Violence

[Doobah47]

Originally Posted by Aedes

Well, also remember that something isn't a psychiatric disorder until it interferes with normal functioning in life (loosely defined though that may be). We ALL get depressed or bereaved from time to time, but we DON'T all have major depressive disorder. Humans can be aggressive in sports, war, arguments, whatever. But normal human behavior restricts aggression to a reasonable context. So excessive aggression that interferes with life may indeed be the result of an underlying psych disorder, or substance-induced disinhibition, or whatever, rather than being simply a variant of normal.

So would you say that an ordinary, mentally 'stable', sane boxer does not suffer from any particular disorder? That their passion for violence is well within the moral and medical codes of what is 'good'/'healthy'? I would say most certainly NO! I think that this passion for violence that so many people adore, profit from and admire is very detrimental to our lives in this society. Remember that there are words - such as 'sporting' - that identify a morally acceptable level of effort, and I believe (through interpretation of the word 'sporting') that aggressive behaviour is outside the limits of said word; one can try incredibly hard, and make abstracted aggression part of the game (attacking shots in squash for example), yet this is not the kind of aggression which I talk of - I'm talking about the arguing with the referee, or the spiteful use of language to harm other players performances; the kind of simplistic aggressive bodily behaviour and not the type of shots or plays one makes.

It is actually an idea of mine that politics be an entirely linguistic affair, based on the internet and word processors in order to extinguish the kind of aggressive, socialite leadership qualities that many politicians profit from - the bullying by influence and sly secrets would be no more if the politicians could only be identified by a name on a computer screen, and not by their race/class/winking eyes/sly taps on the nose; as well as this it would be their policies and not their demagogue that were known to the audience/citizens.

[Aedes]

Originally Posted by Doobah47

So would you say that an ordinary, mentally 'stable', sane boxer does not suffer from any particular disorder? That their passion for violence is well within the moral and medical codes of what is 'good'/'healthy'? I would say most certainly NO! I think that this passion for violence that so many people adore, profit from and admire is very detrimental to our lives in this society.

This is hardly black and white, though, and it's both culturally determined and an individual judgement. My father thinks football and hockey are needlessly brutal and violent. Most Americans think that's not the case, and the violence (and risk of injury) just goes with the territory. I completely abhor sport hunting -- but I'd bet Americans are quite split on this one (certainly regionally). I'm sure nearly all Americans think that ****fighting, dogfighting, dueling with pistols, and deathmatches (like in Bloodsport) are horribly cruel and unnecessarily violent.

As for disorder among the participants? It certainly takes a certain type to want to punch and be punched, or tackle and be tackled. And I'm sure there's a spectrum of those who are globally aggressive and that's one of several outlets, versus people who channel ALL aggression into a socially acceptable outlet (like playing hockey or perhaps boxing). So for a culturally acceptable thing, I'm not sure a disorder can be readily diagnosed. For someone who likes to torture animals, you might not be able to make a diagnosis but there is certainly high likelihood that this person is not mentally healthy.

It is actually an idea of mine that politics be an entirely linguistic affair, based on the internet and word processors in order to extinguish the kind of aggressive, socialite leadership qualities that many politicians profit from - the bullying by influence and sly secrets would be no more if the politicians could only be identified by a name on a computer screen, and not by their race/class/winking eyes/sly taps on the nose; as well as this it would be their policies and not their demagogue that were known to the audience/citizens.

Food for a different thread.

[Ruthless Logic]

Originally Posted by Aedes

For god's sake, here is the FDA-approved package insert and full prescribing information for phenytoin. Take a brief look at "indications and usage":

http://media.pfizer.com/files/produc...i_dilantin.pdf

Being one of the oldest drugs still in use (first marketed around 1960), phenytoin has been tried for a lot of things, both off-label and in clinical trials. But we're talking about a generation ago. Phenytoin is a notoriously toxic drug that has a very limited set of uses these days.

Distal phalanges is only word salad when used in the sentence "Phenytoin is used to treat most types of distal phalanges", which is what you wrote. A phalanx (the singular of phalanges) is an anatomic word and "distal" refers to the end farther away from the body (it's the opposite of "proximal"). So what you wrote is like writing "Tylenol is used to treat most types of heads."

Yes, osteoarthritis affects the interphalangeal joints (arthritis refers to joints, not bones which the phalanges are). However, antiinflammatories in clinical trials are marginally effective for osteoarthritis, with little difference between antiinflammatories (like ibuprofen) and non-antiinflammatory analgesics (like acetominphen).

Phenytoin is not an effective antiinflammatory, it is not used therapeutically for osteoarthritis, and in fact it is known to worsen osteoarthritis in rare cases (Eur J Intern Med. 2001 Sep;12(5):448-450). It has been studied for rheumatoid arthritis which is a completely different disease than osteoarthritis, and it has had some efficacy in those few studies, but it is not in clinical use because there are numerous better, safer drugs for RA. It's a very toxic drug that has limited use, almost exclusively for acute and chronic seizure management (it's probably used off-label for some refractory psychiatric disorders and severe neuropathic pain disorders as well, but that's not my specialty so I'm not sure). Phenytoin has a LOT of toxicities, including drug interactions, hepatotoxicity, and drug rashes, so its use is pretty limited.

As for my medical training, Harvard Medical School and the University of Connecticut School of Medicine have been kind enough to be my homes for the last 11 years of my medical career, and I've just taken a faculty position as one of the core teachers in the internal medicine and med-peds residencies at Duke Medical School. I hold three board certifications, two licenses, DEA certification, and a number of publications and awards. But hey, you were close.

Why are we fighting about this, by the way? Oh, because you called it a cardiac drug and I said that it wasn't. Can we just get back to the topic now?

Could you kindly provide research-able evidence with regards to your credentialing claims, basically provide information that a potential patient might request in evaluating the academic criteria of a potential Physician(doctors do it everyday). If you can follow through with the request, I will certainly apologize to you with regards to the evaluation process of prescription drugs, as your education and profession provides you with the expertise to provide more credible counsel, as mine is woefully inadequate in comparison, but I am 98.50% confident based on your style of responses that you are just another Internet Hack indulging in fantastical misrepresentations.

[de_budding]

Originally Posted by Ruthless Logic

Could you kindly provide research-able evidence with regards to your credentialing claims, basically provide information that a potential patient might request in evaluating the academic criteria of a potential Physician(doctors do it everyday). If you can follow through with the request, I will certainly apologize to you with regards to the evaluation process of prescription drugs, as your education and profession provides you with the expertise to provide more credible counsel, as mine is woefully inadequate in comparison, but I am 98.50% confident based on your style of responses that you are just another Internet Hack indulging in fantastical misrepresentations.

Well even if you did apologies on those grounds it would be a lousy apology. Reminds me of the bully who apologizes when he realizes his victim has a 24 y.o brother with a car and real muscles.

[de_budding]

Did you get your honey moon in the end?

[Aedes]

Originally Posted by de_budding

Did you get your honey moon in the end?

Yeah, it was on the way home. Ironically we had been stuck in Maui an extra 3 days because of a huge snowstorm in Chicago and an ice storm in Dallas, so it was serendipitous that we were on that particular flight.

We were in Hawaii for a meeting earlier this year and on the flight home we discovered by pure luck that one of my med school classmates was on the same plane (he wasn't at the meeting). He's a cardiology fellow at Mass General, so that meant HE could deal with the heart attacks. I'm much happier dealing with meningitis or tuberculosis than with a heart attack

[Ruthless Logic]

Why are we fighting about this, by the way? Oh, because you called it a cardiac drug and I said that it wasn't. Can we just get back to the topic now?


The claim that Phenytoin is NOT a cardiac drug is carelessly inaccurate. Phenytoin is used for certain Cardiac Arrhythmias (irregular rhythms). The link will directed you to ACCURATE information.

Dilantin - Phenytoin, Phenytoin sodium - Cancer Drug=



Do you know what distal phalanges are? They're the tips of your fingers and toes. That's it -- fingertips. So phenytoin is used to treat fingertips -- last I checked fingertips aren't a disease.

I also find it disconcerting that a health care professional could possibly think that Distal Phalanges are immune to any disease processes.

[Aedes]

*Edit -- I spoke earlier this morning with a PharmD who is the head of our hospital pharmacy, and I also spoke with one of the senior cardiologists in our practice who has been in practice for about 30 or 40 years, and neither one has ever heard of phenytoin being used as an antiarrhythmic*


Getting accurate medical information as a layperson is very tricky, especially on the internet, because there isn't an easy way to know which sites are reputable and there isn't a peer-review process. You have had a difficult time differentiating the actual clinical use of phenytoin from a potential use that has been investigated but was never commonly used clinically. We spend a lot of time with patients trying to inform them and provide resources online and elsewhere with accurate information.

OUR main resource for accurate information is the National Library of Medicine, which has online access to the medical literature going back to around 1963. You can use various search engines like PubMed or Ovid to access it. We also use textbooks that have good referenced reviews. For drug information the FDA requires that all package inserts include information about approved uses, toxicities, and other information. Phenytoin is NOT FDA approved for arrhythmias, as you will find by looking at the package insert that I linked. Its antiarrhythmic activity is class IB, and there are only a few class I antiarrhythmics in use anymore (like lidocaine, procainamide, a couple others) because better and safer drugs are out..

Originally Posted by Ruthless Logic

The claim that Phenytoin is NOT a cardiac drug is carelessly inaccurate. Phenytoin is used for certain Cardiac Arrhythmias (irregular rhythms). The link will directed you to ACCURATE information.

If you want accurate information, check MicroMedex, check PubMed, or call a cardiologist.

Phenytoin works on the brain by modulating ion channels. Turns out the heart has ion channels as well, and other antiarrhythmics work on the same site. Because of this there were early trials of phenytoin as an antiarrhythmic but as far as I can tell in PubMed, which catalogs all medical journal articles back to 1963 I can find NO evidence of it ever being used clinically as an antiarrhythmic. The LAST published clinical trial of it for arrhythmias was published in 1988. It is not FDA approved for this indication and probably has not been even used off label for it for a generation. I've seen a lot of people with bad, refractory arrhythmias who are on multiple antiarrhythmics, and who have implanted defibrillators and pacemakers, and never once has phenytoin been part of the cardiologists' repertoire.

If you do a PubMed search, you'll find that nearly all the literature about phenytoin for arrhythmias comes from the late 1960s and early 1970s, with the most recent trial of nine patients being in 1988. Why do I underline nine? Because most cardiology trials have tens of thousands of patients. There is a national registry of clinical trials that you can check to see if someone is actually studying it. I believe you access it throug the NIH website.

Phenytoin is quite toxic and there are tons of safer alternatives. I've been certified in ACLS, PALS, and NALS/NRP several times each, I've worked in adult and pediatric ICUs, I've run resuscitations for people in cardiac arrest from arrhythmias, I am constantly consulting cardiologists, and never in my career has ANYONE ever regarded phenytoin as a viable therapeutic antiarrhythmic. So if it's actually used as an antiarrhythmic anywhere, it's either investigational or for extreme, refractory cases.

If you want independent corroboration of this, get away from Google and go ask someone else. Go find the chief of cardiology at your local hospital or a professor of cardiology at a local medical school. See how often they've used phenytoin to treat arrhythmias.

I'll do the same for you. I'll probably run across 5 to 10 cardiologists over the course of today at work. I'll ask them all.

I also find it disconcerting that a health care professional could possibly think that Distal Phalanges are immune to any disease processes.

Where pray tell did I say that? I didn't. In fact I have a patient right now with a Staph infection of his middle and distal phalanges of one finger, I recently had a patient with sickle cell disease who had sequestration in the distal phalanges, I've got a patient with RA with disease of the phalanges, and I've had a recent patient with endocarditis who had septic embolization to the distal phalanges.

I was responding to your aphasic dribble "Phenytoin is used to treat most types of distal phalanges". You didn't say used to treat most types of diseases of the distal phalanges (which would be ludicrous unto itself, because we think of diseases as PROCESSES, not PLACES). You said "most types of distal phalanges". Turns out that there are 20 types of distal phalanges -- one for each finger and toe. We also have middle phalanges and proximal phalanges.

Now which disease of the distal phalanges are you referring to? Are you referring to osteomyelitis? Onychomycosis? Sickle cell bone infarcts? Traumatic amputation? Frostbite? Osteosarcoma? Animal bites? Burn injuries? Osteoporosis? Osteogenesis imperfecta? Polydactyly? Diabetic ulcers?

These are hardly MOST types of diseases of your digits, but it should illustrate why you can't just speak of "most types of distal phalanges" as if its a disease that any doctor would recognize as such.

Like I said, you didn't refer to treating disease. You referred to treating anatomy.

Oh, and I'm still looking for a disease of the distal phalanges other than neuropathic pain that is routinely treated with phenytoin.



If you don't believe me, that's fine. I don't care. Everyone here has had a chance to see our respective credibility on this topic, decide for themselves, and then get on with their lives.

Now I'm going to lock this thread if this digression keeps going on, and that is a shame because it's a good philosophy topic. If you want to have a chat about pharmacotherapy, feel free to start a topic in the Lounge. Otherwise, let's get back on track.

[Doobah47]

I'd like to retract my statement that cocaine and violence aren't related. I've recently discovered that a small dose of cocaine leaves the user disgruntled and prone to loss of temper; large doses leave the user calm and tranquil though... ah well, it should be cheaper is all I'll say.

As for violence in society, I think it is probably more closely relevant to indoctrination than to carnal, primal instincts...

Any thought?

[Aedes]

Originally Posted by Doobah47

I've recently discovered that a small dose of cocaine leaves the user disgruntled and prone to loss of temper; large doses leave the user calm and tranquil though...

In the patients I've seen, the higher the dose the higher the level of agitation and belligerence. I don't know if the dose-response relationship has been formally studied, but I don't think your impression of it is accurate.