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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 50 to 74 of 135. Go back in thread:
Posted by linkadge on January 6, 2007, at 21:02:44
In reply to Re: the case for neuroleptics is kind of weak » med_empowered, posted by Phillipa on January 6, 2007, at 19:09:01
>And with cogentin etc. many side effects of the >older antipsychotics were completed avoided
Cogentin simply blocks the symptomatic expression of TD. There is no evidence that it blocks the morphocological changes that resulting from AP's that cause dyskinesias to progress.
Its just like how they can help parkinsons, but they do nothing to slow the progression of parkinsons.
Linkadge
Posted by linkadge on January 6, 2007, at 21:14:01
In reply to Re: the case for neuroleptics is kind of weak, posted by linkadge on January 6, 2007, at 21:02:44
You are saying that you've AP's must be good because you've seen so many patients improve on them.
Well, lets think back to the early days of L-dopa usage. A Parkinson's patient was brought out on stage, shaking, perhaps in a wheelchair. He was then taken backstage and administered l-dopa. The patient then walks back in, dances around, plays the piano etc.
To the untrained observer, l-dopa was the cure.
It wasn't till later that researchers realized that l-dopa was actually speeding the progression of the illness, and enhancing dopaminergic cell loss in movement areas of the brain.
So, I would argue that it is necessary to look very long term, to see if these drugs are really benifitting the patients.
Whats the point of winning a battle if you loose the war?
Linkadge
Posted by laima on January 6, 2007, at 22:22:01
In reply to Re: Patient paid to accept neuroleptic depot injec » linkadge, posted by Phillipa on January 6, 2007, at 18:57:52
Fish oil? Vitamins? Stress relief, social support? Therapy? Quit illegal drugs? Excercise and good diet?Not even clear anymore if there is a such thing as "true schizophrenia" per the most up to date reports--they argue it's more of an umbrella term.
> How do you recover from schizophrenia without some sort of med? And maybe the payment would allow some of them to not have to live in a shelter. And doesn't true schizophrenia show up on MRI's? Love Phillipa
Posted by laima on January 6, 2007, at 22:23:38
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Phillipa on January 6, 2007, at 19:21:14
They go sell their antipsychotic drugs somewhere? Who on earth buys that stuff?> Except if truly psychotic money is not something they are even aware of they just want the symptoms of voices tv talking to them, spiritual warfare in the minds to go away. A lot go off their meds to sell them for money. And it takes quite a while for the symptoms to abate as they tend to make the patient extremely tired. Also very poor hygiene creates other problems as well. Love Phillipa
Posted by Phillipa on January 6, 2007, at 22:27:25
In reply to Re: Patient paid to accept neuroleptic depot injec » Phillipa, posted by laima on January 6, 2007, at 22:22:01
Laima problem as I would see it with fish oil etc is that they would be paranoid to take them. Maybe first take it in steps. Eleviate the paronoia and say when it's gones off the antipschotics and lets try vitamins? I have a schizophrenic person I e-mail with who love haldol, lithium and anafranil I'll ask him what he thinks about your idea okay? Love Phillipa
Posted by Phillipa on January 6, 2007, at 22:30:10
In reply to Re: Patient paid to accept neuroleptic depot injec » Phillipa, posted by laima on January 6, 2007, at 22:23:38
Someone posted that people in jail were snorting seroquel horrible. But that's evidently going on too. Love Phillipa
Posted by Quintal on January 6, 2007, at 22:38:32
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by laima on January 6, 2007, at 15:19:33
>And I keep mulling over my experience with the prima-donna psychiatrist who genuinely believed that if I felt zyprexa was making me feel bizarre, it was evidence of a developing psychosis and indicated that I needed even MORE. Meanwhile, I noticed she had a zyprexa pen and notepad.
I had that exact experience with a cocky new psychiatry graduate who tried to tell me Zyprexa was a regular antidepressant like Prozac. When I corrected him he asked me how I knew that olanzapine was the generic name despite the fact that it was written in plain view on his desk top jotter and coffee mug. I did eventually take it and he refused to believe that 5mg was making me feel spaced out and drowsy. He also thought Zyprexa would cause no significant impairment in driving performance even if taken in the morning.
I'm believing ever more strongly that they should really think about taking some of these drugs themselves before making comments like that.
Q
Posted by yxibow on January 6, 2007, at 22:38:40
In reply to Re: Patient paid to accept neuroleptic depot injec, posted by linkadge on January 6, 2007, at 18:29:11
> I think you'd see a better long term outcome with vitamin C, and Niacin.
>
> LinkadgeMy experience with time release Niacin has been less than stellar -- the idea of low flush did not work, it did not solve any anxiety, in fact it generated more and flushing. But as they say, your miles may vary.
Posted by laima on January 6, 2007, at 22:39:59
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Phillipa on January 6, 2007, at 22:27:25
?
I don't know much about the treatment of schizophrenic disorders, but heard that fish oil is effective for many- much as it's effective for many for depression. Brain is made out of fat...
I still think therapy/stress reduction/coaching shouldn't be ignored, and there is a lot of literature which posits that marijuana or other drugs can bring out schizophrenia in individuals who already are at risk. (Not to restart that debate--it's a speculation that a lot of experts are bringing up- thats all.)
I'll have to reread the article- are these people who are being coerced into shots getting any therapy or other social support???Again, "schizophrenia" seems to be increasingly thought of as an umbrella term- not just one disorder. Bunch of various disorders, various symptoms, causes, and prognosises.
Thank god I wasn't worse off when that awful doctor suggested that my dislike of zyprexa was evidence of psychosis! Glad no one forces any of us to get anti-depressant shots. One can argue about how expensive depression is for society, too: unemployment, presenteeism, drug abuse, health-care costs...sounds terrible.
Organ sellers often can use the money, too-and they do such a nice favor for the buyers.
> Laima problem as I would see it with fish oil etc is that they would be paranoid to take them. Maybe first take it in steps. Eleviate the paronoia and say when it's gones off the antipschotics and lets try vitamins? I have a schizophrenic person I e-mail with who love haldol, lithium and anafranil I'll ask him what he thinks about your idea okay? Love Phillipa
Posted by laima on January 6, 2007, at 22:47:49
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Quintal on January 6, 2007, at 22:38:32
Wow! How about that Lilly sales job?Imagine you, mental patient, knowing zyprexa's generic name. Bet you startled the young doctor :)
I agree! I too have occasionally thought that some of these doctors got some nerve telling us how we feel using certain drugs when all they are going by is observation, literature, and sales reps.
I've had experiences like this numerous times:
"Heart palpitations? No, you don't have heart palpitations- it's not one of the side effects on the list." (Note in chart: patient thinks she has heart palpitations.) Etc.> I had that exact experience with a cocky new psychiatry graduate who tried to tell me Zyprexa was a regular antidepressant like Prozac. When I corrected him he asked me how I knew that olanzapine was the generic name despite the fact that it was written in plain view on his desk top jotter and coffee mug. I did eventually take it and he refused to believe that 5mg was making me feel spaced out and drowsy. He also thought Zyprexa would cause no significant impairment in driving performance even if taken in the morning.
>
> I'm believing ever more strongly that they should really think about taking some of these drugs themselves before making comments like that.
>
> Q
Posted by laima on January 6, 2007, at 22:48:55
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Phillipa on January 6, 2007, at 22:30:10
Wow- that sounds awfully bizarre! I wonder if they were bored and trying to fall asleep?> Someone posted that people in jail were snorting seroquel horrible. But that's evidently going on too. Love Phillipa
Posted by yxibow on January 6, 2007, at 22:50:34
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Quintal on January 6, 2007, at 22:38:32
> >And I keep mulling over my experience with the prima-donna psychiatrist who genuinely believed that if I felt zyprexa was making me feel bizarre, it was evidence of a developing psychosis and indicated that I needed even MORE. Meanwhile, I noticed she had a zyprexa pen and notepad.
>
> I had that exact experience with a cocky new psychiatry graduate who tried to tell me Zyprexa was a regular antidepressant like Prozac. When I corrected him he asked me how I knew that olanzapine was the generic name despite the fact that it was written in plain view on his desk top jotter and coffee mug. I did eventually take it and he refused to believe that 5mg was making me feel spaced out and drowsy. He also thought Zyprexa would cause no significant impairment in driving performance even if taken in the morning.
>
> I'm believing ever more strongly that they should really think about taking some of these drugs themselves before making comments like that.
>
> QYou will always find "green" (new) psychiatrists lulled by current medical practices but having no patient-hour experience themselves. The questions to ask are how much peer experience does your psychiatrist have? Do they have regular discussions and anonymous journal club meetings with other psychiatrists more experienced than themselves.
There is something to be said for conservatism in psychiatry even if it means that the Lyrica you ask for may not be given quite as soon as you would like because they don't have the patient-hours with that drug.
Example, myself -- I have to take on occasion atropine like agents such as Artane for sialorrhea due to complex adjustments in medication. I insisted that it didn't take effect until a higher dose and my doctor relented and gave me a larger prescription. Bottom line with all my medications I had chill spells. (slight to medium atropine toxicity -- mostly uncomfortableness) Mea culpa, and less was better. Nothing fatal, but my doctor who practices on the fairly conservative side since I will always have some side effect to a new drug, we agreed perhaps it was a bit too much.
But some doctors who aren't as experienced, just pull out the script pad once a month. Blame it on HMO style care.
-- tidings
Posted by yxibow on January 6, 2007, at 23:03:14
In reply to Re: Patient paid to accept neuroleptic depot injection » med_empowered, posted by Phillipa on January 5, 2007, at 22:34:53
> Med I have to disagree as I saw so many schizophenics off their meds and miserable with voices and seeing things, and once stabalized they were productive in society again and happy and felt normal. Love Phillipa not by force
I too have to disagree. I happen to live near a certain fairly liberal city on the west coast of the US which has become a magnet for homeless feeding, homeless congregation in general. A fair portion of those there are not on medication, are probably seeing things and hearing voices, may be agressive -- because the state dumped its mental health population on the streets in the 60s due to lack of funding. Its a battle thats becoming more conservative as businesses and people don't want "those people" on their stoop, and mass feedings attracting large crowds.
Given a depot injection, and maybe even being paid for it, better yet paid for it in food and some sort of temporary housing not on the bluff parks where they sit daily talking to the air, making a stink and defecating and other lovely things, but somewhere else in the city, instead of using the money to become intoxicated, some people might be well enough to return to some civic oriented job.
Its not a lovely thought for things to be done by force, so an incentive depot injection is better than by force but sometimes voices and intoxication lead to violence. Schizophrenia is a greater than $2 billion problem annually in the US. And by problem I mean the sheer misery that people must endure -- I mean no ill will to anyone on here with a schizophreniform disorder.
The trouble is, once it becomes unruly, eventually they end up in a police cruiser and taken and probably evaluated, given a depot injection and discharged with medication that is never taken and the cycle continues. Its disheartening but that's our system.
-- tidings
Posted by yxibow on January 6, 2007, at 23:08:42
In reply to Patient paid to accept neuroleptic depot injection, posted by ed_uk on January 5, 2007, at 18:47:06
> From PJOnline.........
>
> Financial incentives may improve patients’ adherence to their antipsychotic medication
>
> Financial incentives to encourage patients to adhere to antipsychotic medication might help them stay out of hospital, according to UK researchers (Psychiatric Bulletin 2007;31:4). However, their conclusions are reached from limited data.
>
> The researchers, based in East London, explored the use of direct financial incentives through questionnaires sent to 150 assertive outreach teams in England and by offering payments of £5–£15 to five formerly non-adherent patients for single depot injections of their antipsychotic medication.
>
> The researchers surmised from the 70 questionnaire responses returned that attitudes towards the approach are generally negative. Most outreach team managers (76 per cent) had objections to such schemes and just under half (42 per cent) considered the approach unethical.
>
> However, the researchers say that patients who accepted the offer of payment (four of the five patients in the study) had improved adherence to their medication and three of the patients have not been admitted to hospital since entering the scheme.
>
> The researchers concede that there are a number of practical issues that need to be addressed if this scheme is to become widespread. They conclude: “Financial incentives might be a treatment option for a high-risk group of non-adherent patients for whom all other interventions to achieve adherence have failed.”
>
> Graham Parton, chairman of the UK Psychiatric Pharmacy Group, commented: “Although this small study does not tell us a great deal in terms of the effectiveness of using financial incentives to improve adherence, it does raise the premise that it could be an attractive option and is certainly worth exploring.”
>
> David Taylor, chief pharmacist, South London and Maudsley NHS Trust, added: “There will be numerous viewpoints on the ethics of such a practice but it would be best first to establish whether or not the practice is effective — as with any other untested intervention. The ethical standpoint is partly determined by the likely outcome. This study does not inform debate in this respect.”
>
>Financial incentives are done all the time in drug trials in the US. Just listen to your favourite AM radio station and you'll get ads for clinical trials and "payment and compensation up to..."
Its the non-payment aspect of the system I sometimes wonder the ethics -- frequently Phase II drug trials are conducted all over the world, in patients in developing parts of Eastern European, Southeast Asian, Carribean, African countries, on people who have desperation for medication and frequently little compensation.Its the Phase III trials that are conducted in areas of high Western medicine and are probably compensated in a greater fashion.
This may stray a bit from the subject but it draws some parallels I think
-- tidings
Posted by Phillipa on January 6, 2007, at 23:14:36
In reply to Re: Patient paid to accept neuroleptic depot injec » Phillipa, posted by laima on January 6, 2007, at 22:48:55
Laima someone just posted a link on seroquel in prisons and on the street sick behavior in my opinion only . I can't imagine it. But then I'm not a drug seeker. Hope this is civil. I think it's something that needs to be studied immediatedly as atypical antipsychotics are thought of as not being addictive or abused. And your earlier question. No no no to antidepressants with a needle point well made. Love Phillipa
Posted by Quintal on January 6, 2007, at 23:18:36
In reply to Re: Patient paid to accept neuroleptic depot injec » Quintal, posted by laima on January 6, 2007, at 22:47:49
>I've had experiences like this numerous times:
>"Heart palpitations? No, you don't have heart palpitations- it's not one of the side effects on the list." (Note in chart: patient thinks she has heart palpitations.) Etc.Hmmm..... according to my learned Dr. the rash covering my arms and legs that appeared while re-starting Lamictal was actually caused by Personality Disorder Unspecified (Asperger's Syndrome is a more likely explanation according to Prof. Quintal). That's what she filed this symptom under in any case while advising me to raise the dose in the hope that would make it disappear because "Lamictal has been beneficial in the past".
>Imagine you, mental patient, knowing zyprexa's generic name. Bet you startled the young doctor :)
I certainly did and gave him a piece of my mind about prescribing antipsychotic drugs for anxiety that responds well to benzodiazepines (he was suggesting Zyprexa as a safer alternative to clonazepam and Prozac). He still maintained Zyprexa has fewer potential side effects than benzos (I'm guessing Eli Lily told him that) and discharged me, presumably because his ego was dented and he wanted to avoid any potential future injury.
Q
Posted by Quintal on January 6, 2007, at 23:30:49
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Phillipa on January 6, 2007, at 23:14:36
> Laima someone just posted a link on seroquel in prisons and on the street sick behavior in my opinion only . I can't imagine it. But then I'm not a drug seeker. Hope this is civil. I think it's something that needs to be studied immediatedly as atypical antipsychotics are thought of as not being addictive or abused. And your earlier question. No no no to antidepressants with a needle point well made. Love Phillipa
Phillipa, I posted a similar link a while ago for us all to laugh at. I really don't think Seroquel has any serious abuse potential. As far as I can tell from those links the people are using Seroquel to treat the insomnia and jitters caused cocaine abuse, not as a pure drug of abuse in itself. Likewise in prisons a minority of people may prefer the mindless stupor of Seroquel to the boredom and frustration of being incarcerated. I have a history of substance abuse and have had no desire to abuse Seroquel. I still have nearly a full packet that I got a year ago. This is someone who managed to get abuse potential from Parnate.
http://www.dr-bob.org/babble/20070101/msgs/719973.html
As far as I can tell from the other case report the guy simply got frustrated about the doctors trying to deprive him of a med that had been very effective and stormed out in a temper saying he'd get it from his fellow prisoners who were probably using for the purposes I described above.
That's my opinion on the whole 'Seroquel abuse' issue anyway.
Q
Posted by laima on January 6, 2007, at 23:43:21
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Phillipa on January 6, 2007, at 23:14:36
I just saw that about the seroquel abuse! One of the strangest things I've heard here in a long while. I can't imagine they get high from it, maybe it does something special combined with cocaine? Of course, could most of us guessed some years back that cough syrup would end up behind the pharmacy counter due to abuse?
> Laima someone just posted a link on seroquel in prisons and on the street sick behavior in my opinion only . I can't imagine it. But then I'm not a drug seeker. Hope this is civil. I think it's something that needs to be studied immediatedly as atypical antipsychotics are thought of as not being addictive or abused. And your earlier question. No no no to antidepressants with a needle point well made. Love Phillipa
Posted by laima on January 6, 2007, at 23:46:49
In reply to Re: Patient paid to accept neuroleptic depot injec » laima, posted by Quintal on January 6, 2007, at 23:18:36
Did you notice if he had a zyprexa pen?
> I certainly did and gave him a piece of my mind about prescribing antipsychotic drugs for anxiety that responds well to benzodiazepines (he was suggesting Zyprexa as a safer alternative to clonazepam and Prozac). He still maintained Zyprexa has fewer potential side effects than benzos (I'm guessing Eli Lily told him that) and discharged me, presumably because his ego was dented and he wanted to avoid any potential future injury.
>
> Q
Posted by Phillipa on January 6, 2007, at 23:47:59
In reply to Re: Patient paid to accept neuroleptic depot injec » Quintal, posted by laima on January 6, 2007, at 23:46:49
Oh I bet he did along with a notepad. Love Phillipa
Posted by laima on January 6, 2007, at 23:50:28
In reply to Re: Patient paid to accept neuroleptic depot injec » Phillipa, posted by Quintal on January 6, 2007, at 23:30:49
Your take on the scenario makes a lot of sense. One can really sleep long and well on seroquel, I hear. Reminds me of wanting to oversleep when feeling really depressed and bored, wishing I was tireder.> Phillipa, I posted a similar link a while ago for us all to laugh at. I really don't think Seroquel has any serious abuse potential. As far as I can tell from those links the people are using Seroquel to treat the insomnia and jitters caused cocaine abuse, not as a pure drug of abuse in itself. Likewise in prisons a minority of people may prefer the mindless stupor of Seroquel to the boredom and frustration of being incarcerated. I have a history of substance abuse and have had no desire to abuse Seroquel. I still have nearly a full packet that I got a year ago. This is someone who managed to get abuse potential from Parnate.
>
Posted by Quintal on January 7, 2007, at 0:06:51
In reply to Re: Patient paid to accept neuroleptic depot injec » Quintal, posted by laima on January 6, 2007, at 23:46:49
>Did you notice if he had a zyprexa pen?
Yes, he did. Along with a Cipralex mouse mat, Zantac notepad and what appeared to be a Risperdal door jamb (!). Those drug companies really know how to lay on the PR with a trowel. I wonder how many (now likely diabetic, obese, neurologically damaged) ex-Zyprexa users here would relish wiping their posterior on rolls of Zyprexa toilet tissue - if only Eli Lily would be so kind?
Q
Posted by med_empowered on January 7, 2007, at 0:06:57
In reply to Re: Patient paid to accept neuroleptic depot injec » Quintal, posted by laima on January 6, 2007, at 23:50:28
thought i'd break up the string w/ a new title.
I think the whole seroquel thing is like another poster said--some people just get bored (and, I'm guessing, scared) in prison, and I imagine neuroleptics (especially sedating ones w/ low EPS) could counter that. If I recall correctly, there has long been a minority of prisoners who will feign psychosis to get a low-dose prescription of thorazine, thioridazine, etc...anything low-potency to take the edge off w/o being intolerable, like Haldol.
I think shrinks can sometimes (unintentionally) be hilarious. I remember I had a shrink try to RX Abilify right off the bat, and I kept saying "no, I don't really like neuroleptics" and she would say "its the cleanest thing we have..." so on and so forth. I looked at her for a second and saw...a shiny, new Abilify clipboard.
Posted by Klavot on January 7, 2007, at 4:23:46
In reply to atypicals, etc., posted by med_empowered on January 7, 2007, at 0:06:57
> I think shrinks can sometimes (unintentionally) be hilarious. I remember I had a shrink try to RX Abilify right off the bat, and I kept saying "no, I don't really like neuroleptics" and she would say "its the cleanest thing we have..." so on and so forth. I looked at her for a second and saw...a shiny, new Abilify clipboard.
>My pdoc has a Zyprexa picture frame on her desk, with pictures of her children in it ?!?!?!?
Klavot
Posted by SLS on January 7, 2007, at 6:57:14
In reply to atypicals, etc., posted by med_empowered on January 7, 2007, at 0:06:57
I'm surprised you haven't brought into the conversation the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study.
It supports your point of view.
I don't think it proves very much more than that perphenazine is a pretty good typical antipsychotic. I didn't like it when I took it, though. I felt numb and passified. I felt like a zombie. The same was true of Thorazine and Prolixin. I have not experienced such a thing with any of the atypicals, and I have taken them all with the exception of clozapine. Not only that, but the atypicals have been more effective in producing an antidepressant effect. Zyprexa was a potent antimanic and produced great clarity of thought.
n=1
Paper versus real life.
I don't know what to make of the CATIE study. It has been scrutinized and debated, of course. If you search on Google, you will find critiques of it. I really don't think much of the design, and I think the study was to ambitious, but I'll let Google worry about that.
---------------------------------------------Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia
Jeffrey A. Lieberman, M.D., T. Scott Stroup, M.D., M.P.H., Joseph P. McEvoy, M.D., Marvin S. Swartz, M.D., Robert A. Rosenheck, M.D., Diana O. Perkins, M.D., M.P.H., Richard S.E. Keefe, Ph.D., Sonia M. Davis, Dr.P.H., Clarence E. Davis, Ph.D., Barry D. Lebowitz, Ph.D., Joanne Severe, M.S., John K. Hsiao, M.D.,
for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators
Background The relative effectiveness of second-generation (atypical) antipsychotic drugs as compared with that of older agents has been incompletely addressed, though newer agents are currently used far more commonly. We compared a first-generation antipsychotic, perphenazine, with several newer drugs in a double-blind study.
Methods A total of 1493 patients with schizophrenia were recruited at 57 U.S. sites and randomly assigned to receive olanzapine (7.5 to 30 mg per day), perphenazine (8 to 32 mg per day), quetiapine (200 to 800 mg per day), or risperidone (1.5 to 6.0 mg per day) for up to 18 months. Ziprasidone (40 to 160 mg per day) was included after its approval by the Food and Drug Administration. The primary aim was to delineate differences in the overall effectiveness of these five treatments.
Results Overall, 74 percent of patients discontinued the study medication before 18 months (1061 of the 1432 patients who received at least one dose): 64 percent of those assigned to olanzapine, 75 percent of those assigned to perphenazine, 82 percent of those assigned to quetiapine, 74 percent of those assigned to risperidone, and 79 percent of those assigned to ziprasidone. The time to the discontinuation of treatment for any cause was significantly longer in the olanzapine group than in the quetiapine (P<0.001) or risperidone (P=0.002) group, but not in the perphenazine (P=0.021) or ziprasidone (P=0.028) group. The times to discontinuation because of intolerable side effects were similar among the groups, but the rates differed (P=0.04); olanzapine was associated with more discontinuation for weight gain or metabolic effects, and perphenazine was associated with more discontinuation for extrapyramidal effects.
Conclusions The majority of patients in each group discontinued their assigned treatment owing to inefficacy or intolerable side effects or for other reasons. Olanzapine was the most effective in terms of the rates of discontinuation, and the efficacy of the conventional antipsychotic agent perphenazine appeared similar to that of quetiapine, risperidone, and ziprasidone. Olanzapine was associated with greater weight gain and increases in measures of glucose and lipid metabolism.
---------------------------------------------
- Scott
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