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July 4, 2006

BehindTheMedspeak: Transcranial magnetic stimulation for depression

Depression_4

Elena Cherney wrote about the availablity of this promising new therapy in a June 6 Wall Street Journal article.

Long story short: you have to go to Canada to get it because it's not yet approved for use in depression in the U.S.

Here's the piece.

    Patients Seek Off-Label Depression Therapy

    Magnetic Stimulation Shows Promise in Intractable Cases; Heading to Canada for Help

    Pediatrician Laura Schulman suffered from depression so severe that it forced her to stop practicing medicine five years ago. A string of drug cocktails over the years failed to help. Then she read about an experimental treatment called repetitive transcranial magnetic stimulation [rTMS].

    The treatment hadn't been approved for depression, but a clinic in Canada was offering it to U.S. residents, and would even help arrange travel and lodging. So last summer, the Seattle resident dipped into her savings and headed north to a MindCare Centers clinic in Vancouver, British Columbia, where three to four weeks of treatment costs nearly $7,000.

    After a few sessions of rTMS, which delivers electromagnetic pulses to the brain via a magnetic coil held against the skull, Dr. Schulman says she felt her depression lifting. As she made her way around Vancouver she started finding it easier to manage everyday tasks that had once felt so burdensome -- such as buying a bottle of water at a corner store. "It was like putting on glasses for the first time if you've been myopic all your life," she says.

    Dr. Schulman is one of many desperate patients leaving the U.S. to obtain rTMS after failing numerous antidepressant medications. And while some doctors are cautioning patients to wait for the Food and Drug Administration to weigh in, scores of other patients have traveled to U.S. clinics that offer the treatment on an "off label" basis. The technique is approved in the U.S. only for brain research, but doctors can use it to treat depression, just as other drugs and therapies can be used in applications other than those for which they are approved. In Canada, the rTMS device has limited federal approval for safety, but provincial health-insurance plans won't cover it, citing lack of evidence on its efficacy.

    The therapy is showing promise in studies. In the first big multisite trial of rTMS, the method was shown to benefit about 42% of patients with treatment-resistant depression -- or severe depression that doesn't improve with medication. And side effects were considered mild, mostly consisting of headache. The 300-patient study, released last month, was sponsored by Neuronetics Inc., which is seeking Food and Drug Administration approval for use of its rTMS device in treating depression. A spokeswoman for the FDA declined to comment on the review process.

    Many psychiatry experts say rTMS is likely to be approved soon in the U.S. But some doctors note that for now, the clinics in both Canada and the U.S. are operating without direct regulatory authority, and may not be following the same protocols in screening patients that researchers use in their clinical trials. So some patients who aren't appropriate candidates may be paying for pointless treatment, these doctors say, and failing to pursue the treatment that they do need. Since rTMS isn't covered by insurance, patients typically pay thousands of dollars out of pocket.

    "The results are very promising, but standards need to be in place" before patients seek treatment, says Sarah H. Lisanby, a lead investigator on the Neuronetics study and a psychiatrist at the Brain Stimulation and Neuromodulation division of the New York State Psychiatric Institute.

    Treating stubborn depression remains one of psychiatry's most puzzling problems. About 14 million people in the U.S. suffer from depression, and some 70% don't fully respond to the first antidepressant drug they try. At least one-third of patients still have symptoms after adding a second drug or switching to another medicine, according to recent studies by the National Institutes of Health. "These are people who've lived their lives in misery or have tried many medications," says Mark George, a psychiatrist at the Medical University of South Carolina, who is an investigator on the Neuronetics trial and has consulted for the MindCare clinics.

    Only two nondrug treatments have been approved by the FDA for depression. Electroconvulsive therapy, or ECT, is considered the gold standard in hard-to-treat cases, based on its efficacy. But because it works by causing a seizure, it must be performed in a hospital. And it can have serious side effects, including memory loss and cognitive problems. Dr. Schulman of Seattle, for instance, said she didn't want to try ECT because of the risk of side effects.

    Vagus nerve stimulation, approved last year, involves surgery to implant a device in the neck, but is only approved as an add-on to medication for chronic or recurrent depression.

    In rTMS a strong magnetic field is directed through a coil held against the head for a series of sessions that last less than an hour each. The magnetic force stimulates a part of the brain believed to play a role in depression. The treatment doesn't require anesthesia and produces few side effects, though it doesn't work for as many people, or as effectively, as ECT.

    The treatment does carry a small risk of seizure, and the American Psychiatric Association guidelines for research state that rTMS should be supervised by a licensed doctor. In research trials, patients are screened to make sure they don't have medical conditions that could put them at risk for having a seizure. Patients in the studies are also screened by a psychiatrist to make sure that they in fact are suffering from depression.

    Atlanta psychiatrist Mark Hutto has treated about 100 patients with rTMS at his clinic, North Atlanta Psychiatric Associates, since 2001. Dr. Hutto says he has patients sign a consent form that explains that the treatment isn't FDA-approved for depression. He says he also requires patients to undergo physical and psychiatric exams to determine whether they are good candidates.

    Dr. Hutto, who says he has trained a technician to do the treatment but is in the building when it's done, wasn't able to get malpractice insurance for doing rTMS because it isn't approved for depression. But "I think it's a very safe procedure," says Dr. Hutto, who uses a Neuronetics device. "I'm not worried about it."

    Dr. Hutto says he charges $75 to $150 per session, depending on a patient's income, since the treatment isn't covered by insurance. Most patients get 15 to 25 sessions, so their cost is about $1,125 to $3,750, he says. A course of ECT, which is covered by most insurers, can cost more than $12,000, he says.

    At the two MindCare clinics in Vancouver and Toronto, almost 400 people have been treated for depression since 2001, about half of whom traveled up from the U.S., says Chief Executive Officer Iain Glass. They charge $4,500 to $6,750 for a three-to-four-week course of treatment and cater to an international clientele by helping to arrange hotel accommodations for patients.

    Mr. Glass has approval from the Canadian government to sell the device, which has been deemed safe for use. But while there is no rule that says the device cannot be used, neither is there an official sanction of its use in depression by provincial authorities. An Ontario government panel considered the evidence in 2004 and ruled there weren't yet enough data to warrant the government health system paying for the procedure. Mr. Glass says his technique is very similar to the one used in the Neuronetics study, but he uses a device made by a unit of Medtronic Inc., Minneapolis.

    The British Columbia College of Physicians and Surgeons, which licenses doctors in the province, says the device doesn't pose a risk of "direct harm" to patients, according to college registrar Morris Van Andel.

    At the Toronto MindCare clinic, which occupies an examining room in a suburban walk-in clinic, treatment is administered by a technician who is trained as a surgeon in his native Ukraine, Mr. Glass says. He says a family doctor from the walk-in clinic supervises and assesses patients before treatment. The Vancouver clinic has a staff psychiatrist who does the exams, but that doctor isn't always in the room when patients are treated, Mr. Glass says.

    The method won't help all patients with treatment-resistant depression. The randomized, controlled Neuronetics trial involved patients at 22 sites who had failed to respond to at least one drug during their current depressive episode, and had been depressed for at least six months. In the first phase of the study, only 25% of patients who received treatment showed a response. But that response rate was more than double the response of the patients in the placebo group, who received a sham treatment.

    When the sham patients were offered active treatment, and more sessions were given to patients who hadn't improved on the active treatment, response rates rose to between 42% and 43%. "This is not a cure," says study investigator Dr. Lisanby. "It's not going to be for everyone. It did help a significant percentage of patients."

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The best website in the world for a depressed person to visit is McManweb.com.

July 4, 2006 at 04:01 PM | Permalink | Comments (1) | TrackBack

Instant Dog House

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Because you just never know when you'll find yourself in one.

From the website:

    Instant Dog House

    Unlike traditional dog houses that are heavy and require time-consuming assembly, this is a comfortable, well-vented pet shelter that pops up or folds away in less than five seconds.

    Ideal for taking on vacations, for a day at the park or simply at home in the yard, the dog house is easily moved from place to place in its own compact storage bag that can be carried in one hand or by using the attached shoulder strap.

    The durable nylon has an SPF of 50 to protect your dog from the sun's rays, and the house has three windows and a wide door that can be left open for cool venting or zipped closed to protect against the elements.

    Includes sand pockets and stakes to keep the lightweight structure in place.

    33"H x 42"W x 42"D.

    Weight: 6 lbs.

$79.95 (dog not included).

July 4, 2006 at 03:01 PM | Permalink | Comments (2) | TrackBack

Ritz-Carlton Hotels in the 21st Century

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They've always been known for their 20 rules, dubbed the Ritz-Carlton Basics."

Two weeks ago they dropped them in favor of 12 new "Service Values," hoping to transform the chain into a sleek avatar of modernity while retaining the high standards that have always distinguished their hotels.

Peter Sanders wrote about the shift in a story which appeared in the June 23 Wall Street Journal, and follows.

    Takin' Off the Ritz -- a Tad

    Chain Relaxes Service 'Rules' To Rely on Workers' Judgment; No More Escorts to Restroom

    For more than two decades, every "lady and gentleman" patrolling a Ritz-Carlton hotel -- whether on the Bosphorus or the Kapalua beaches -- was secure in the knowledge that they carried in their breast pockets the exact instructions to pamper any guest.

    There, laminated between two pieces of plastic, were the 20 rules dubbed the "Ritz-Carlton Basics": Never say "Hello" to a guest; always opt for a more formal greeting like "Good Morning." Never give directions to the restroom; always escort the guest right to the door. And, never, under any circumstances, let a guest carry his own luggage.

    This week, all that changes. The name that has defined luxury as a cross between formal elegance and unwavering service bordering on the robotic is scaling back the 20 rules to 12 "service values" and asking employees to think for themselves.

    "It's all about staying relevant in a space that has changed dramatically in the last 20 years," says Simon Cooper, Ritz's president and chief operating officer. "Ritz-Carlton has the best and most recognized luxury brand names in the world, and we need to focus on 'relevant luxury.' "

    Ritz is struggling with an idea that is confronting many high-end hoteliers: how to define luxury in a crowded and evolving market. No longer is the typical luxury-hotel guest a middle-age male business traveler, or a wealthy jet-setter of a certain age. These days, the 30-year-old in a T-shirt and jeans fiddling with his BlackBerry in the lobby could be worth millions.

    So while Ritz's motto has long been "Ladies and Gentlemen serving Ladies and Gentlemen," it is coming to grips with the idea that some luxury travelers don't necessarily want to be addressed that way.

    "The notion of what our parents wanted in terms of luxury and formality is different from what today's generation wants," says Cathy Enz, professor of strategy at the Cornell University School of Hotel Administration. "As times change, so does the expectation for the luxury guest who has more choices than ever."

    With change, though, comes the risk of alienating loyal guests like Debbie Baumgart, who recently spent time at the Ritz-Carlton in Palm Beach, Fla. The 51-year-old travel agent from Cleveland thinks "more is always better than less," when it comes to service. "You're paying a lot of money when you're there," she says, "so I am always happy to be catered to and expect a higher caliber of service from the employees than if you were staying somewhere either cheaper or more hip."

    For Ritz-Carlton, the key to pleasing travelers is delivering top-drawer service without being so dogmatic about what that means. "In the past we would help a guest with their luggage 100% of the time," says Rainer Burkle, general manager at the Ritz in Berlin and a 15-year employee. "These days, most business travelers don't want us to touch their bags, but our current rules tell our employees they have to."

    Though folksy language by employees is still forbidden, the oft-heard catchphrase "Certainly, my pleasure" will be discouraged -- replaced instead by more natural responses depending on the particular situation.

    The shift is crucial for Ritz, a wholly owned subsidiary of lodging giant Marriott International Inc. Company officials acknowledge that it needs to reposition itself vis-à-vis archrival Four Seasons Hotel Co., which seems to be edging out the Ritz in the hipster zeitgeist of late, even though formal surveys still place Ritz-Carlton at or near the top of the sector. Ritz-Carlton officials dispute any suggestion that the brand has lost its luster. "We don't agree with that perception and don't think that's what our customers believe or that the survey results and data bear that out," says Bruce Himelstein, senior vice president of sales and marketing.

    While the luxury segment represents only a small fraction of the world's hotel rooms, the sector helped drive the booming hotel engine last year. Luxury hotels reported a 3.5% increase in occupancy over 2004. More surprising: PKF Consulting estimates the average nightly rate at a luxury hotel in the U.S. in 2005 was $283.35 -- a nearly 7% increase from 2000, which was a record year in the travel industry. Revenue per available room at luxury hotels -- a key industry indicator -- was up 11.4% from 2004 to $201.98.

    For Ritz-Carlton, which began its modern incarnation by carving its niche in the highest end of the hotel industry with one hotel in Atlanta in 1983, the change goes to the very core of what the company is. Every weekday at 9:05 a.m., roughly 75 corporate "ladies and gentlemen" gather in the eighth-floor lobby of a suburban office building here for the company's daily "Lineup." Inspirational quotations are read aloud ("It's beauty that captures your attention; personality which captures your heart." -- Anonymous); visitors and guests in the room are introduced; and an employee recites one of the new 12 service values (until this week, it had been one of the 20 basic rules). The same ritual is played out at the beginning of each shift in every department for all 32,000 employees at the company's 61 hotels.

    The changes were received with some grumbles when presented to the company's general managers at a meeting in Barcelona earlier this year. There were worries expressed about ruining the company's high standards and reputation, according to people who were there.

    "Our reputation for service is our Holy Grail, and we didn't want to mess with that," says Ed Staros, who oversees two Ritz resorts in Naples, Fla., and is one of the founding partners of the company. "I was also concerned we would implement these changes in a way that one hotel would be following different rules than another and that would send mixed messages to our guests."

    His concerns, however, were allayed when it was decided that the policies would be phased in over the course of no longer than 10 days.

    The change comes as Ritz-Carlton has developed a large portion of its business catering to corporate meetings and group events. "The broader spectrum of traveler they're now accommodating may not have the appreciation of that highest level of service," says Mark Woodworth, of PKF Hospitality Research in Atlanta.

    Keith Hanks, who often stays at Ritz-Carltons when attending work-related functions, sums up the problem facing the push for a more-relaxed luxury. The 54-year-old manager of a Toyota dealership in Metairie, La., stayed at one of the company's urban hotels in Chicago this spring and then spent the following week at one of its resorts in St. Thomas. "In St. Thomas you really felt like when they said 'my pleasure,' the staff really meant it," he says. "Everywhere else, it felt like they were reading from a cheat sheet in their pocket."

    He wouldn't mind seeing the "laid-back attitude" he encountered in the islands translated to other Ritz-Carlton hotels -- as long as the quality of service doesn't suffer.

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How do you spell "psychobabble?"

July 4, 2006 at 02:01 PM | Permalink | Comments (2) | TrackBack

Leather Headband

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From the website:

Leather Headband

Matte and patent leathers mix in peeper-popping shades of red,

Redredred

green

Greengreengreen

or navy.

Navynavynavy

Imported.

1.5" wide.

$32.

July 4, 2006 at 01:01 PM | Permalink | Comments (1) | TrackBack

The Who — 'Live at Leeds'

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Good, better and best — that's how this record comes, in three flavors.

The music was recorded at Leeds University (U.K.) on February 14, 1970.

Good is the original album, consisting of six songs ("Young Man Blues," "Substitute," "Summertime Blues," "Shakin' All Over," "My Generation" and "Magic Bus") and released in 1970.

Better is the 1995 release, containing all the songs performed by The Who that night outside of "Tommy," but including the "Amazing Journey/Sparks" medley.

Best is the 2001 version (tracks below), with the entire Leeds performance including "Tommy."

20l

So far I've only heard the first six songs from disc one but I'm already in heaven.

Their sound is so rich and immediate it's like listening to them for the very first time.

More than ever I believe that in 2050 the favorite rock group among Mars colonists will be The Who, far surpassing the Beatles, the Stones, U2 and the rest.

The more time that passes, the better The Who get.

The album's three versions are $6.98, $10.99 and $26.98 at Amazon.

July 4, 2006 at 12:01 PM | Permalink | Comments (0) | TrackBack

Petri Dish Ashtray

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Still in the concept stage.

From the website:

    見覚えのあるガラスの容器。

    化学の実験などに使われるシャーレです。その一部をタバコの形に凹ませた灰皿。とてもシンプルで、センス・オブ・ユーモアがあると思いませんか?灰皿以外にも、ちょっとした小物入れにどうぞ。

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Wait a minute, idiotstick: this is the English-version bookofjoe, not the Japanese one.

Sheesh.

OK, then, Take 2 — from the website:

    Petri Dish Ashtray

    A glass receptacle that appears familiar. It's a Petri dish used in chemical experiments and the like. An ashtray, part of which has been indented to conform to the shape of a cigarette. It's very simple and has a sense of humor to it, don't you think? Can also be used to hold small knickknacks.

....................

[via Shawn Lea and everythingandnothing]

July 4, 2006 at 11:01 AM | Permalink | Comments (0) | TrackBack

Schmap.com — Interactive Travel Guides

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Google Earth + Frommer's + Mapquest = Schmap.

That's the idea, anyway.

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You download the free Schmap player and then access any or all of the 70 interactive guides currently available.

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PC only, though; the Mac version is "real soon now" — November, in this iteration.

[via Carol Sottili and the Washington Post]

July 4, 2006 at 10:01 AM | Permalink | Comments (1) | TrackBack

95-Decibel Amplified Phone Ringer Strobe Light

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A party every time your phone rings.

If that's your idea of a good time then you'll want to be getting out your credit card right about now.

From the website:

    Amplified Phone Ringer/Flasher

    Now you’ll really hear the phone ring, even from a distance, and you’ll see it ring too!

    If you've had trouble hearing your phone ring, whether from close range or the other side of your house, this Amplified Phone Ringer will make sure you hear it and see it!

    It generates a loud ringing sound at up to 95 decibels — about as loud as a subway train from 200' away!

    Plus, a bright strobe light flashes at the same time to get your complete attention.

    You can adjust the volume and tone control and choose from three ringing tones.

    Has override switch, modular phone jack, UL-listed adapter.

    8" x 5" x 5".

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Me, you couldn't pay me to own this thing.

I turned off my phone's ringer long ago and life has been so much sweeter since.

I'm not that important.

Neither are you — but you may not yet have realized it.

$59.99.

July 4, 2006 at 09:01 AM | Permalink | Comments (0) | TrackBack

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