apos;t happen with his eating habits, but he&apos;s gained back only 10 of those 52 pounds in the year since his participation in the trial ended.&lt;/p&gt;
&lt;p&gt;The still-investigational drug is lorcaserin  --  a combination of benzazepine and hydrochloride, two neurological agents. Susman says it is &quot;supposed to improve your willpower, your ability to overcome compulsions.&quot;&lt;/p&gt;
&lt;p&gt;Lorcaserin is a selective 5-HT&lt;sub&gt;2C&lt;/sub&gt; receptor agonist, working through the serotonin system, which regulates appetite, mood, and motor behavior.&lt;/p&gt;
&lt;p&gt;Two other investigational obesity drugs target the dopamine reward system  --  Contrave, which is a combination of bupropion and naltrexone, and Qnexa, which combines phentermine and topiramate.&lt;/p&gt;
&lt;p&gt;&quot;Some medications that have used similar dopamine modulation, until now, have failed,&quot; Wang said. &quot;These two companies are using the command of the modulation of the dopamine system with other neurological systems, such as the opiate or norepinephrine system. According to the trials, they&apos;ve been very effective.&quot;&lt;/p&gt;
&lt;p&gt;Wang called the new medications &quot;a bright light for the treatment of obesity.&quot;&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Kicking the Habit&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;Basically, the idea of medications that act on the dopamine system is &quot;to cool down those reward pathways,&quot; Levounis says. There are two strategies for doing so: an agonist strategy, or an antagonist strategy.&lt;/p&gt;
&lt;p&gt;The agonist strategy is &quot;feeding the beast, providing activity in the cell so that the cravings go down,&quot; Levounis said. Classic examples are nicotine patches, or methadone for opioid dependence.&lt;/p&gt;
&lt;p&gt;On the other hand, the antagonist strategy is to block the receptors. Naltrexone, for example, will block opioid receptors so that the drug addict won&apos;t feel anything if he or she attempts to get high.&lt;/p&gt;
&lt;p&gt;&quot;After a while, you say, &apos;This is not worth my time, my money, my trouble,&apos; so you stop using,&quot; Levounis explains.&lt;/p&gt;
&lt;p&gt;These have been the two main strategies in addiction pharmacotherapy, but there&apos;s now a &quot;third avenue&quot;  --  the partial agonist approach.&lt;/p&gt;
&lt;p&gt;The partial agonist is one molecule that blocks most receptors while still providing just a little bit of an &quot;oomph&quot; to calm cravings. That&apos;s how varenicline (Chantix) helps smokers quit, and how buprenorphine gets junkies off heroin or other opioids.&lt;/p&gt;
&lt;p&gt;But what about inhibitory control? What if medications could ramp up will power?&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s an area of active research,&quot; Levounis says. &quot;There are some medications proposed, but nothing to write home about.&quot;&lt;/p&gt;
&lt;p&gt;He said treatment is typically twofold. For addicts, psychiatrists will try to &quot;cool down&quot; the reward pathways, often with medication. Then, they target the diminished frontal lobes.&lt;/p&gt;
&lt;p&gt;&quot;We try to beef up the frontal lobes as much as we can, and we do that with psychotherapy,&quot; Levounis said.&lt;/p&gt;
&lt;p&gt;Researchers agree that psychotherapy is key to regaining self-control, and it&apos;s the predominant treatment used in patients with addictive behaviors.&lt;/p&gt;
&lt;p&gt;Mark Smaller, PhD, a psychoanalyst in private practice in Chicago, said psychotherapy often reveals an underlying cause for an addiction or compulsive behavior. Usually, it&apos;s anxiety or depression.&lt;/p&gt;
&lt;p&gt;Acknowledging those problems may help change behaviors. Once they&apos;re realized, a patient can start working against them, with the help of the brain&apos;s own neuroplasticity. Essentially, neurons can disconnect and reconnect, or loosen their connections and tighten them, which often manifests in noticeable change.&lt;/p&gt;
&lt;p&gt;&quot;[Psychological] insights can actually begin to change brain chemistry and diffuse compulsions,&quot; he said. &quot;If you address those issues, you can have a positive impact on your life that can change the chemistry of your brain.&quot;&lt;/p&gt;
&lt;p&gt;Smaller said it &quot;creates a new psychological  --  if not neurological  --  structure that can help regulate behavior.&quot;&lt;/p&gt;
&lt;p&gt;Although research on neuroplasticity is relatively young, the concept of &quot;rewiring&quot; the brain is not new.&lt;/p&gt;
&lt;p&gt;In fact, too often, the electrician metaphor has been employed as an excuse for indulging, an explanation for a New Year&apos;s resolution deferred: &quot;I can&apos;t stop eating chocolate, I&apos;m just not wired that way.&quot;&lt;/p&gt;

&lt;hr&gt;
&lt;p&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/30/16717.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/30/16717.jpg&quot; alt=&quot;&quot;&gt;&lt;em&gt; is a collaboration between &lt;/em&gt;MedPage Today &lt;em&gt;and&lt;/em&gt; ABC News&lt;em&gt;.&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_335"
                     title="Ultrasound Helps Predict Liver Damage in NAFLD (CME/CE)"
                     score="0.005"
                     href="http://www.medpagetoday.com/Gastroenterology/GeneralHepatology/tb/18211?impressionId=1265769841625"
                     
      &lt;p&gt;An ultrasound technique called transient elastography can accurately detect liver damage in most patients with non-alcoholic fatty liver disease (NAFLD), a condition that often accompanies obesity and type 2 diabetes, a new study found.&lt;/p&gt;
&lt;p&gt;Transient elastography (TE) accurately measured levels of liver stiffness, an indication of the amount of fibrosis, in more than 97% of patients with a body mass index below 30 kg/m&lt;sup&gt;2&lt;/sup&gt; and in 75% of obese patients, according to a report in the February issue of &lt;em&gt;Hepatology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The adoption of transient elastography could potentially spare two-thirds of NAFLD patients from liver biopsies,&quot; Victor de L&amp;#233;dinghen, MD, PhD, of H&amp;#244;pital Haut-L&amp;#233;v&amp;#234;que, in Pessac Cedex, France, and colleagues wrote. &quot;Since the prevalence of NAFLD is high in many affluent countries, this approach would be cost saving.&quot;&lt;/p&gt;
&lt;p&gt;Non-alcoholic fatty liver disease has become more common as the incidence of metabolic syndrome and obesity has grown. The condition can progress to cirrhosis and hepatocellular carcinoma, particularly among patients with non-alcoholic steatohepatitis (NASH), in which fat in the liver causes inflammation and tissue damage.&lt;/p&gt;
&lt;p&gt;Liver biopsy is typically used to determine levels of inflammation and fibrosis associated with NASH, but the procedure carries a small risk of hemorrhage, puncture of other internal organs, infection, and spread of cancer cells. Transvenous liver biopsy carries an additional risk of adverse reaction to the contrast material.&lt;/p&gt;
&lt;p&gt;These problems, in addition to the mixed results due to sampling variance&lt;strong&gt; &lt;/strong&gt;biopsies sometimes deliver, have researchers searching for alternative methods of determining the extent of liver fibrosis.&lt;/p&gt;
&lt;p&gt;L&amp;#233;dinghen and colleagues compared the accuracy of TE to biochemical tests for the diagnosis of fibrosis and cirrhosis in 246 NAFLD patients who underwent liver biopsies between May 2003 and April 2009 at University Hospital of Pessac and Prince of Wales Hospital in Hong Kong. The accuracy of the TE measurements was validated by biopsy results.&lt;/p&gt;
&lt;p&gt;Of the patients, 31 (12.6%) had advanced fibrosis and 25 (10.2%) had cirrhosis.&lt;/p&gt;
&lt;p&gt;The liver stiffness measurements of patients with F0, F1, F2, F3, and F4 stages of fibrosis were 5.7, 6.8, 7.8, 11.8, and 25.1 kPa, respectively (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001, by analysis of variance).&lt;/p&gt;
&lt;p&gt;TE was accurate for predicting fibrosis in patients with liver stiffness of at least 7.9 kPa; measurement and accuracy were not affected by hepatic steatosis, necroinflammation, and obesity.&lt;/p&gt;
&lt;p&gt;The most disagreement between the results of the TE and biopsy methods occurred in patients with short liver biopsy lengths and mild or no fibrosis.&lt;/p&gt;
&lt;p&gt;In patients with complete biochemical data, the accuracy of TE was compared with that of other means of predicting liver stiffness, and was found to be more reliable than aspartate aminotransferase&amp;#8211;to&amp;#8211;alanine aminotransferase ratio, aspartate aminotransferase&amp;#8211;to&amp;#8211;platelet ratio index, FIB-4, BARD, and NAFLD fibrosis scores.&lt;/p&gt;
&lt;p&gt;The authors cautioned that the results of the liver biopsies potentially could have been influenced by sampling bias and that referral&lt;strong&gt; &lt;/strong&gt;patients enrolled in the study may have had more advanced liver disease than the general population. They also noted that a significant proportion of obese patients were not analyzed because a liver stiffness measurement could not be obtained.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Leon Adams, PhD, of the University of Western Australia, noted that the majority of individuals with NAFLD will not develop liver-related morbidity or die from liver disease.&lt;/p&gt;
&lt;p&gt;&quot;Thus, he wrote, &quot;the difficulty facing the managing physician is predicting which patients are at greatest risk of developing cirrhosis, thus identifying those who will benefit most from specific treatments, more intensive therapy, and monitoring.&quot;&lt;/p&gt;
&lt;p&gt;The new study, he wrote, suggests that TE is effective at excluding advanced fibrosis and cirrhosis in patients with NAFLD. However, he argues that the technique requires further validation in obese and morbidly obese populations and that sensitivity of the test is likely to vary between differing patient populations, different medical personnel administering the test, and underlying prior probability of fibrosis.&lt;/p&gt;
&lt;p&gt;&quot;Lastly,&quot; he concluded, &quot;if noninvasive markers are going to form part of the routine assessment of the millions of individuals with NAFLD, the expense and availability of each modality may play a decisive role in which the noninvasive method is most appropriately taken up by community physicians and specialty hepatologists.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the Chinese University of Hong Kong.&lt;/p&gt;&lt;p&gt;Co-investigator Henry Lik-Yuen Chan reported receiving advising and speaking fees from Novartis, Bristol-Myers Squibb, Pharmasset, and Schering-Plough.&lt;/p&gt;&lt;p&gt;Co-investigator Sung reported receiving advising and speaking fees from AstraZeneca, GlaxoSmithKline, and Roche.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_555"
                     title="Fatty Liver Associated With Hypertension Regardless Of Alcohol Use"
                     score="-0.005"
                     href="