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Archive for the ‘Health’ Category

Sunday, May 5th 2013

Post Spinal Tap Headaches Can Be A Real Problem


You can imagine that if the pressure inside of your head is high you might, amongst other things, have a headache. Your skull is a closed box and the contents of the box are relatively fixed with a certain amount of blood, cerebrospinal fluid and brain. Adding additional contents to the box such as blood or cerebrospinal fluid, such as in hydrocephalus or pseudotumor cerebri, or more brain, such as in some tumors, increases the contents without increasing the volume which necessarily increases the pressure.

What’s interesting is that you can also get terrible headaches if the pressure is too low. Such appears to have happened to Chicago Bulls forward Luol Deng.

Your spinal cord, and the nerves that run to your legs, bowel and bladder, are protected by a tough sheath known as dura. The spinal cord and the nerves are bathed in a fluid your body makes, known as cerebrospinal fluid, which is contained within the dura as well. Some diseases require sampling the cerebrospinal fluid to help diagnose them. Examples of such include hydrocephalus, to see if the pressure is high, or meningitis or multiple sclerosis.

In Luol Deng’s case he apparently had symptoms that made the ER physicians concerned that he might have meningitis and so he had a lumbar puncture. This is a procedure wherein a needle is inserted into the back, between the vertebrae, and through the dura to get a sample of cerebrospinal fluid.

In most cases the hole the needle makes in the dura heals up easily by itself. However sometimes the durotomy does not heal and cerebrospinal fluid can continue to leak through the hole after the lumbar puncture is done.

The image above is technically post operative, involving a surgery where the dura had to be opened. However the idea is similar, you can see the cerebrospinal fluid (and actually the nerves themselves) are leaking out of the dura. Because the cerebrospinal fluid in your back is continuous with the cerebrospinal fluid in your head and around your brain, a persistent leakage of cerebrospinal fluid can actually lower the pressure inside your head. Low intracranial pressure can lead to headaches as well.

The initial treatment for cerebrospinal fluid leaks from small holes in the dura, such as typically caused with a lumbar puncture, is to have the patient lay flat for several days. The idea is that cerebrospinal fluid is more likely to leak when you’re upright and gravity is pulling the fluid down towards the hole. If you’re flat and prevent a continuous leak the dura can heal itself. If that fails then often a blood patch will be attempted. Here blood is drawn from a patient’s vein and then injected into the area right around the durotomy to try to produce a clot that seals the leak. Failing that, and incredibly rarely, patients may have to go to the operating room to have surgery to close the leak.

It sounds as if Luol Deng may be feeling better. I wish him the best. As I write this his teammates are winning Game 7 of their second round matchup with the Brooklyn Nets.

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Sunday, May 5th 2013

Facing The Truth On Cancer

You need to read this piece in Salon by Mary Elizabeth Williams who is living with widely metastatic melanoma.

[T]he fate of people with metastatic cancer is the same as everybody else’s – to go on living until life ends

It raises important issues, and links to posts from others on the same subject, about how the end of life with cancer makes even cancer patients and cancer support groups and cancer researchers uncomfortable.

Wednesday, May 1st 2013

How To Find A Neurosurgeon On Craigslist

An uninsured Seattle man has put out an ad offering to trade his 2006 Mustang GT for brain surgery. He provides an image from a MRI of his brain even. The poster doesn’t describe what symptoms he attributes to his arachnoid cyst but the relationship between arachnoid cysts and late symptoms is often difficult to establish.

Arachnoid cysts have been associated with headaches, nausea, seizures, vertigo and even in anecdotal cases with psychiatric symptoms or the onset of dementia. But the relationship is often hard to establish. Up to a third of people with chronic headaches have some sort of abnormality on there MRI, including arachnoid cysts. Relating the findings and the symptoms is often difficult; sometimes you have a finding on an MRI or a CT scan but it is a red herring as far as the symptoms are concerned.

Arachnoid cysts are collections of cerebrospinal fluid trapped between the brain and spinal cord and the arachnoid membrane. They’re primarily a congenital entity but can be associated with trauma, infection or be iatrogenic following surgery. The vast majority of cysts are discovered incidentally and associated with no major symptoms. While even asymptomatic cysts can progress to cause symptoms and they can be associated with post traumatic, or even spontaneous, hemorrhage the risk of such is low enough that in small asymptomatic cysts it is often more than reasonable to do nothing.

I’m a little bit dubious of the poster as he relates that he’s been thinking of trying to get to the cyst himself. However, if it’s an honest post I think the poster really needs to sit down with a neurosurgeon in consultation and go over the above in detail and discuss the best course of action.

I suppose health insurance is coming in 2014.

Sunday, April 28th 2013

The Government Telling You What Drugs You Can Take Is A Balancing Act

What’s the substantial difference between hydrocodone or dihydromorphone or diacetylmorphine? Beyond their manmade designations. Their potential risks versus their potential benefits are difficult things to quantify. In some studies diacetylmorphine is a better analgesic than morphine; nowadays, at least in the United States, only the criminal can tell us anecdotally. The various governments of our federal republic nominally weigh the risk versus reward of all controlled substances in determining under what conditions they will allow them.

It is true that government regulatory behavior appears to influence clinical providers utilization of opiates. But considering physicians can’t even agree on the appropriate use of the opiates the government does lend them to use,

It is unlikely these standards will be developed until there is a consensus among pain specialists about opioid use for nonmalignant pain because boards/agencies have no consistent, reliable source of expert information: Pain specialists should initiate efforts to develop this consensus.

Long term opiates for nonmalignant chronic conditions remain a controversial subject. I say that despite their wide use. Many factors including many psychological and social and financial factors that favor benefit from opiates play into any improvement (or lack thereof) in such pain. And the long term benefit from opiates in a condition like chronic back pain is questionable at best despite the fact such drugs may be the only thing that seems to make your loved friend or family functional. To be fair, not as dubious as surgery itself often.

Nor, as above, is the utilization of opiates, even amongst pain specialists, standardized for such conditions. It is remarkable both the variations amongst clinicians in opiate use for nonmalignant pain and the factors that influence such use. So a belief your personal health care providers know best for your pain may be an inadequate argument against government regulation of opiates.

I’m not a fan of government regulation of opiates whether in a medical setting

My wife suffers from chronic pain…she…requires daily narcotic pain medication to manage her pain.

[...]

My wife is not the criminal. Colorado and the DEA are forcing her to live in pain as they restrict her legal access to pain relief. No one should have to watch the person they love suffer in unimaginable pain just because of bureaucratic hurdles put in place to slow illegal drug use.

…or for personal treatment or other reasons. The point of this post is the distinction is smaller than you may imagine. “[I]llegal drug use” is whatever the government says. Philosophically is there much difference between restricting the hours when you can get morphine from a pharmacy and making the very possession of heroin out of the lab illegal?

Monday, April 22nd 2013

The Two Thousand Dollar CABG

I remember reading a profil of Devi Shetty and dismissing his dream of cheap surgery as unreproducible in the West. His Narayana Hrudayalaya hospital in Bangalore India supposedly does the most heart operations in the world. He contracts with fabric companies to make his own low cost suture, trains families to perform the duties of western nurses (although such is the way in much of the world), is aided by India’s lax recognition of pharmaceutical patents and uses his huge volume to drive a bargain on medical equipment he cannot replicate in cheaper form. All of such is done on the cheap for patients with a tiered progressive pricing system that has the truly poor pay nothing and those that can afford it pay on a scale and for more comfortable accommodations.

He continues to push boundaries by opening facilities across India and one in the Cayman Islands. In a new profile, he compares his ambitions to health care in the western world,

“Near Stanford (in the US), they are building a 200-300 bed hospital. They are likely to spend over 600 million dollars,” [Devi Shetty] said.

“There is a hospital coming up in London. They are likely to spend over a billion pounds,” added the father of four, who has a large print of mother Teresa on his wall — one of his most famous patients.

“Our target is to build and equip a hospital for six million dollars and build it in six months.”

There may indeed be things to take away from Dr. Shetty’s work. Ideas about continuous operations and large volumes and standardization of processes. Here is his talk on such things to an NHS trust. But it is not wholly replicable. And isn’t merely a matter of entrenched interests or unnecessary regulation. Certainly such are major obstacles. The biggest obstacle and a foolish obstacle.

But even if such didn’t exist in western health care there are other more inherent considerations. At least one of which is that I think much of what Dr. Shetty has done has benefited from costs borne by western health care.

India and Africa and the Cayman Islands didn’t bear the development costs of those dialysis machines or heart valves that Dr. Shetty’s company is now buying in bulk. And they can’t. The technology in fifty years or a hundred years that is going to make all of Dr. Shetty’s valve replacement operations obsolete isn’t going to come from the still developing world.

That’s not to completely justify the massive difference in costs between what Dr. Shetty is doing and America. Like I said, there is much to learn from him. I agree in the specialization of physicians as technicians, of tertiarization of specialized care, of volume and of operating closer to capacity and with greater efficiency. There is probably amazing savings for western health care there. But the idea of the two thousand dollar CABG in England or France or Canada is infeasible and, to be honest, I’m not sure desirable.

Friday, April 19th 2013

The Studies Are All Bad

One of my fellow residents might be a Ben Goldacre disciple except amongst all his citations in conversation I’ve never heard him reference the English Physician. I’ll call Dr. Goldacre the ‘Bill Nye’ or the ‘Neil Degrasse Tyson’ of the antagonistic medical epidemiology circle. But it’s a growing group. Amongst them as well the Greek epidemiologist, John Ioannidis.

There is a horrific set of facts about what we know in medicine.

1) Most medical research is so poorly designed that conclusions you can draw from it are…limited

2) The medical research we are conducting is low yield

3) Most medical research performed never comes to light because it fails to meet the hypothesis of those who conducted it

4) There is strong incentive to falsify results

Ioannidis has a famous paper entitled “Why Most Published Research Findings Are False,”

[T]he majority of modern biomedical research is operating in areas with very low pre- and post-study probability for true findings. Let us suppose that in a research field there are no true findings at all to be discovered.

A Huffington Post article by Dr. Ida Sim,

About 80 percent of clinical trials are funded by the commercial sector, but the commercial sector disproportionately studies drugs, and understudies behavioral treatments or older treatments that can’t be patented or profited from. When 75 percent of our medical costs are for chronic diseases that are largely due to poor lifestyle habits, where are the studies on prevention? On behavior? On effective patient-doctor or public health strategies? Where are the studies that examine the balance of benefits and harms, that guide patients and doctors on side effects and cost-effectiveness?

In England a researcher working for Aptuit is set to serve a prison sentence for falsifying lab results for a cancer drug.

Steven Eaton, from Cambridgeshire, has become the first person in the UK to be jailed under scientific safety laws.

[...]

Sheriff Michael O’Grady said: “I feel that my sentencing powers in this are wholly inadequate. You failed to test the drugs properly – you could have caused cancer patients unquestionable harm.

“Why someone who is as highly educated and as experienced as you would embark on such a course of conduct is inexplicable.”

Speaking after the case, Gerald Heddell, the Medicines and Healthcare Products Regulatory Agency’s director of inspection, enforcement and standards, said he welcomed the conviction.

He added: “This conviction sends a message that we will not hesitate to prosecute those whose actions have the potential to harm public health.”

Biomedical research is difficult to call science. What you can assume your doctor or surgeon knows about your condition is surprisingly less than you think. They will certainly act like they know and truly believe that they do but such knowledge is based on a limited amount of reliable data. In Dr. Ionnaidis’ essay there are some suggestions on making medical research better. And of course as Dr. Goldacre calls for all results of all medical research should be public. Even if that disincentivizes some research we may not be missing out on much.

Monday, January 28th 2013

You Are Going To Die

Sometimes the New York Times puts out poignant opinion pieces. Often these are essays of Tim Kreider. Indeed, his piece, The ‘Busy’ Trap, is amongst the most on the nose things I’ve ever read. But this is about something more pertinent to this blog. Last week The New York Times published this,

Segregating the old and the sick enables a fantasy, as baseless as the fantasy of capitalism’s endless expansion, of youth and health as eternal, in which old age can seem to be an inexplicably bad lifestyle choice, like eating junk food or buying a minivan, that you can avoid if you’re well-educated or hip enough. So that when through absolutely no fault of your own your eyesight begins to blur and you can no longer eat whatever you want without consequence and the hangovers start lasting for days, you feel somehow ripped off, lied to. Aging feels grotesquely unfair. As if there ought to be someone to sue.

It is well worth a read.

Saturday, January 12th 2013

Culturally Competent Care In A Rush

Providing culturally nuanced medical care is held up, sometimes, as a right of patients and a goal that should be paramount in medical care; even with all else that needs attention. Sometimes the emphasis on culturally component care is stressed to a laughable degree. As if a physician practice, without a significant east African patient population, should have immediate access to an in person female Somali speaker, of the same dialect as the patient,

Though the state requires all medical providers to offer translation, current services fall short. Most rely on special phone lines for translation, which are based out of state and offer little control over the gender (Muslim women prefer female translators) and dialect of the translator.

Even with phone services available, a slapdash approach to translation is the status quo. Providers and patients often rely on neighbors or children, who cannot legally act as interpreters in California.

I’m not saying culturally component care isn’t important. Although the term is broad, it leads to better outcomes through better communication and better patient compliance with therapy. But there is obviously a limit to what can be achieved in most of health care within reason and examples like the above show a naïveté amongst proponents of such care.

Then of course, there are examples of the opposite.

I train in a city where more than half the population speaks Spanish as a first language. Obviously that figure is likely even more impressive for the specific population served by the county hospital. The encatchment area of the hospital extends into territories where the prevalence of Spanish is even more complete. Many of these patients do not speak English in addition. And while translation services are often relatively easy to maintain the established process is haphazard and in more than one instance has failed.

This story has obviously been changed substantially but I think it is in line with some recent experiences which have frustrated me.

I had a patient recent who needed a neurosurgical procedure. He was an inpatient and it was my first time meeting him and his first time meeting a neurosurgeon; their was no established repoire or understanding about what we were about to discuss. He was a Spanish speaking only gentleman with no family. He had had extensive, destructive sinus surgery which had made him nearly unintelligible in speech at times. While the surgery wasn’t urgent, there was an opportunity it done the same day and move the patient’s care along. That obviously depended on, most importantly, discussing such with the patient.

So, after my halting introduction of myself in Spanish, knowing I was over my head I went to his nurse, who did not speak Spanish, and asked if he could help me find someone to translate. He rather unhelpfully, but not rudely, merely offered up a name of a tech who was on the floor who could translate. So I went to the front desk and inquired for the tech with the clerk, who not having seen him recently paged him overhead to the patient’s room. I went back and waited awkwardly with the patient. No one showed. Back to the clerk I went and inquired again. This time I asked for the charge nurse who the clerk promised to find and in the meantime she suggested I use the translation phone that exists on every ward and unit. While trying to explain that the patient’s speech was garbled, I still took the phone while I waited. I set up the phone and dialed in and the translator on the other end did his best but essentially could not comprehend the great majority of the patient’s responses. At the end of my discussion and introduction of what I thought we needed to do next for the patient, with surgery, he offered up questions which were useless and devolved into me trying to read his Spanish writing over the phone to the translator. The patient merely shook his head finally, shrugged and said, I think, in English, “Is okay.”

During the conversation over the translation phone the nurse popped in again and left, on a journey he said to find a translator. He didn’t return with any haste.

The entire ordeal took perhaps twenty or thirty minutes. No doubt the institution failed. I’m not sure, serving a majority Spanish speaking population, that organized, readily available, in person Spanish translation can even be called something like cultural competency under such circumstances. It seems even better practice than that; a necessity. And yet here we are.

To be fair I could’ve done better. A surgical intervention is a major life altering point and thirty minutes looking for the appropriate translator was worse than my patient deserved. I should called up the line of command in my pursuit. But in house, with sixty patients under care and consults stacking up in the emergency room, real time pressure exists. Not that I got, say, four consults while I was talking to the patient, only that there are other pressing things that require attention. A reason; not an excuse.

Tuesday, January 8th 2013

Venous Sinus Thrombosis

In case you missed it our Secretary of State, Hilary Clinton, has a cerebral venous sinus thrombosis. Such may be a consequence of her mild traumatic brain injury earlier in December. But considering these can be relatively asymptomatic things, especially in older individuals, and that the madame Secretary has a likely procoaguable disposition, considering her history of deep venous thrombosis, it may just be this clot in her right transverse sinus was found incidentally on a follow up brain MRI.

The Heart has a good video on Mrs. Clinton’s condition. An NEJM review article from 2005 can be found here (PDF).

In general these are clots in the large draining veins from the brain. They’re associated with procoaguable states including a strong association with pregnancy; as well as with cancer and trauma and infections of the inner ear amongst other things but in at least 15% and perhaps as many as 30 or 40% of cases no underlying risk factor or etiology is identified. They can lead to raised intracranial pressure by cerebral edema in the areas where blood backs up and by affecting the reabsorption of cerebral spinal fluid. Raised intracranial pressure can have relatively non-specific findings including headache, nausea, the consequences of papilledema. At times they can lead to frank venous inarcts; venous strokes in the brain. These strokes can even be hemorrhagic. his can lead to more devastating consequences. Or they can be asymptomatic.

As with venous clots elsewhere the treatment is generally anticoagulants. And it appears Mrs. Clinton is back on coumadin, although there are other, newer oral anticoagulants that could serve the same treatment. Typically it would be expected for her to continue treatment for at least six months, depending on what repeat imaging and exam shows.

My thoughts are with her as she deals with this.

Thursday, October 11th 2012

Fungal Meningitis After Epidural Steroid Injections

While only level II evidence through the literature I am a firm believer in epidural steroid injections for the short term relief of radicularesque pain. As most etiologies of this type of pain over the long term improve with or without surgery, epidural steroid injections can be a part of controlling symptoms in the short term while the disease process itself, usually a nerve pinched by a disc, improves. I refer plenty of patients, with symptoms that are very young or symptoms that are poorly localized or symptoms I think otherwise may be poorly responsive to decompressive surgery, to pain specialists for consideration of injections.

While hematoma, intravascular embolic events, and infection are all well reported after epidural steroid injections the procedure generally has a low complication rate; seemingly lower than a minimally invasive surgery for decompression of a nerve root. So while I know that reasonably this recent outbreak of fungal meningitis associated with contaminated compounded steroid used in epidural steroid injections does not raise the risk for any patient I refer for such in the future, and should not likely in anyway influence a referal for such, it is still a little scary.

About 13,000 people may have been exposed to the tainted steroid that has been linked to a growing outbreak of fungal meningitis, a spokesman for the Centers for Disease Control and Prevention said.

[...]

The company that made the drug, the New England Compounding Center in Framingham, Mass., has shut down, surrendered its license and recalled all its products, not just the steroid.

The disease centers said that the company began shipping potentially contaminated lots of the drug on May 21, and that people who had the treatment for back pain — called a lumbar epidural steroid injection — after that date should seek medical attention if they develop symptoms like severe or worsening headache, fever, stiff neck, dizziness, weakness, sensitivity to light or loss of balance.

The death toll from the exerohilum and aspergilis meningitis has risen to 14. That’s about a 10% mortality so far considering just under 170 cases have been reported. The CDC has a website listing recommendations for those afraid they may have been exposed, as well as a list of the facilities which used the recalled methylprednisolone. It is scary and a reminder that even the simplest procedures hold inherent risks, but it shouldn’t move us off rationally judging those risks and continuing to use effective treatments when warranted.