Utility Numbers for New Move

UTITLITY INFO

Water, sewer, and garbage = will be turned on

           

            Town of Christiansburg                         540-382-6128

            100 East Main St.

 Water                                                                        540-382-9519

 

Atmos Energy (Gas)                                                540-951-9184

                                                                        540-639-1662 (local)

 

All connect                                                            866-269-4825

Ø    Account number = 8785582

 

AEP (Power) will be turned on Sept 23            800-956-4237

Ø    AEP account number = 02462166832

 

Verizon Phone                                                            540-954-6222

Ø    Our land line number is 540-381-2898

Ø    Cost = $49.99

Ø    Verizon Internet confirmation number = 779218096

 

Direct TV                                                            800-488-5069 or 628-5175

Ø    Account number = 81655270

Ø    Will be connected from 0800-1200 AM on October 1

Ø    Will get about 200 channels for $39.95 if file for two rebates

o      After activation of TV go to internet and enter DirectTV.com/rebate give the account number (81655270) and apply for rebate

o      The go to www.dstvgift.com and print off a form and complete form and mail in and will get first 6 months of free internet for $29.99 after that

 

Mowing = Harvey @ First Impressions            540-392-7783

 

Roanoke Times                                                540-381-1655

 

Jet Broadband Cable                                                1-877-743-8538

 

Internet NRV Unwired                                    540-239-0318           

 

$1300 rent due the first of each month to Oak Tree Town Homes

Ø    I E-mailed Wende this info

Ø    Jim Wesel 540-382-5885                        

Children Get Older Too

With my love walked up valleys and down

Climbed a mountain and turned around

Saw my reflection in sun shining souls

The heart’s joy brought me down.

Reflections in the eye

Where is love?

Can the child in my heart go with the ride?

Can I sail thru the changing ocean tide?

Can I handle the seasons rearranging?

Well, I’ve been afraid of changing

Cause I’ve built my life around you

But time makes you bolder

Children get older

I’m getting older too.

Take my love, take it around

Climb a mountain and turn back down

If you see my reflection in sun shining souls

May the new destinations make it shine on?

NEUROPSYCHIATRIC ASPECTS OF CEREBROVASCULAR DISEASE

The neuropsychiatric complications associated with cerebrovascular disease include a wide range of emotional and cognitive disturbances.

MAJOR DEPRESSION

Ø    Prevalence: 20% of patients with cerebrovascular disease

Ø    Clinical symptoms: Disheartened mood, gloominess, dreariness, pessimism, diurnal mood variation, anergia, weight loss, early-morning awakening

Ø    Associated lesion location: Left frontal lobe and left basal ganglia during the acute period after stroke

Ø    Treatment: Pamelor: proved effective in randomized placebo-controlled dbl studies

MINOR DEPRESSION

Ø    Prevalence: 10-40% of patients with cerebrovascular disease

Ø    Clinical symptoms: Lugubrious mood, disinclined to social interaction, decreased appetite, uneasiness, disquiet

Ø    Associated lesion location: Left posterior parietal and occipital regions during the acute poststroke period

Ø    Treatment: No controlled studies. SSRIs perhaps???

APATHY

Ø    Prevalence: 22% of patients with cerebrovascular disease

Ø    Clinical symptoms: Anhedonia, doleful demeanor, ennui, languor

Ø    Associated lesion location: Posterior internal capsule

Ø    Treatment: No controlled studies. Cognitive Behavior Therapy, perhaps???

MANIA

Ø    Prevalence: Rare

Ø    Clinical symptoms: Grandiloquent mood, libertine appetites, magniloquent well-being

Ø    Associated lesion location: Right basotemporal or right orbitofrontal lesions

Ø    Treatment: Depakote

ANXIETY DISORDER

Ø    Prevalence: 27% of patients with cerebrovascular disease

Ø    Clinical symptoms: Apprehensive dread, restiveness, insomnia, fretfulness, angst

Ø    Associated lesion location: Left cortical lesions, usually dorsolateral frontal lobe

Ø    Treatment: Avoid benzodiazepines because they impair cognition

CATASTROPHIC REACTION

Ø    Prevalence: 19% of patients with cerebrovascular disease

Ø    Clinical symptoms: Choleric agitation, strident acrimony, bellicosity, vitriolic brooding, menacing intimidation, obstreperous attitude, scurrilous vocabulary

Ø    Associated lesion location: Left anterior-subcortical region

Ø    Treatment: No studies. Depakote, perhaps???

MEDICATIONS TO AUGMENT ANTIDEPRESSANTS

         At least 40% patients treated with adequate doses of standard antidepressant medications fail to respond. That means four out of ten depressed patients are inadequately treated. Here are some suggestions for augmenting the effects of antidepressants.

 

BRAND NAME (GENERIC NAME)	HOW THE DRUG WORKS	APPROVED OR SPECIAL USES	DAILY DOSE
Provigil (Modafinil)	Enhances activity in the hypothalamic wakefulness center	Narcolepsy, shift work sleep disorder, sleep apnea, fatigue, ADD	200 mg once daily or 200 mg twice daily
Eskalith CR (lithium)	May alter second messenger systems	Bipolar depression, mania	450 mg twice daily
Trilafon (perphenazine)	Blocks dopamine D2 receptors	Used in combination with amitriptyline and sold under the trade name Triavil. Especially useful in patients with multiple physical complaints	Triavil 2/10 or 2/25 one to six tablets
Risperdal (risperidone)	Alpha 2 antagonist properties may contribute to antidepressant actions.	Schizophrenia, psychosis, bipolar disorders, impulse control disorders	0.5 mg-6 mg
Lamictal (lamotrigene)	Blocks sodium channels, inhibits release of glutamate	First line treatment option for bipolar depression	25 mg-400 mg
Adderall	Enhances dopamine actions	Attention deficit disorder	20-60 mg

Computer Heaven

Carey:

Just in case you decide to come back to the office, our computer has now taken the trip to pc heaven. When the people putting in the phones blew the Navasota hospital circuit our computer bleeped over. We called Code Blue but it could not be resuscitated. People from HISS came today and took the body parts away. No files could be recovered. Its all gone...gone...gone.  I called Wende and asked what we had lost and she couldn't think of much. The mailing list had already been sent to me. I have most of the important stuff on my home computer. We will have to get the daily census from one of the hospital's computers. This death brings good news that there is one less item to move to Virginia. It was good that our long suffering pc died here rather than be buried in a foreign land.

Dad:

Glad you can laugh about it, even if it is the hysterical, admit-me-to-the-BHU type of laughter!

Love,

Wende

Dear Wende:

What an unbelievable transition. Everything, literally, everything that could go wrong has gone wrong at the office. I don't know how much your mother has told you and the tragedy is too involved to write about. Your wonderful Mother deserves the Nobel Prize for Grace Under Pressure. She has done fantastically well. Anyone else, including Carey and Chrystal, would be in the hospital receiving ECT. 

Thankfully a few minutes ago Carey called on her way back from her vacation. I told her that I wanted her to return her bonus check for leaving us and that I her mother and father would be unforgiven forever for taking her away. With those threats she agreed to come back for a few days. Of course, she called to say she wanted to come back and help us. She was concerned about us even before she heard the American Office Tragedy. I want you to pay her $20/hour (this actually computes to a little under time-and-a-half, but sounds better) because she has been so faithful. Before she left Vicki and I decided that she did the work of three people and her absence proved our conviction. (Chrystal also did the work of three). Their absence makes me realize how lucky I have been these last eight years and how glad I am to get out of the office, because I would never be able to find another like them.

I really haven't suffered any except to watch the trials and tribulations of your mother. 

Love,

Dad

THIRD-GENERATION AND SPECIAL ANTIDEPRESSANTS

BRAND NAME (GENERIC NAME)	HOW THE DRUG WORKS	SPECIAL USES	DAILY DOSE
Desyrel (Trazodone)	Serotonin 2 antagonist	Insomnia—the drug of choice for insomnia because it is not addicting and boosts serotonin which often is the reason for insomnia. Very useful for alcoholics and drug abusers.	50-600 mg
Effexor XR (venlafaxine)	Boosts serotonin (and norepinephrine in doses greater than 150 mg)	Energizing antidepressant, generalized anxiety, panic disorder, chronic pain (at doses of 225 mg or higher). Taper dose slowly when discontinuing med.	75-300 mg
Cymbalta (duloxetine)	Boosts serotonin and norepinephrine in equal amounts	Energizing antidepressant, peripheral neuropathy, fibromyalgia, chronic pain, stress urinary incontinence	60 mg
Wellbutrin XL (bupropion)	Boosts dopamine and norepinephrine	Activating and motivating antidepressant, useful in cocaine-induced depression, improves cognitive slowing, reverses SSRI-induced sexual dysfunction, reduces craving during smoking cessation	150-450 mg
Remeron (mirtazapine)	Blocks alpha 2 adrenergic presynaptic receptors, blocks 5HT2A, 5HT2C, 5HT3 serotonin receptors	Boosts usefulness of Effexor XR, improves appetite, insomnia and anxiety. Good med for nausea because of 5HT3 effects. Ideal patient for this med is depressed, skinny, sleepless and anxious (or sad, skinny, sleepless and scared).	15-45 mg

CHOOSIING AN ANTIDEPRESANT BASED ON NEUROTRANSMITTER FUNCTION

            Currently three neurotransmitters—serotonin, norepinephrine and dopamine—have been implicated as the most important neurotransmitters in depression. Depletion of these neurotransmitters cause specific symptoms that can help the physician choose which antidepressant would be the first choice for each patient.

Symptoms of Neurotransmittor Depletion

SEROTONIN LOSS	NOREPINEPHRINE LOSS	DOPAMINE LOSS
Anxious depression	Lethargic depression	Joyless depression
Waking during night	Restless sleep	Sleeping too much
Panic symptoms	Worry	Apathetic
Obsessions and compulsions	Feeling tired all the time	No motivation
Anger, irritability	Lethargic	No pleasure
Traumatic dreams	Run down feeling	Decreased sexual drive and function
Flashbacks	Chronic pain symptoms	Poor concentration & attention

Specific Medications that primary work on the “Big” three neurotransmitters

SEROTONIN	NOREPINEPHRINE	DOPAMINE
Prozac	Effexor XR (“pure” serotonin med at doses below 150 mg daily; in doses higher than 150 mg increases both norepinephrine and serotonin)P	Wellbutrin XL
Paxil-CR	Cymbalta (Boosts serotonin & norepinephrine in equal amounts)	Vivactil
Zoloft	Norpramin
Celexa	Pamelor
Lexapro	Vivactil
Remeron

The Unseen

Although on the outside it looks like things are falling apart, on the inside God is making new life. The things we see now will be gone tomorrow, but the things we can't see will last forever. Christ's love surpasses anything any of us can do. He included everyone in his death so that everyone could also be included in his life, a resurrection life, and a far better life than people ever lived on their own. The love of Jesus comforts us with the assurance that the horrible times we experience on earth are temporary, but the unseen times are eternal and glorious.

The Power of the Unseen

While I was showering, a persons name popped into my head. I didn’t know this person well at all, had met her a few times at church, had seen her in the church choir, but her name suddenly came to mind. After I had finished showering and toweling off, I decided, feeling rather foolish, to give her a call. With some trepidation, I found her phone number in the church directory, and punched in the numbers. When she answered the phone, I introduced myself. I told her that her name had inexplicable come into my mind, and I wondered if she might be having trouble in her life. She immediate broke into tears and told me that her mother had died last night.

 

What is seen is temporary what is unseen is eternal

A Prose Ode

I am going to miss you so much. I can always depend on you for the truth (kindly told). I can count on your devotion to follow through and your good cheer when helping me. No one is irreplaceable, but you come close. The work you do for the clinic is unbelievably difficult, but you carry it off with the panache of a Musketeer (per Dumas, not Disney). 

Therapies for Treatment Resistant Depression

Therapies for Treatment Resistant Depression

Approximately 17% of individuals—nearly one out of five people— experience a major depressive episode during their lifetime. Many of these patients are unrecognized or receive inadequate treatment. A few definitions will help in understanding treatment-resistance:

Nonresponse—no clinically meaningful response. One-third of patients given one antidepressant will fail to show any meaningful improvement.

Partial response—25-50% improvement in symptoms.

Treatment response—50% or greater improvement in symptoms.

Remission—absence of virtually all psychopathology.

Inadequate epidemiological research obscures the number of patients who experience a partial response or a treatment response. Patients may be satisfied with a partial response because the think “this is as good as it can get.” The goal for all treatment, however, should be full remission.

A simple test can help the physician follow the response to treatment. The physician can ask,”On a scale of zero to ten with zero being the worst you have ever felt and 10 being the best you have ever felt, how would you rate yourself?” The goal—a nine or a ten following an adequate course of treatment. If the patient fails to progress the physician has several options to improve outcome:

1. Raise the dose of the antidepressant. Unfortunately some antidepressants have a flat dose-response curve, so after a certain dose has been reached, raising it will have no further effect on symptoms.
2. Switch to another antidepressant. Switching from an SSRI to a different type of agent may be effective. Switching from one SSRI to another may be effective as well.
3. Add psychotherapy. For mild to moderate depression, Cognitive Behavior Therapy has been show to be just as effective as antidepressant medication. CBT in combination with medication is powerful.
4. Switch to a dual-mechanism antidepressant. A decrease in the firing activity of noradrenergic locus ceruleus neurons has been noted after three weeks of SSRI administration. This action may explain why the SSRIs are effective treatments for anxiety disorders. This decrease may also explain why some depressed patients respond to dual-action antidepressants or augmentation with other agents.
5. Combine two antidepressants. Disadvantages of combination (and augmentation) include increased cost and decreased compliance.
6. Augment with another medication.

·      Add a second generation neuroleptic. Atypical antipsychotics may augment antidepressants by increasing norepinephrine activity.

·      Add a mood stabilizer. Depressed patients may have a bipolar disorder and the manic phase of the illness has not yet emerged.

7. Recommend ECT.  ECT remains the most effective treatment for severe depression but is seldom used because of stigma and misinformation.
8. Emerging therapies. Transcranial magnetic stimulation, vagus nerve stimulation and deep brain stimulation may prove effective.

Life Is Difficult

Over the course of a lifetime almost 1 of 3 experience a major mental disorder.

U.S. employers spend $150-$200 Billion annually on stress and anxiety.

52% of Americans say work is the main cause of stress in their lives.

48% say home stress is the main cause of decreased work productivity.

Paper Shred Work

Authorities told a friend who was president of a bank (I believe it was Conroe) that he had to keep real estate records for 15 years, but he could destroy the others by shredding. (for some reason authorities disallowed incineration). Anyway, he started shredding records that were 15 years old or older. It took the shredding company using a huge industrial shredder working 8 hours a day Monday-Friday five (yes, five) months to shred all the records. This was a relatively small bank--think of all the records in Houston, say, that are over 15 years old--what a massive task; could they ever finish? 

One other question—who were those authorities?

The authorities I know always increase paperwork. The Joint Commission of Health Care Paperwork always find some sort of record keeping that must be added every time they inspect a hospital. If a hospital is found in total compliance with all the rules and regulations, never mind. The joint commission will invent a regulation that must be added to the rules. After all, the Joint Commission members have to justify their jobs. If they find nothing out of compliance, they may be deemed useless. I already deem them useless, but I am no bureaucrat.

 

 

Utility Numbers for New MOVE

UTITLITY INFO

Water, sewer, and garbage = will be turned on

           

            Town of Christiansburg                         540-382-6128

            100 East Main St.

 Water                                                                        540-382-9519

 

Atmos Energy (Gas)                                                540-951-9184

                                                                        540-639-1662 (local)

 

All connect                                                            866-269-4825

Ø    Account number = 8785582

 

AEP (Power) will be turned on Sept 23            800-956-4237

Ø    AEP account number = 02462166832

 

Verizon Phone                                                            540-954-6222

Ø    Our land line number is 540-381-2898

Ø    Cost = $49.99

Ø    Verizon Internet confirmation number = 779218096

 

Direct TV                                                            800-488-5069 or 628-5175

Ø    Account number = 81655270

Ø    Will be connected from 0800-1200 AM on October 1

Ø    Will get about 200 channels for $39.95 if file for two rebates

o      After activation of TV go to internet and enter DirectTV.com/rebate give the account number (81655270) and apply for rebate

o      The go to www.dstvgift.com and print off a form and complete form and mail in and will get first 6 months of free internet for $29.99 after that

 

Mowing = Harvey @ First Impressions            540-392-7783

 

Roanoke Times                                                540-381-1655

 

Jet Broadband Cable                                                1-877-743-8538

 

Internet NRV Unwired                                    540-239-0318           

 

$1300 rent due the first of each month to Oak Tree Town Homes

Ø    I E-mailed Wende this info

Ø    Jim Wesel 540-382-5885