"An Angel in the book of life wrote down my baby's birth. And whispered as she closed the book "too beautiful for earth."

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Hello all! I just though I would send out an update! Thank you all for the sweet messages of concern and prayer. Please keep them coming as they are very needed these next few weeks especially! 


I started my Lupron shots on the 26th and other than the actual medicine stinging like crazy and a few crying spells, and an allergic reaction on my arms, I haven't noticed any side effects (lol, I love to be complicated).  I will do my best to explain what the meds do since I have people ask me constantly. Lupron in a nutshell causes a "flare effect". The flare effect of Lupron can be used at the beginning of a fresh IVF cycle to help stimulate the development and maturation of eggs. Lupron is given for a few days and then injectable fertility medications are started.  It essentially acts by suppressing the pituitary gland (the gland which is normally responsible for triggering ovulation). However, before suppression occurs, Lupron will briefly stimulate the pituitary causing an increase in the pituitary hormones LH (luteinizing hormone) and FSH (follicle stimulating hormone).

Two days later I started Gonal F injections. Gonal FSH increases the number of growing follicles and stimulates their development. Within the follicles are the developing eggs. FSH also increases the production of oestrogen, and under the influence of this hormone, the largest follicle continues to develop. This medicine is used to stimulate the development of follicles and eggs in women who are having difficulties getting pregnant due to problems with ovulation. 

So the side effects of both of these are:

• Pain, bruising and inflammation at the injection site in men and women.
• Headache in women.
• Ovarian cysts

• Mild to moderate over-stimulation of the ovaries (ovarian hyper stimulation), causing the production of many eggs.
• Disturbances of the gut, such as nausea, vomiting, diarrhoea, abdominal cramps and bloating in women.
• Breast enlargement, weight gain, acne and swelling of the veins in the scrotum in men.

I am experiencing every one of them except the scrotal swelling which if Steven doesn't play his cards right...he may experience! (lololol! crack myself up again).
I have this entire week off which is a God send because I am going to need a lot of sleep I do believe. 
Please pray for me this week. As if the hormones are not atrocious enough, this would have been my week to deliver nugget #1! November 6 would have been my first babies due date (at least by my calculations) and anybody that has ever had a miscarriage knows, a mommy never forgets that date. I cannot dwell on the past, however I do feel like that baby deserves some remembrance and I won't ever stop thinking about it! It was my only "first child"! Hopefully I'll be adding a sister or brother to the mix here shortly! 
Enough about that (sniff, sniff)...I go back to the doctor to see my new babies again this Friday. At that point they will assess how the medicines are working and at what stage the eggs are in order to plan their retrieval. November 10 is the tentative date for removing those bad boys. They will put me to sleep and use a very large needle to poke through my uterus and into my ovaries and get each individual egg out of it's nest! How cool is that?! Then we will put them together with Steven contribution to the process, and wait..... 
Somewhere around November 13-15 they will take the good embryos and implant the two best ones back in and WAIT...
All of this is assuming they have enough eggs to harvest and that they survive this process. I am praying and believing that I will produce more than enough and that they will be exceptionally gorgeous! (ha)At this point, if they are ugly PLEASE DON'T TELL ME! I will dress them cute anyway.
Many prayers needed for my health, sanity and marriage over the next month please! 
Here is a sweet reminder of my first angel that I won't ever forget! XOXO sweet fetus!


                       Nothing will ever out do this I don't believe! 
Have a great week!

Top 5 Things You Can Do With an Associate's Degree

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You may think that an associate's degree can't open up as many doors for you as a bachelor's degree.



Think again.



Truth be told, there's a lot you can do with an associate's degree these days. It can a faster, less expensive way to start a one of 2010's top careers, start a rewarding vocational career, or work towards a four-year degree.



Here are our 5 favorite things an associate's degree can do for you:



1. Start a Vocational Career
If you don't want to spend your weekdays locked in a cubicle, there are a lot of fantastic, high-paying vocational careers out there for you to explore. From cosmetology careers to automotive careers, these options can help you to turn your favorite hobby into a paycheck.



To start these careers, you'll need highly-specialized skills. That's where the associate's degree comes in. Many community, junior and technical colleges offer associate's degrees for a variety of vocational careers, which provide the skills and technical know-how you need to get started.



That means the minute you have your degree in hand, you'll be ready to join the workforce. No unpaid internships required.



2. Start a Career You Can Advance In
Who doesn't want a career that you can start fast, advance in, and make a good paycheck? Associate's degrees are often the keys that can unlock these kinds of career options.



Take nursing, for example. You can become a registered nurse by earning your Associate's of Science in Nursing. In approximately two years, this degree will have you working in a hospital, treating patients and helping doctors.



While you're working as an RN, you can take the next steps by earning a Bachelor's of Science in Nursing online. This will give you more career options, and the chance to eventually earn a Master's of Science in Nursing (MSN). The MSN allows you to become a nurse practitioner and enter a whole range of specialties, some of which pay a higher salary than a doctor's.



And it all starts with the associate's degree.



3. Work Towards a Bachelor's Degree
If you want a bachelor's degree, or know you'll need one to eventually advance in your career, but can't commit to a four-year program just yet, an associate's degree is a great place to start.



The associate's degree will allow you to complete your prerequisites and preliminary coursework, many of which will count towards a four-year bachelor's degree program when you're ready to enroll.



(An added bonus: associate's programs tend to be less expensive per credit hour than bachelor's programs, which will allow you to save some serious cash on your first two years of school.)



4. Make a Career Change
Let's say you're already working on a particular career path. One day, you wake up and realize you hate your job and what you really want to do is start a cupcake delivery business. (When you do, feel free to put the myFootpath corporate office address on your delivery route. Thanks.)



But while you need to get some business classes under your belt, you already have a bachelor's degree in accounting, and you don't want to start another four-year program. So what are you to do?



Enter the associate's degree. A specialized associate's degree can build on the education you already have, and provide the knowledge you need to make that career change.



5. Start One of Today's Best Careers
You don't need a PhD in rocket science to land one of today's top careers. These days, an associate's degree is the key to entering one of the 2010 top careers, including veterinary technician careers, dental hygienist careers, physical therapist assistant careers, and more

Just a 'Lil' Encouragement 3 - Strength

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Video Request: What's in my nursing bag?

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We had a good read. For the benefit of yourself. Be sure to read to the end. I want you to get good knowledge from Adn Nursing .I get asked this question a lot :-) Share with me what's in your nursing bag :-)I hope you will get new knowledge about Adn Nursing . Where you can offer easy use in your day-to-day life. And above all, your reaction is lowest price Adn Nursing |the full report Adn Nursing }.View Related articles related to Adn Nursing . I Roll below. I have suggested my friends to help share the Facebook Twitter Like Tweet. Can you share Video Request: What's in my nursing bag?.

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"I can't have a testimony without a test"

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Well, here is the update. Try to stick with me as I endeavor to explain a very complicated process via blog! There is good news and bad news! The good news is that I can't eat jack and I have lost 3 pounds this week! And that's about where it ends. Up until now Steven and I have been told that I have 2 out of 3 things wrong. We were made aware this week at the fertility clinic that I have 3 out of 3 wrong! (I always say, "go big or go home" right?) So...now we are faced with a decision. The doctor has advised us that she wants to do 2 more IUI procedures adding stimulation medications and ovulation medication to assist with this. I am not producing enough follicles and therefore the chance of an egg being produced is slim to none. My uterus is misshapen, and my hormones completely whacked (SHOCKING). Basically this is the deal. We are having to come up with 1500 bucks per cycle and the first cycle should start this week...no pressure. I will inject meds and take them by mouth. I will have ultrasounds, another HSG which will tell her exactly what my uterus looks like, and then we will try to get the eggs to come out and play. I would undergo the IUI in about 3 weeks. 

I am overwhelmed and scared. Steven and I are praying and well, worrying about what the right thing to do is. According to the specialist we have less than a 10% chance of ever conceiving and carrying a baby naturally. These medications will at least put me back up to a 20-25% chance of conceiving. That's a normal chance. The risks are minimal. If the meds make me produce too many eggs, they will simply go in with a huge needle and puncture all of the small eggs. Easy peasy right? (WTH?)...the other risk is...
It is estimated that the risk of becoming pregnant with twins while taking letrozole is 10%, while the risk of becoming pregnant with triplets is less than 1%. On the other hand, women who take gonadotropins in conjunction with IUI have as much as a 30% chance for multiple and high-order pregnancies and births. 


OH MMMMMMMMMMM GEEEEEEE.
I Found this video and it pretty well depicts this whole process in 3d. Take a look!

So all that said, I hope pregnant women are okay with one kidney because Steven and I will be donating ours on Monday morning!  When we make a decision and move forward I will update. Please say a prayer for us as this reality is very hard to deal with and our hearts are broken for it to have come to this. Trying to keep the faith and let God do His thing!

Psalm 113:9
He gives the childless woman a family, making her a happy mother. Praise the LORD!

Give all your worries and cares to God, for he cares about you.

Thank God I have a rich daddy (in heaven that is). I'm continuing to have faith and believe. I don't care if they tell me I don't have a uterus at all!

Until I see some results...




P.S. If you get a chance, go listen to this song. And get your tissue out! It's precious!  MySpace.com - Kellie Coffey - OKLAHOMA CITY, Oklahoma - Country / Pop / Rock - www.myspace.com/kelliecoffeyartistpage. It's called I would die for that. It looks like the play button is above the actual song so if you start listening to something else go press the one above it!

"An Angel in the book of life wrote down my baby's birth. And whispered as she closed the book "too beautiful for earth."

To contact us Click HERE
Hello all! I just though I would send out an update! Thank you all for the sweet messages of concern and prayer. Please keep them coming as they are very needed these next few weeks especially! 


I started my Lupron shots on the 26th and other than the actual medicine stinging like crazy and a few crying spells, and an allergic reaction on my arms, I haven't noticed any side effects (lol, I love to be complicated).  I will do my best to explain what the meds do since I have people ask me constantly. Lupron in a nutshell causes a "flare effect". The flare effect of Lupron can be used at the beginning of a fresh IVF cycle to help stimulate the development and maturation of eggs. Lupron is given for a few days and then injectable fertility medications are started.  It essentially acts by suppressing the pituitary gland (the gland which is normally responsible for triggering ovulation). However, before suppression occurs, Lupron will briefly stimulate the pituitary causing an increase in the pituitary hormones LH (luteinizing hormone) and FSH (follicle stimulating hormone).

Two days later I started Gonal F injections. Gonal FSH increases the number of growing follicles and stimulates their development. Within the follicles are the developing eggs. FSH also increases the production of oestrogen, and under the influence of this hormone, the largest follicle continues to develop. This medicine is used to stimulate the development of follicles and eggs in women who are having difficulties getting pregnant due to problems with ovulation. 

So the side effects of both of these are:

• Pain, bruising and inflammation at the injection site in men and women.
• Headache in women.
• Ovarian cysts

• Mild to moderate over-stimulation of the ovaries (ovarian hyper stimulation), causing the production of many eggs.
• Disturbances of the gut, such as nausea, vomiting, diarrhoea, abdominal cramps and bloating in women.
• Breast enlargement, weight gain, acne and swelling of the veins in the scrotum in men.

I am experiencing every one of them except the scrotal swelling which if Steven doesn't play his cards right...he may experience! (lololol! crack myself up again).
I have this entire week off which is a God send because I am going to need a lot of sleep I do believe. 
Please pray for me this week. As if the hormones are not atrocious enough, this would have been my week to deliver nugget #1! November 6 would have been my first babies due date (at least by my calculations) and anybody that has ever had a miscarriage knows, a mommy never forgets that date. I cannot dwell on the past, however I do feel like that baby deserves some remembrance and I won't ever stop thinking about it! It was my only "first child"! Hopefully I'll be adding a sister or brother to the mix here shortly! 
Enough about that (sniff, sniff)...I go back to the doctor to see my new babies again this Friday. At that point they will assess how the medicines are working and at what stage the eggs are in order to plan their retrieval. November 10 is the tentative date for removing those bad boys. They will put me to sleep and use a very large needle to poke through my uterus and into my ovaries and get each individual egg out of it's nest! How cool is that?! Then we will put them together with Steven contribution to the process, and wait..... 
Somewhere around November 13-15 they will take the good embryos and implant the two best ones back in and WAIT...
All of this is assuming they have enough eggs to harvest and that they survive this process. I am praying and believing that I will produce more than enough and that they will be exceptionally gorgeous! (ha)At this point, if they are ugly PLEASE DON'T TELL ME! I will dress them cute anyway.
Many prayers needed for my health, sanity and marriage over the next month please! 
Here is a sweet reminder of my first angel that I won't ever forget! XOXO sweet fetus!


                       Nothing will ever out do this I don't believe! 
Have a great week!

Changing Perceptions: Clozapine no longer a 'last resort'

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(Original Post Date: December 7, 2009)
A thanks to one of my wonderful students, for sending along this article about Clozapine. http://www.currentpsychiatry.com/article_pages.asp?AID=8165 We actually just attend the Yale Master Psychopharmacology conference last week, where the speaker on Advances in Schizophrenia, Dr. Cyril D’Souza, was quite clear in his preference to see patients treated with Clozapine. Interesting to see this publicized in this way, given the initial introduction of this drug with such care. When introduced, it was suggested as the drug for those treatment resistant patients, with I believe the understanding that those not responding to other agents might find benefit in the drug vs. the risk of potentially life threatening agranulocytosis. This was later widened to include those with schizophrenia or schizoaffective disorder who were a suicide risk. Use of the drug has led to individuals being treated with clozapine while closely scrutinized for the development of life-threatening side effects. More recent studies have suggested clozapine has antiaggressive properties(per Krakowski et al, 2006) and offers superior symptom management (per CATIE results).This article suggests thinking more broadly about the use of clozapine, given studies showing its efficacy. As I translate the idea: rather than thinking of it as a 'last resort', we should consider it a ‘second choice’ after a first trial of antipsychotic medication is not effective. It seems to me that clozapine needs a new marketing strategy. Although we should expect that if we begin to use clozapine in a larger proportion of the population we will see its side effect, agranulocytosis, occurring in greater numbers (i.e. it will have the same frequency, but if more of your patients are taking it, the likelihood you will see a case of agranulocytosis will increase.) Whenever we do prescribe clozapine, we must carefully attend to the potential it has for this side effect, and be sure that we monitor individuals closely.
Posted by Joanne at 12:57 PM

And thanks also for the comment, which shows your use of this clinical information!

Joanne, I wanted to share a recent and ongoing clinical case (without going into too much detail) that I have been a part of at my current clinical site in a forensic setting. The article that I forwarded to you I had also forwarded to my clinical preceptor, a psychiatrist. Not more than a week or two after this conference and stumbling upon this article did it come to our attention that one of the inmates, had presented a couple of months ago in the midst of an acute psychotic episode. It is likely paranoid schizophrenia but with a mood component thus our differentials of adding a bipolar diagnosis per history or leaning towards schizoaffective. This inmate, prior to arrival, had been misdiagnosed with mood and anxiety disorders only (as far as we could gather from collateral sources). Nonetheless, we started slowly titrating up on Risperdal. First 1mg BID and so on up to 6mg according to response; we also concurrently followed the antipsychotic with adequate amounts of Cogentin, Amantadine and even some Klonopin to aide with anxiety as well as hoping to prevent and treat some already apparent EPS. Along with this titration we slowly introduced Depakote as well to stabilize mood. As we responded to symptoms with the Risperdal increases, the psychosis almost completely cleared. The turn around was rapid and the medications effective. BUT, of course this was too good to be true and by this time EPS and Parkinsonian symptoms had become too much to bear. The inmate was at times unable to eat or take pills because of shaking so badly. We had of course had “the benefits outweigh the risks” talk prior to administering the medication, but it was at this point that we attempted to back off several of the meds. We switched from Risperdal to Abilify to see if this might help decrease the EPS, but no changes were noted. It struck me as we were sitting pondering this difficult case, "Why not Clozaril!?" With its very good side effect profile (except of course the life-threatening agranulocytosis, ha) it would give the antipsychotic and even mood stabilizing properties without the same high risk for EPS. At first my preceptor and the nurses were very hesitant and questioned this high-risk medication yet soon at least my preceptor was on board and telling me the more consideration, the more sure it might work very well for this particular patient. We began a titration down off all meds and did basically a washout (in the safety of an inpatient setting) while keeping low-dose Klonopin onboard. So, the current status is that some Parkinsonian symptoms seemed to have decreased but the resting tremor remains. We are weekly monitoring WBC levels (for agranulocytosis as Joanne mentioned) and titrating the dose up. So far so good! I’ll try and update to let you all know how things are progressing…..Thanks again Joanne for posting on this topic, it’s really interesting as well as clinically applicable. ☺ (Comment Date: January 13, 2010)

My Thoughts on 'Anti-Energy' Drinks

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Let me be perfectly clear: I am not an expert on nutrition, nor do I research these agents or drinks. I do have an opinion though, which I shared on my blogs Wednesday and I will share today.

I was asked by someone if I knew anything about the effects of anti-energy drinks such as Drank, which just recently started being sold in Connecticut. The product contains three main ingredients: valerian root, rose hips and melatonin. Part of the question was if there was evidence of an effect of these ingredients on stress relief and/or relaxation. In addition I was asked if I know anything about the three main ingredients. I do not have special knowledge to answer these questions with, they are not my areas of study. They are excellent questions!

I do think this is an interesting twist on the use of nutrients and other agents in beverages. In fact I have not researched energy drinks to any great degree, except to look up some of the ingredients. I just have a long standing concern: people think just because something is a ‘natural’ substance (herb or vitamin or mineral) it is ok to take it however they wish. I also don’t think people understand the lack of protections we have, given the lack of required evidence of safety to put products like these on the market. People may also think because it is on the store shelf it must be safe.

Unfortunately the websites available about drinks of these kinds do not have specifics about the amounts of each ingredient. They do not identify specifically the labelling with nutritional information (at least that I could find on the website for Drank). I'll have to go to the store and see what the label says. Despite the ingredients mystery, they are very direct in suggesting this is a fun new way to relax though.

I do not know off-hand of the safety of the ‘anti-energy’ drinks. My concerns about safety would be similar to those of all energy or 'nutritional' drinks. Whenever we begin to use agents in food or beverage that are commonly consumed at meals or other times, we have to wonder about the effects of exposure (i.e. how many of these drinks might you drink in a day? What is the dose of the substance you get over the day?). Is it like water and you can drink as much as you want?. Over long periods of time and with penetration of these products in the marketplace there is increased population exposure. Because they are foods/drinks they are differently regulated. How many people do you know that would take 3 pills a day (valerian, rose hips and melatonin) without considering the safety? Drinking them seems to make them appear safe to people. That is my concern. What if they are on other medication? Could they interact and cause negative effects? Do they check with their health practitioner to be sure it won’t cause a problem?

The other concern is we may have studies of a substance like melatonin for example and consider it safe for some use in some dose, but are there potential interactions between the three substances in this particular drink? Also where is the long term evidence of safety of these substances (individually and combined) in such a common food/drink source? An absence of evidence does not equal an absence of negative effect. It just means we haven’t studied it in this way.

I suspect ‘anti-energy’ drinks will be popular in the marketplace… It makes you wonder whether people will be pumping up on energy drinks all day and then trying to settle down with the anti-energy drinks in the evening. I am sure the beverage industry is very excited about all this… It is like they are the new but unregulated pharma – without having to shoulder the costs of safety research and clinical trials.

I am sure I told you more than you are really interested in. I am not the ‘expert’ on these ingredients. There are many people I am sure who have much more knowledge than I do about these ingredients. (actually you might look at the medline plus search info for supplements from the national library of medicine, if you haven’t already found it). Here is the link to info about melatonin: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-melatonin.html I would consider medline plus a trustworthy source of data on ingredients like this.

Of course as Mental Health Clinicians, we should also be inquiring about beverages like this, particularly given the lack of knowledge of amount of ingredient in each drink and that if one doesn't settle me down, maybe I will need a few... Something new to consider in our assessments.

50 worker's lives at risk: The Fukushima 50

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I saw the wife and small child of one of the nuclear power plant workers on the morning news today.  I can only imagine the fears and anxiety associated with having a loved one in this situation.  I am sure many share the same feelings I do in terms of the courage and bravery of these workers, who are daily putting their lives at risk to prevent even greater disaster than has already been experienced. Here is a link to the news story:
http://today.msnbc.msn.com/id/26184891/vp/42207681#42207681 

I imagine these workers have already been exposed to high levels of radioactivity while at work securing these plants.  They are literally risking their lives for those in the area of the plant, as well as society at large.

I always find it disturbing when workers are put in harm's way to earn a paycheck.  Regardless of the fact that they get paid and in some dangerous jobs they may earn extra pay due to the great risk involved, it seems hard to imagine that trade off. I often worry that decisions like this are made without full understanding of the risk.... Or perhaps without other options?

More disturbing is that this man-made industry is of course capable of catastrophic disaster.  Despite systems of safety procedures developed and strict standards and requirements to protect the public.  We only need to consider the 'disaster of the moment' to realize that despite the perception that we can control things with rules and requirements, things do go wrong...earthquakes and tsunami's are possible.  Terrorist attacks (and yes, unfortunately on US soil) are possible.  Terrible mistakes, accidents and weather events are possible.

We would like to think we are civilized and mostly in control of what happens.  Yet we are every so often reminded of our own helplessness and vulnerability.  As with risks of other rare events- we do not think about these risks in a regular way and often are struck by the possibility only when confronted by a one in a million event.

I think each of us identifies with those workers.  We have all had the experience of loyalty or devotion to a job or role.  Or a sense of duty or responsibility for getting a job done.

Do they continue today at work for the paycheck or the extra bonus due to the risk?  I doubt that.  I suspect they sacrifice their own safety for the others they protect outside of the plant walls... The wife and child I watched today, anxiously awaiting their safe return.  I suspect the paycheck is low on their priorities now.  I suspect their employer is also not high on their list either.

To those workers and to all workers who risk their own safety for the greater good... We are all indebted to you.

Most of us have the luxury of allowing work to be 'only a job'.  We are never faced with such decisions.  Hopefully those of us who don't risk our lives aren't part of the reason these workers may pay with their lives.

I consider the individuals reassuring us of safety when there are unanswered questions or they really are not sure.  No one really can be sure of safety in all circumstances.  Do business priorities sometimes encourage risks to be taken or safety standards or concerns to be overlooked?  When faced with a tragedy like this I wonder why didn't we imagine the possibility of a situation like this?  Why didn't we imagine the oil spilling into the gulf last year...  Competing interests sometimes do not result in good decisions for society.  A reason we have standards and oversight and why money or profit as a driver is not always a good thing.

I hope we all very carefully consider the responsibilities we carry out that do affect the health and safety of others. If only we could act as bravely and courageously in protecting society as those 50 workers are.  I would like to believe they would not risk other's safety for profit.

Here is another view on the story...
http://www.telegraph.co.uk/news/worldnews/asia/japan/8393018/Japan-nuclear-crisis-Fukushima-Fifty-cut-off-from-family.html

"An Angel in the book of life wrote down my baby's birth. And whispered as she closed the book "too beautiful for earth."

To contact us Click HERE
Hello all! I just though I would send out an update! Thank you all for the sweet messages of concern and prayer. Please keep them coming as they are very needed these next few weeks especially! 


I started my Lupron shots on the 26th and other than the actual medicine stinging like crazy and a few crying spells, and an allergic reaction on my arms, I haven't noticed any side effects (lol, I love to be complicated).  I will do my best to explain what the meds do since I have people ask me constantly. Lupron in a nutshell causes a "flare effect". The flare effect of Lupron can be used at the beginning of a fresh IVF cycle to help stimulate the development and maturation of eggs. Lupron is given for a few days and then injectable fertility medications are started.  It essentially acts by suppressing the pituitary gland (the gland which is normally responsible for triggering ovulation). However, before suppression occurs, Lupron will briefly stimulate the pituitary causing an increase in the pituitary hormones LH (luteinizing hormone) and FSH (follicle stimulating hormone).

Two days later I started Gonal F injections. Gonal FSH increases the number of growing follicles and stimulates their development. Within the follicles are the developing eggs. FSH also increases the production of oestrogen, and under the influence of this hormone, the largest follicle continues to develop. This medicine is used to stimulate the development of follicles and eggs in women who are having difficulties getting pregnant due to problems with ovulation. 

So the side effects of both of these are:

• Pain, bruising and inflammation at the injection site in men and women.
• Headache in women.
• Ovarian cysts

• Mild to moderate over-stimulation of the ovaries (ovarian hyper stimulation), causing the production of many eggs.
• Disturbances of the gut, such as nausea, vomiting, diarrhoea, abdominal cramps and bloating in women.
• Breast enlargement, weight gain, acne and swelling of the veins in the scrotum in men.

I am experiencing every one of them except the scrotal swelling which if Steven doesn't play his cards right...he may experience! (lololol! crack myself up again).
I have this entire week off which is a God send because I am going to need a lot of sleep I do believe. 
Please pray for me this week. As if the hormones are not atrocious enough, this would have been my week to deliver nugget #1! November 6 would have been my first babies due date (at least by my calculations) and anybody that has ever had a miscarriage knows, a mommy never forgets that date. I cannot dwell on the past, however I do feel like that baby deserves some remembrance and I won't ever stop thinking about it! It was my only "first child"! Hopefully I'll be adding a sister or brother to the mix here shortly! 
Enough about that (sniff, sniff)...I go back to the doctor to see my new babies again this Friday. At that point they will assess how the medicines are working and at what stage the eggs are in order to plan their retrieval. November 10 is the tentative date for removing those bad boys. They will put me to sleep and use a very large needle to poke through my uterus and into my ovaries and get each individual egg out of it's nest! How cool is that?! Then we will put them together with Steven contribution to the process, and wait..... 
Somewhere around November 13-15 they will take the good embryos and implant the two best ones back in and WAIT...
All of this is assuming they have enough eggs to harvest and that they survive this process. I am praying and believing that I will produce more than enough and that they will be exceptionally gorgeous! (ha)At this point, if they are ugly PLEASE DON'T TELL ME! I will dress them cute anyway.
Many prayers needed for my health, sanity and marriage over the next month please! 
Here is a sweet reminder of my first angel that I won't ever forget! XOXO sweet fetus!


                       Nothing will ever out do this I don't believe! 
Have a great week!

Changing Perceptions: Clozapine no longer a 'last resort'

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(Original Post Date: December 7, 2009)
A thanks to one of my wonderful students, for sending along this article about Clozapine. http://www.currentpsychiatry.com/article_pages.asp?AID=8165 We actually just attend the Yale Master Psychopharmacology conference last week, where the speaker on Advances in Schizophrenia, Dr. Cyril D’Souza, was quite clear in his preference to see patients treated with Clozapine. Interesting to see this publicized in this way, given the initial introduction of this drug with such care. When introduced, it was suggested as the drug for those treatment resistant patients, with I believe the understanding that those not responding to other agents might find benefit in the drug vs. the risk of potentially life threatening agranulocytosis. This was later widened to include those with schizophrenia or schizoaffective disorder who were a suicide risk. Use of the drug has led to individuals being treated with clozapine while closely scrutinized for the development of life-threatening side effects. More recent studies have suggested clozapine has antiaggressive properties(per Krakowski et al, 2006) and offers superior symptom management (per CATIE results).This article suggests thinking more broadly about the use of clozapine, given studies showing its efficacy. As I translate the idea: rather than thinking of it as a 'last resort', we should consider it a ‘second choice’ after a first trial of antipsychotic medication is not effective. It seems to me that clozapine needs a new marketing strategy. Although we should expect that if we begin to use clozapine in a larger proportion of the population we will see its side effect, agranulocytosis, occurring in greater numbers (i.e. it will have the same frequency, but if more of your patients are taking it, the likelihood you will see a case of agranulocytosis will increase.) Whenever we do prescribe clozapine, we must carefully attend to the potential it has for this side effect, and be sure that we monitor individuals closely.
Posted by Joanne at 12:57 PM

And thanks also for the comment, which shows your use of this clinical information!

Joanne, I wanted to share a recent and ongoing clinical case (without going into too much detail) that I have been a part of at my current clinical site in a forensic setting. The article that I forwarded to you I had also forwarded to my clinical preceptor, a psychiatrist. Not more than a week or two after this conference and stumbling upon this article did it come to our attention that one of the inmates, had presented a couple of months ago in the midst of an acute psychotic episode. It is likely paranoid schizophrenia but with a mood component thus our differentials of adding a bipolar diagnosis per history or leaning towards schizoaffective. This inmate, prior to arrival, had been misdiagnosed with mood and anxiety disorders only (as far as we could gather from collateral sources). Nonetheless, we started slowly titrating up on Risperdal. First 1mg BID and so on up to 6mg according to response; we also concurrently followed the antipsychotic with adequate amounts of Cogentin, Amantadine and even some Klonopin to aide with anxiety as well as hoping to prevent and treat some already apparent EPS. Along with this titration we slowly introduced Depakote as well to stabilize mood. As we responded to symptoms with the Risperdal increases, the psychosis almost completely cleared. The turn around was rapid and the medications effective. BUT, of course this was too good to be true and by this time EPS and Parkinsonian symptoms had become too much to bear. The inmate was at times unable to eat or take pills because of shaking so badly. We had of course had “the benefits outweigh the risks” talk prior to administering the medication, but it was at this point that we attempted to back off several of the meds. We switched from Risperdal to Abilify to see if this might help decrease the EPS, but no changes were noted. It struck me as we were sitting pondering this difficult case, "Why not Clozaril!?" With its very good side effect profile (except of course the life-threatening agranulocytosis, ha) it would give the antipsychotic and even mood stabilizing properties without the same high risk for EPS. At first my preceptor and the nurses were very hesitant and questioned this high-risk medication yet soon at least my preceptor was on board and telling me the more consideration, the more sure it might work very well for this particular patient. We began a titration down off all meds and did basically a washout (in the safety of an inpatient setting) while keeping low-dose Klonopin onboard. So, the current status is that some Parkinsonian symptoms seemed to have decreased but the resting tremor remains. We are weekly monitoring WBC levels (for agranulocytosis as Joanne mentioned) and titrating the dose up. So far so good! I’ll try and update to let you all know how things are progressing…..Thanks again Joanne for posting on this topic, it’s really interesting as well as clinically applicable. ☺ (Comment Date: January 13, 2010)

My Thoughts on 'Anti-Energy' Drinks

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Let me be perfectly clear: I am not an expert on nutrition, nor do I research these agents or drinks. I do have an opinion though, which I shared on my blogs Wednesday and I will share today.

I was asked by someone if I knew anything about the effects of anti-energy drinks such as Drank, which just recently started being sold in Connecticut. The product contains three main ingredients: valerian root, rose hips and melatonin. Part of the question was if there was evidence of an effect of these ingredients on stress relief and/or relaxation. In addition I was asked if I know anything about the three main ingredients. I do not have special knowledge to answer these questions with, they are not my areas of study. They are excellent questions!

I do think this is an interesting twist on the use of nutrients and other agents in beverages. In fact I have not researched energy drinks to any great degree, except to look up some of the ingredients. I just have a long standing concern: people think just because something is a ‘natural’ substance (herb or vitamin or mineral) it is ok to take it however they wish. I also don’t think people understand the lack of protections we have, given the lack of required evidence of safety to put products like these on the market. People may also think because it is on the store shelf it must be safe.

Unfortunately the websites available about drinks of these kinds do not have specifics about the amounts of each ingredient. They do not identify specifically the labelling with nutritional information (at least that I could find on the website for Drank). I'll have to go to the store and see what the label says. Despite the ingredients mystery, they are very direct in suggesting this is a fun new way to relax though.

I do not know off-hand of the safety of the ‘anti-energy’ drinks. My concerns about safety would be similar to those of all energy or 'nutritional' drinks. Whenever we begin to use agents in food or beverage that are commonly consumed at meals or other times, we have to wonder about the effects of exposure (i.e. how many of these drinks might you drink in a day? What is the dose of the substance you get over the day?). Is it like water and you can drink as much as you want?. Over long periods of time and with penetration of these products in the marketplace there is increased population exposure. Because they are foods/drinks they are differently regulated. How many people do you know that would take 3 pills a day (valerian, rose hips and melatonin) without considering the safety? Drinking them seems to make them appear safe to people. That is my concern. What if they are on other medication? Could they interact and cause negative effects? Do they check with their health practitioner to be sure it won’t cause a problem?

The other concern is we may have studies of a substance like melatonin for example and consider it safe for some use in some dose, but are there potential interactions between the three substances in this particular drink? Also where is the long term evidence of safety of these substances (individually and combined) in such a common food/drink source? An absence of evidence does not equal an absence of negative effect. It just means we haven’t studied it in this way.

I suspect ‘anti-energy’ drinks will be popular in the marketplace… It makes you wonder whether people will be pumping up on energy drinks all day and then trying to settle down with the anti-energy drinks in the evening. I am sure the beverage industry is very excited about all this… It is like they are the new but unregulated pharma – without having to shoulder the costs of safety research and clinical trials.

I am sure I told you more than you are really interested in. I am not the ‘expert’ on these ingredients. There are many people I am sure who have much more knowledge than I do about these ingredients. (actually you might look at the medline plus search info for supplements from the national library of medicine, if you haven’t already found it). Here is the link to info about melatonin: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-melatonin.html I would consider medline plus a trustworthy source of data on ingredients like this.

Of course as Mental Health Clinicians, we should also be inquiring about beverages like this, particularly given the lack of knowledge of amount of ingredient in each drink and that if one doesn't settle me down, maybe I will need a few... Something new to consider in our assessments.

50 worker's lives at risk: The Fukushima 50

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I saw the wife and small child of one of the nuclear power plant workers on the morning news today.  I can only imagine the fears and anxiety associated with having a loved one in this situation.  I am sure many share the same feelings I do in terms of the courage and bravery of these workers, who are daily putting their lives at risk to prevent even greater disaster than has already been experienced. Here is a link to the news story:
http://today.msnbc.msn.com/id/26184891/vp/42207681#42207681 

I imagine these workers have already been exposed to high levels of radioactivity while at work securing these plants.  They are literally risking their lives for those in the area of the plant, as well as society at large.

I always find it disturbing when workers are put in harm's way to earn a paycheck.  Regardless of the fact that they get paid and in some dangerous jobs they may earn extra pay due to the great risk involved, it seems hard to imagine that trade off. I often worry that decisions like this are made without full understanding of the risk.... Or perhaps without other options?

More disturbing is that this man-made industry is of course capable of catastrophic disaster.  Despite systems of safety procedures developed and strict standards and requirements to protect the public.  We only need to consider the 'disaster of the moment' to realize that despite the perception that we can control things with rules and requirements, things do go wrong...earthquakes and tsunami's are possible.  Terrorist attacks (and yes, unfortunately on US soil) are possible.  Terrible mistakes, accidents and weather events are possible.

We would like to think we are civilized and mostly in control of what happens.  Yet we are every so often reminded of our own helplessness and vulnerability.  As with risks of other rare events- we do not think about these risks in a regular way and often are struck by the possibility only when confronted by a one in a million event.

I think each of us identifies with those workers.  We have all had the experience of loyalty or devotion to a job or role.  Or a sense of duty or responsibility for getting a job done.

Do they continue today at work for the paycheck or the extra bonus due to the risk?  I doubt that.  I suspect they sacrifice their own safety for the others they protect outside of the plant walls... The wife and child I watched today, anxiously awaiting their safe return.  I suspect the paycheck is low on their priorities now.  I suspect their employer is also not high on their list either.

To those workers and to all workers who risk their own safety for the greater good... We are all indebted to you.

Most of us have the luxury of allowing work to be 'only a job'.  We are never faced with such decisions.  Hopefully those of us who don't risk our lives aren't part of the reason these workers may pay with their lives.

I consider the individuals reassuring us of safety when there are unanswered questions or they really are not sure.  No one really can be sure of safety in all circumstances.  Do business priorities sometimes encourage risks to be taken or safety standards or concerns to be overlooked?  When faced with a tragedy like this I wonder why didn't we imagine the possibility of a situation like this?  Why didn't we imagine the oil spilling into the gulf last year...  Competing interests sometimes do not result in good decisions for society.  A reason we have standards and oversight and why money or profit as a driver is not always a good thing.

I hope we all very carefully consider the responsibilities we carry out that do affect the health and safety of others. If only we could act as bravely and courageously in protecting society as those 50 workers are.  I would like to believe they would not risk other's safety for profit.

Here is another view on the story...
http://www.telegraph.co.uk/news/worldnews/asia/japan/8393018/Japan-nuclear-crisis-Fukushima-Fifty-cut-off-from-family.html

Top 5 Things You Can Do With an Associate's Degree

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You may think that an associate's degree can't open up as many doors for you as a bachelor's degree.



Think again.



Truth be told, there's a lot you can do with an associate's degree these days. It can a faster, less expensive way to start a one of 2010's top careers, start a rewarding vocational career, or work towards a four-year degree.



Here are our 5 favorite things an associate's degree can do for you:



1. Start a Vocational Career
If you don't want to spend your weekdays locked in a cubicle, there are a lot of fantastic, high-paying vocational careers out there for you to explore. From cosmetology careers to automotive careers, these options can help you to turn your favorite hobby into a paycheck.



To start these careers, you'll need highly-specialized skills. That's where the associate's degree comes in. Many community, junior and technical colleges offer associate's degrees for a variety of vocational careers, which provide the skills and technical know-how you need to get started.



That means the minute you have your degree in hand, you'll be ready to join the workforce. No unpaid internships required.



2. Start a Career You Can Advance In
Who doesn't want a career that you can start fast, advance in, and make a good paycheck? Associate's degrees are often the keys that can unlock these kinds of career options.



Take nursing, for example. You can become a registered nurse by earning your Associate's of Science in Nursing. In approximately two years, this degree will have you working in a hospital, treating patients and helping doctors.



While you're working as an RN, you can take the next steps by earning a Bachelor's of Science in Nursing online. This will give you more career options, and the chance to eventually earn a Master's of Science in Nursing (MSN). The MSN allows you to become a nurse practitioner and enter a whole range of specialties, some of which pay a higher salary than a doctor's.



And it all starts with the associate's degree.



3. Work Towards a Bachelor's Degree
If you want a bachelor's degree, or know you'll need one to eventually advance in your career, but can't commit to a four-year program just yet, an associate's degree is a great place to start.



The associate's degree will allow you to complete your prerequisites and preliminary coursework, many of which will count towards a four-year bachelor's degree program when you're ready to enroll.



(An added bonus: associate's programs tend to be less expensive per credit hour than bachelor's programs, which will allow you to save some serious cash on your first two years of school.)



4. Make a Career Change
Let's say you're already working on a particular career path. One day, you wake up and realize you hate your job and what you really want to do is start a cupcake delivery business. (When you do, feel free to put the myFootpath corporate office address on your delivery route. Thanks.)



But while you need to get some business classes under your belt, you already have a bachelor's degree in accounting, and you don't want to start another four-year program. So what are you to do?



Enter the associate's degree. A specialized associate's degree can build on the education you already have, and provide the knowledge you need to make that career change.



5. Start One of Today's Best Careers
You don't need a PhD in rocket science to land one of today's top careers. These days, an associate's degree is the key to entering one of the 2010 top careers, including veterinary technician careers, dental hygienist careers, physical therapist assistant careers, and more

"An Angel in the book of life wrote down my baby's birth. And whispered as she closed the book "too beautiful for earth."

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Hello all! I just though I would send out an update! Thank you all for the sweet messages of concern and prayer. Please keep them coming as they are very needed these next few weeks especially! 


I started my Lupron shots on the 26th and other than the actual medicine stinging like crazy and a few crying spells, and an allergic reaction on my arms, I haven't noticed any side effects (lol, I love to be complicated).  I will do my best to explain what the meds do since I have people ask me constantly. Lupron in a nutshell causes a "flare effect". The flare effect of Lupron can be used at the beginning of a fresh IVF cycle to help stimulate the development and maturation of eggs. Lupron is given for a few days and then injectable fertility medications are started.  It essentially acts by suppressing the pituitary gland (the gland which is normally responsible for triggering ovulation). However, before suppression occurs, Lupron will briefly stimulate the pituitary causing an increase in the pituitary hormones LH (luteinizing hormone) and FSH (follicle stimulating hormone).

Two days later I started Gonal F injections. Gonal FSH increases the number of growing follicles and stimulates their development. Within the follicles are the developing eggs. FSH also increases the production of oestrogen, and under the influence of this hormone, the largest follicle continues to develop. This medicine is used to stimulate the development of follicles and eggs in women who are having difficulties getting pregnant due to problems with ovulation. 

So the side effects of both of these are:

• Pain, bruising and inflammation at the injection site in men and women.
• Headache in women.
• Ovarian cysts

• Mild to moderate over-stimulation of the ovaries (ovarian hyper stimulation), causing the production of many eggs.
• Disturbances of the gut, such as nausea, vomiting, diarrhoea, abdominal cramps and bloating in women.
• Breast enlargement, weight gain, acne and swelling of the veins in the scrotum in men.

I am experiencing every one of them except the scrotal swelling which if Steven doesn't play his cards right...he may experience! (lololol! crack myself up again).
I have this entire week off which is a God send because I am going to need a lot of sleep I do believe. 
Please pray for me this week. As if the hormones are not atrocious enough, this would have been my week to deliver nugget #1! November 6 would have been my first babies due date (at least by my calculations) and anybody that has ever had a miscarriage knows, a mommy never forgets that date. I cannot dwell on the past, however I do feel like that baby deserves some remembrance and I won't ever stop thinking about it! It was my only "first child"! Hopefully I'll be adding a sister or brother to the mix here shortly! 
Enough about that (sniff, sniff)...I go back to the doctor to see my new babies again this Friday. At that point they will assess how the medicines are working and at what stage the eggs are in order to plan their retrieval. November 10 is the tentative date for removing those bad boys. They will put me to sleep and use a very large needle to poke through my uterus and into my ovaries and get each individual egg out of it's nest! How cool is that?! Then we will put them together with Steven contribution to the process, and wait..... 
Somewhere around November 13-15 they will take the good embryos and implant the two best ones back in and WAIT...
All of this is assuming they have enough eggs to harvest and that they survive this process. I am praying and believing that I will produce more than enough and that they will be exceptionally gorgeous! (ha)At this point, if they are ugly PLEASE DON'T TELL ME! I will dress them cute anyway.
Many prayers needed for my health, sanity and marriage over the next month please! 
Here is a sweet reminder of my first angel that I won't ever forget! XOXO sweet fetus!


                       Nothing will ever out do this I don't believe! 
Have a great week!

Changing Perceptions: Clozapine no longer a 'last resort'

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(Original Post Date: December 7, 2009)
A thanks to one of my wonderful students, for sending along this article about Clozapine. http://www.currentpsychiatry.com/article_pages.asp?AID=8165 We actually just attend the Yale Master Psychopharmacology conference last week, where the speaker on Advances in Schizophrenia, Dr. Cyril D’Souza, was quite clear in his preference to see patients treated with Clozapine. Interesting to see this publicized in this way, given the initial introduction of this drug with such care. When introduced, it was suggested as the drug for those treatment resistant patients, with I believe the understanding that those not responding to other agents might find benefit in the drug vs. the risk of potentially life threatening agranulocytosis. This was later widened to include those with schizophrenia or schizoaffective disorder who were a suicide risk. Use of the drug has led to individuals being treated with clozapine while closely scrutinized for the development of life-threatening side effects. More recent studies have suggested clozapine has antiaggressive properties(per Krakowski et al, 2006) and offers superior symptom management (per CATIE results).This article suggests thinking more broadly about the use of clozapine, given studies showing its efficacy. As I translate the idea: rather than thinking of it as a 'last resort', we should consider it a ‘second choice’ after a first trial of antipsychotic medication is not effective. It seems to me that clozapine needs a new marketing strategy. Although we should expect that if we begin to use clozapine in a larger proportion of the population we will see its side effect, agranulocytosis, occurring in greater numbers (i.e. it will have the same frequency, but if more of your patients are taking it, the likelihood you will see a case of agranulocytosis will increase.) Whenever we do prescribe clozapine, we must carefully attend to the potential it has for this side effect, and be sure that we monitor individuals closely.
Posted by Joanne at 12:57 PM

And thanks also for the comment, which shows your use of this clinical information!

Joanne, I wanted to share a recent and ongoing clinical case (without going into too much detail) that I have been a part of at my current clinical site in a forensic setting. The article that I forwarded to you I had also forwarded to my clinical preceptor, a psychiatrist. Not more than a week or two after this conference and stumbling upon this article did it come to our attention that one of the inmates, had presented a couple of months ago in the midst of an acute psychotic episode. It is likely paranoid schizophrenia but with a mood component thus our differentials of adding a bipolar diagnosis per history or leaning towards schizoaffective. This inmate, prior to arrival, had been misdiagnosed with mood and anxiety disorders only (as far as we could gather from collateral sources). Nonetheless, we started slowly titrating up on Risperdal. First 1mg BID and so on up to 6mg according to response; we also concurrently followed the antipsychotic with adequate amounts of Cogentin, Amantadine and even some Klonopin to aide with anxiety as well as hoping to prevent and treat some already apparent EPS. Along with this titration we slowly introduced Depakote as well to stabilize mood. As we responded to symptoms with the Risperdal increases, the psychosis almost completely cleared. The turn around was rapid and the medications effective. BUT, of course this was too good to be true and by this time EPS and Parkinsonian symptoms had become too much to bear. The inmate was at times unable to eat or take pills because of shaking so badly. We had of course had “the benefits outweigh the risks” talk prior to administering the medication, but it was at this point that we attempted to back off several of the meds. We switched from Risperdal to Abilify to see if this might help decrease the EPS, but no changes were noted. It struck me as we were sitting pondering this difficult case, "Why not Clozaril!?" With its very good side effect profile (except of course the life-threatening agranulocytosis, ha) it would give the antipsychotic and even mood stabilizing properties without the same high risk for EPS. At first my preceptor and the nurses were very hesitant and questioned this high-risk medication yet soon at least my preceptor was on board and telling me the more consideration, the more sure it might work very well for this particular patient. We began a titration down off all meds and did basically a washout (in the safety of an inpatient setting) while keeping low-dose Klonopin onboard. So, the current status is that some Parkinsonian symptoms seemed to have decreased but the resting tremor remains. We are weekly monitoring WBC levels (for agranulocytosis as Joanne mentioned) and titrating the dose up. So far so good! I’ll try and update to let you all know how things are progressing…..Thanks again Joanne for posting on this topic, it’s really interesting as well as clinically applicable. ☺ (Comment Date: January 13, 2010)