Assessing Consciousness

This week’s Green Journal has an interesting fMRI study in which the authors identify specific lesional areas in the pontine tegmentum that are associated with coma. The study raises the possibility that such imaging could be useful in the diagnosis and prognosis of disorders of consciousness. This is important because, as the accompanying editorial points out, the risk of misdiagnosis is quite high in such disorders.

The assessment of consciousness offers yet another example of where adherence to protocols can improve clinical performance. There’s a tool called the Coma Recovery Scale – Revised that has been shown to be superior to clinical consensus in differentiating the vegetative state from the minimally conscious state. I added a “Rehab” entry to the clinical neurology resources in the menu above, with a link to this scale. It appears to be somewhat cumbersome, but worthwhile. After all, the stakes can be high in such cases, as decisions about the intensity of care may hinge on the neurologist’s assessment. Moreover, to the extent that such cases sometimes engender disputes among family members and between families and the clinical teams, employing a validated tool could be helpful in achieving consensus.

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Quick Followup on Torture

File:Rod of Asclepius2.svgA few years ago, I posted an essay about the medical and psychological, professions’ involvement in torture, particularly of detainees in the war on terror, and my own possible light brush with that world. Last week the New York Times ran a piece describing in more detail the role of physicians in not only carrying out the torture program, but in designing it. Again, this isn’t something that most of us will ever confront, but I think it’s worth noting the recent history and reminding ourselves every once in a while of our ethical obligations . . .

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Cui bono

Maria Popova’s Brain Pickings is a very interesting blog with articles and links relevant to what might be called popular neuroscience. As I’ve mentioned several times on this blog, however, one of my pet peeves with respect to some popular (and even academic) neuroscience is what Peter Hacker calls the mereological fallacy–the ascription to people’s brains properties that really apply to people. For example, brains don’t think; people think. Brains don’t see; people see.

As described by Hacker, the mereological fallacy applies to psychological predicates–feeling, thinking, knowing, perceiving, etc. A related practice, and a very common one (or at least, I notice it all the time), is the tendency to assert that something is good for our brains when it would be more appropriate to state that it is good for us, and above is a example of what I mean. It’s a 4 minute TED talk on the benefits of playing a musical instrument, and you can see in the title that the benefits supposedly accrue to the brain. The talk goes through some fMRI and PET evidence that many brain regions are involved in playing music, that this large-scale activity exceeds what is seen in other activities such as drawing, that it is associated with changes in brain structure, etc. Those are interesting findings vis a vis the neural correlates of musicianship, but are they really benefits? As a patient / lay person / citizen / non-neuroscientist, who cares that playing music is associated with certain patterns of fMRI activity? Or with enlargement of the corpus callosum? The more relevant benefits cited in this talk principally involve improvements in subjects’ memory and executive functions. Now those are potentially important findings, which suggest real benefits to us as people (beyond the obvious ones of giving pleasure and relaxation to ourselves and those listening).

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Involve the Palliative Care Team Early


Here’s a sad story about a family’s struggle with their young son’s fatal ordeal with New Onset Refractory Status Epilepticus (NORSE). NORSE is basically super-refractory status absent an obvious precipitating injury such as encephalitis. The main theme in this account is that the family felt under-informed along the way and then blindsided when it came time to discuss a transition to palliative care.

That frequent and clear communication is both imperative and fraught with challenges will be well-known to most everyone reading this. What I wanted to highlight from this article is actually the follow-on commentary by two neurocritical care physicians, who emphasize that palliative care shouldn’t be reserved for the situation where the patient is on the verge of death. Too often, our palliative care colleagues are consulted when there appears to be no viable means of curing the patient, death is imminent, and assistance is needed with terminal extubation and/or withdrawal of other life-sustaining interventions. However, and this needs to be done with sensitivity so as not to take away the family’s hope, earlier involvement of the palliative care team can be quite beneficial. The palliative care team can recommend measures to ensure the patient’s comfort even while full-on efforts to reverse the condition are underway. They can help clarify the goals of care, ensuring that the patient’s care plan comports with his values. And, if a transition to purely palliative care is eventually desired, it’s helpful for the relationships to have been established earlier in the hospital course and not at the last minute.

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Brain Death Resources

In light of the documented variability in the conduct of brain death evaluations around the country, and the ultra-high stakes, it’s extremely important for residents to know how to do this correctly. I recently became aware of a brain death toolkit published by the neurocritical care society; I added a link to it in Clinical Neurology Resources–>Neurocritical Care in the menu above. The toolkit has lots of helpful information, including links to the relevant guidelines, webinars, simulated video demonstrations, and an online training course developed by the Cleveland Clinic. This course requires a free registration and it’s very good; I highly recommend it. At the least, take the pre-test; if you struggle at all with those questions, they  you should definitely proceed with the course . . .

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Serotonin Syndrome and Ocular Flutter

Serotonin Syndrome is an important entity for residents to be aware of. It’s a toxicity resulting from the use of serotonin-selective reuptake inhibitors and similar drugs, and interactions of those drugs with others such as tramadol and possibly linezolid. The recreational drug MDMA (ecstasy) can also cause it. Manifestations include delirium, rigidity, myoclonus, fever, and life-threatening autonomic instability. Treatment includes discontinuation of the causative agents, benzodiazepines to reduce agitation and help normalize the vital signs and, if necessary, cyproheptadine.

This week’s New England Journal of Medicine has a video of such a patient manifesting ocular flutter in the context of serotonin syndrome. (The link takes you to an image and description of the disease–you have to click the little thumbnail image at the bottom right in order to launch the video). The eye movements are in all directions, so I think it might just as well be called opsoclonus. More examples of these and many other neuro-ophthalmological findings are available at the Neuro-Ophthalmology Virtual Education Library.

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Damn It, Basal Ganglia by Radiolab

Challenge case! Listen to this 12 minute Radiolab podcast and see whether and how fast you can make the diagnosis. The picture below provides a clue. The next paragraph has the answer, so don’t read it until you’re ready.


Continue reading

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Robin Williams’s Lewy Body Disease

Lewy Bodies

Robin Williams, who committed suicide in 2014, turned out to have Lewy Body Disease. His widow has written a poignant and informative essay on their struggles with the disease in the current Green Journal.

I think these kinds of accounts can be quite valuable. It’s one thing to study symptoms, signs, pathophysiology, treatment, and prognosis in a reference book or article. But to really refine the diagnostic art, one must become acquainted with the kinds of stories that patients and family members tell. After all, patient don’t usually recite a bulleted list of classic medical symptoms: Asosmia, resting tremor, accelerated forgetting, etc. They tell a story in their own words and it’s our job to parse the story and try to fit it into a medical frame.

We all have have heard a number of stories that is limited by our experience–a relatively small (but rapidly growing) number for residents and a relatively large number for senior clinicians. These kinds of essays can, in just a few minutes, provide memorable information that adds to our differential diagnostic abilities.

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Articles of Neurological Interest

I have a long and growing list of “things to maybe blog about”, and definitely too little time to cover it all. Following are some interesting articles that I’ve read recently (i.e. in the last year) that may be of interest to neurologists. Enjoy!

‘You Want a Description of Hell?’ OxyContin’s 12-Hour Problem.  An informative L.A. Times investigation of the regulatory, marketing, and clinical history of OxyContin in the context of the growing public health problem of narcotic and heroin abuse.

Lost for Words. I really like reading popular descriptions of neurological diseases and the patient experience. They provide a richness that is usually absent from scientific writings and is helpful for recognizing less common diseases. This Atlantic piece describes primary progressive aphasia.

The Neuroscientist who Lost Her Mind. This is a briefer New York Times piece by the director of the Human Brain Collection Core at the National Institute of Mental Health. She describes her experience of having brain metastases.

Why I Hope to Die at 75. This Atlantic article is by Ezekiel Emanuel, a Penn oncologist and bioethicist. The title is a little misleading in that he doesn’t necessarily want to drop dead precisely on his 75th birthday but rather wants to transition at that time to a comfort-only approach to his medical care, even for easily treatable conditions. It’s a very interesting and provocative piece.

Are You Ready for a Glorious Sunset? If the above article wasn’t provocative enough for you, try this Freakonomics podcast: What if, when faced with a serious illness toward the end of life, your insurance company offered you a cash reward to forgo (expensive) life-prolonging care in favor of palliative care?

A Racial Gap in Attitudes Toward Hospice Care. A short, but informative, New York Times piece on the differing ethnic perspectives about hospice and end of life care.

Balancing Faith and Science in the I.C.U. A loosely-related theme to that above.

Hipaa’s Use as Code of Silence Often Misinterprets the Law. This New York Times piece examines several misunderstandings about the Health Insurance Portability and Accountability Act, or HIPAA.

Wastebasket patient. This essay is from the humanities section of the green journal. It provides a highly valuable lesson that one can sometimes make a difference even in the seemingly least promising cases. It’s a particularly important point for residents, bombarded as they are with consults of varying “appropriateness”.

The digital doctor: hope, hype, and harm at the dawn of medicine’s computer age. This one’s a book–one I enjoyed a great deal and highly recommend. It’s by Dr. Robert Wachter, a hospitalist at UCSF and one of the founders of that specialty. He writes about many facets of medicine that have been affected by computerization, especially electronic medical records. Many are quite obvious, such as the frustration of trying to input orders, clicking boxes, etc. Some are non-intuitive. One example: It used to be that medicine teams made a daily pilgrimage to the radiology reading room in order to review all of their patients’ chest x-rays, etc. Now that the images are available on PACS, this happens much less often. More generally, there is less interaction among the professionals caring for patients as each works in his/her computer-based silo–no more bumping into each other while looking for the same paper chart on the unit. This is just one of many interesting and important discussions of how technology is changing our profession.

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Educational Resources

Preparing for the maintenance of certification exam, I came across some very good educational programs on the AAN’s website. I think these would be good for resident education generally, and particularly for RITE preparation. They are free for AAN members, and I’ll add links to them in a new “Board Review” menu above.

The first program is called NeuroLearn. These are slide presentations on various topics, with audio narration and some interactive features such as built-in multiple-choice questions. They are like those really good grand rounds talks that provide a good overview of a topic without getting to much into the weeds of a particular line of research. I particularly recommend the following:

  • The Brachial Plexus. I found this to be one of the best presentations I’ve seen of this somewhat confusing material.
  • Interpretation of the Normal Adult EEG: Normal Patterns and Common Artifacts. A great primer for the neurology resident.
  • Cervical Spondylotic Myelopathy. J.D. Bartleson of the Mayo Clinic narrates this one, and he’s very engaging. He includes some videos of patient examinations and exam techniques, which are helpful.
  • Interpretation of Autoimmune Neurological Antibody Profiles. Not quite as engaging as the ones above, but still pretty good.
  • Paraproteinemia and Neuropathy. This is an excellent one–makes a sometimes confusing topic very clear.

The other program is NeuroSAE (self-assessment exam). These are question banks, mostly covering general neurology topics. There are topic-specific ones as well, covering epilepsy, neuromuscular, and stroke. The best way to improve test scores (as opposed to the best way to become a better neurologist) is to take tests. These questions are very similar to the questions in the back of Continuum (itself another great resource). I set it up to give feedback (i.e., explanations) after each question. You can also have it defer all of the feedback to the end and even have it time the test for you. Another cool feature is that works just as well on a smartphone or tablet as on a PC. I would sometimes start a test at the office and then work on it a little more at home and it did a great job of picking up right where I left off.

I found that it takes a while to answer each question and carefully read the explanation and maybe look up something to dive deeper into the topic. When I actually sat down to take the re-certification exam, I breezed through the 200 questions because in the real test, you don’t get a lengthy response that you have to read through after each answer!

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