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Archive for the ‘Neurosurgery’ Category

Wednesday, December 11th 2013

Psychofunctional Neurosurgery

The future of functional neurosurgery is going to be really interesting.

This isn’t exactly next day stuff they’re discussing in this NPR story, but it is really fun to see it in the main stream media.

I have major concerns about deep brain stimulation as psychosurgery, not because it might not be effective, but because of the patient population and the systems in place to manage such long term. Few surgeons are going to manage the a patient with depression and the implanted device status post implantation. The devices being studied are largely already in use for other indications; most notably movement disorders such as Parkinson’s disease but the movement disorder neurologists managing such have spent years getting familiar with such. Building a large population of psychiatrists managing such is feasible, especially considering reimbursement associated with managing these, but such is going to take time. It is also going to be very circular, as all new technologies are, in that the more that are implanted the more psychiatrist will manage them but the more psychiatrists managing them the more that are likely to be implanted. As another possibility I’m not sure I’d want one physician managing the device and another the patient’s meds.

Better short term targets for functional neurosurgery might be other “neuro”disorders including dementia which is showing some promise as well in studies. Or how about devices coming online for epilepsy?

Pretty cool stuff.

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Sunday, December 8th 2013

Awake Brain Surgery

Sometimes as a matter of a tumor’s (or other lesion’s) location within the brain it is helpful to have a patient awake for part (or all) of the actual removal of such. It aids staying away from important normal parts of the brain.

Similarly, I’ve been doing/seeing a lot of deep brain stimulator surgery lately and having the patient’s awake can aid in making sure the lead is in the right spot, or at least not in the wrong spot.

It is pretty incredible to see.

Saturday, December 7th 2013

Novel Treatments

The history and evolution of novel clinical research is interesting. The old ideal, “Don’t think; try is, perhaps rightly tempered by the new ideal of not just the informed and consented patient but protected patient. Such is interesting considering our move, otherwise, away from paternalism.

The development of the smallpox vaccine or the first artificial heart would have never happened today as is. Of course, neither would these horrific syphillis experiments hopefully.

Not to argue that IRBs and government agencies have made clinical research too burdensome and are hampering progress.

It’s just that a focus and regulations beyond guaranteeing informed consent seems counter to the way the rest of medicine is moving.

I’m not sure many are arguing three glioblastoma multiforme patients of Drs. Muizelaar and Schrot were at UC-Davis were ill informed. But the treatments they undertook for those patients, without approval, have cost both men their jobs. Dr. Muizelaar was in fact chairman of Neurosurgery at UC Davis prior to this scandal bringing him down.

I’ve covered this previously. But with both men resigning earlier this year its worth bringing up again now that we have some resolution.

Two UC Davis neurosurgeons who intentionally infected three brain-cancer patients with bowel bacteria have resigned their posts after the university found they had “deliberately circumvented” internal policies, “defied directives” from top leaders and sidestepped federal regulations, according to newly released university documents.

[...]

The most contentious issue between the doctors and the university – and even within the university – was this: Were the surgeons performing research? Or were they providing “innovative care?”

Research on humans is tightly controlled in the United States and, according to federal regulations and university policy, must undergo a rigorous approval process to ensure that participants are protected from harm. Innovative treatment, more commonly known as compassionate care, gives a doctor more latitude in offering nonstandard care to a single patient where evidence of safety or success is limited.

[...]

Muizelaar and Schrot called their novel approach “probiotic intracranial therapy,” or the introduction of live bowel bacteria, Enterobacter aerogenes, directly into their patients’ brains or bone flaps. The doctors theorized that an infection might stimulate the patients’ immune systems and prolong their lives.

The first patient lived about 5 1/2 weeks. The second survived another year, an outcome that buoyed the doctors and seemed to bolster their theory, they said.

The institutional trouble began in March 2011, when a newly diagnosed third patient developed sepsis, became unresponsive and died two weeks after being deliberately infected. The university’s first internal investigation soon followed.

What they did was highly unethical and dangerous.

But I have trouble with this paternalism later in the article,

“I think sometimes surgeons and doctors can get caught up in the enthusiasm for what they really believe is going to work,” said Caplan, head of medical ethics at New York University’s Langone Medical Center. “That is exactly why we have FDA oversight and approval and the research ethics requirement we do.

“Every time somebody dies or is injured or we have to recall a product, what we find ourselves saying is, there is no short-cut to innovation,” he said. “Finding the truth is a long, slow, arduous process.”

Informed consent for novel treatments can be difficult. “Informed” consent for proven standard of care is difficult. But maybe the focus should be on that and not necessarily on impeding access to even highly dangerous and unproven treatments.

Thursday, October 31st 2013

The Falliability of Memory

I am fascinated by the faliability of memory. Especially episodic memory.

You and I really don’t remember what we think we remember. It is rarely accurate and yet people are utterly convinced of that their memory is accurate. There are obviously huge implications. Think criminal or civil law.

[Dr. Elizabeth] Loftus discovered that she could modify memories with startling ease. After showing a film of a crash, Loftus asked some volunteers if they “saw a broken headlight” and others if they “saw the broken headlight.” Those who got the latter question were twice as likely to say yes – though, in fact, the film showed no broken headlights.

Loftus was fascinated, and she soon turned her attention to criminal trials. Suspicious of the accuracy of eyewitness identifications, Loftus conducted an experiment in which volunteers looked at photographs of six faces while listening to a story of a crime.

One face was identified as the criminal, five as innocents. Three days later, Loftus showed the volunteers four photographs: one of an innocent character from the crime story, and three of new people. Sixty percent of volunteers identified the innocent character as the perpetrator from the story. They recognized a familiar face but muddled their associations with it.

[...]

One study in particular bolstered Loftus’ belief that much memory is malleable. In a now-famous experiment, Loftus told a volunteer that she had spoken with his mother and learned four things that happened to him as a 6-year-old.

She then ran through three real memories and one fake one. The volunteer sometimes claimed to remember the fake memory, which involved getting lost in a shopping mall then getting rescued by an elderly stranger. (Planting a more traumatic memory would be even more illuminating for psychologists, but researchers try to avoid permanently scarring their volunteers.)

Even odder, the volunteer would usually be happy to elaborate on this implanted memory. His panic, his confusion, his relief; it was all there, hidden away in his memory. Except that it wasn’t—it was all in his imagination. With just a small bit of coaxing, Loftus could insert this memory even into the most skeptical minds.

Or psychiatric illnesses.

Psychologists Miriam Lommen and colleagues studied 249 Dutch soldiers were deployed for a four month tour of duty in Afghanistan. As part of a study into PTSD, they were given an interview at the end of the deployment asking them about their exposure to various stressful events that had occurred. However, one of the things discussed was made up – a missile attack on their base on New Year’s Eve.

[...]

Eight of the soldiers reported remembering this event right there in the interview. The other 241 correctly said they didn’t recall it, but seven months later, when they did a follow-up questionnaire about their experiences in the field, 26% said they did remember the non-existent New Year’s Eve bombardment (this question had been added to an existing PTSD scale.)

Susceptibility to the misinformation was correlated with having a lower IQ, and with PTSD symptom severity.

I think this is one of the most fascinating parts of not just cognitive study but all of neuroscience.

Functional neurosurgery may hold promises to improve memory, not just in pathology (such as dementia), but in normal individuals. Initial studies show poor episodic improvement, but who knows what the future holds. And I wonder the implications of that for these “false” memories.

Monday, October 21st 2013

Neurosurgery Makes For Drama

I’m sure that homicide detectives watch Law & Order and cringe or that White House or congressional staff watch The West Wing and are put off. Same for some doctors and nurses and other health care professionals. Some medical dramas (and comedies) get it better than others but some are downright gut wrenching to watch.

I obviously have a particularly hard time suspending my disbelief when a show depicts a neurosurgeon.

That seems to happen a lot. Surgeons in general seem to get a lot of focus in medical daramas. In particular it would seem to me the neurosurgeon, cardiac surgeon and plastic surgeon. Despite the fact that neurosurgeons only comprise perhaps half a percentage of all U.S. physicians I’ve come up with at least five shows that have a lead as a neurosurgeon that have premiered in the last five years. It is a mixed bag to say the least.

Here is the ridiculous first scene from the, rightfully, canceled show Do No Harm.

What’s interesting is that this show was a retelling of Dr. Jekyll and Mr. Hyde and hardly a traditional medical drama.

Here is the quality, and sadly ended, Monday Mornings based on Sanjay Gupta’s book of the same name.

Another interesting drama to find a (former) neurosurgeon in is the crime procedural Body of Proof.

And let’s not forget that Jack Shephard on Lost is portrayed as following in his father’s footsteps as a neurosurgeon.

Back to recent more traditional depictions of neurosurgeons in a medical environment we find the short lived 3 lbs and the British House, MD knock off, Monroe.

And of course there is the classic show currently carrying the medical drama torch, Grey’s Anatomy.

And while the number of medical dramas, including the number featuring neurosurgeons, has grown recently the specialty has long held a special place on television it would appear. Consider the 1975 NBC drama Doctors’ Hospital. Here is NBC’s promo for the 1975-76 fall line up, including that show.

The brain has a special place in culture and the idea of operating there holds a certain mystique and provides for acuity and drama. But its more than just the activity of the surgery. Neurosurgeons in particular seem to be players in shows that are more than traditional medical dramas.

There are, to be fair, plenty of examples of other archetypes of physicians portrayed beyond classical medical dramas/comedies. The physician in non-medical sitcoms is easy to think of. For example Frasier or Northern Exposure or Arrested Development or more recently, The Mindy Project. I’m having a harder time thinking of dramatic representations of non-neurosurgeon physicians outside the clinical setting. Perhaps the psychiatrist working with police? But even that is them clinically practicing their specialty.

You should post a comment if you can think of a non-medical drama featuring a physician or former physician.

I think the neurosurgeon appears to hold a special place in drama. I think that’s because in making a drama giving your character a backstory as a neurosurgeon achieves some immediate things. The people who would dare, or achieve, to operate on the brain make for interesting characters who are automatically endued with accomplishment, intelligence and perhaps ego and a rough character. Whether those perceptions are accurate is another thing but there’s no doubt the audience has specific stereotypes of a neurosurgeon. The audience automatically understands something of Megan Hunt or even of Jack Shephard based on the given past as that of talented neurosurgeons.

Such displays probably only reenforce our own egos as surgeons. And sometimes the stylization can be hard to watch.

Saturday, September 28th 2013

The Risk of Exposure In Healthcare

Prions, the misformed proteins behind the various spongiform encephalopathies (including Mad Cow disease), are difficult things to sterilize for. They’re not “living” and so the typical techniques used to sterilize surgical instruments before they’re use in the next surgery are ineffective. These prions are infective. You can transmit these fatal, horrific encephalopathies from one patient to another via organ transplants or contaminated surgical equipment. Contaminated equipment may have exposed a number of people undergoing spinal procedures in Massachusetts recently, it was revealed earlier this month.

Five patients underwent spinal surgery at Cape Cod Hospital with the same potentially contaminated instruments used on a New Hampshire patient who likely died from CJD, a rare and fatal brain disease. Dr. Alfred Delmaria with the MA Dept of Public Health says, “The instruments are so specialized, they were carefully tracked, know exactly where they went.”

I remember once doing a stereotactic brain biopsy where, amongst the differential was Creutzfeldt-Jakob disease. It turned out not to be that but before the surgery everyone sat down in a conference room and talked about the steps we were going to take to only use equipment that could safely undergo the sterilization techniques needed to rid prions without destroying the equipment and the quarantine techniques that were going to be used to make sure all the used equipment got to the right place for proper sterilization.

This case in Massachusetts isn’t the first time there has been a scare over prion contaminated surgical equipment as a transmission vector. It won’t be the last despite commercial products coming on line to try to reduce such risk.

Monday, May 27th 2013

Playing A Guitar During Brain Surgery

It is common practice in some techniques for putting in deep brain stimulator electrodes to keep patient’s awake to make sure the electrode is in the right place and giving good symptom relief. Likewise for parts of some surgeries for brain tumors you might have a patient awake to “map” their brain surrounding the tumor so as to not damage important parts that control things like movements or speech. You may ask patients to do certain tasks while they’re awake so that you can see if the stimulation is working or see if an area of the brain is involved in such a task. I don’t think I’ve ever heard of anyone playing the guitar during a surgery however.

Wednesday, January 9th 2013

Do Nothing

I’ve been reminded recently how much of medicine is watch and wait. I’ve been reminded of it in the context of being on call and cross cover. When I’m not on service but I’m taking overnight call I think I probably do less fiddling and tampering with patient’s care than when I’m on service and seeing the same patients day in and day out. Getting along in training also probably predisposes me to such inactivity.

And I’m not sure that’s a bad thing.

As every resident, I get a lot of phone calls from nurses when I’m on call in house. A lot of it is tedious and just things to be taken care of from afar, such as the day team didn’t reorder restraints, and a lot of it is just unnecessary, such as the patient doesn’t have an incentive spirometer at the bedside at 2am, and a little bit of it deserves undivided attention and action, such as the patient has had a legitimate neurological status change, but some of it is just stuff that just raises a shrug. Examples from my last call include the fact that a patient’s urine output was only 20cc for an hour but their pressures were fine, that a lumbar lumbar drain hadn’t drained anything for the last hour but was tidaling, that a patient threw up once but already had prn antiemetics available, that a patient with a monitored head injury and concurrent ARDS and maxed ventilator settings on his current mode had a stable but less than ideal pCO2 of 44.

Thanks for the update, I guess, let’s just watch and see what happens over the next hour or two or three.

Behold the issues turn out not to be issues at all. The patient puts out plenty of urine over the next hour, the lumbar drain starts draining over the next two hours, the patient doesn’t vomit again, the patient’s pCO2 stays stable and he has no intracranial hypertension issues.

Maybe it is just a matter of better triage, teaching patience to those at the bedside. Then again, even if the phone call was after the still tidaling lumbar drain hadn’t drained anything in three hours my solution might still be to just stare at it. It seems to work. I guess helping the triage process and separating the wheat from the chaff and knowing when to just shrug and watch is just part of being a resident; maybe a physician in general.

Thursday, October 25th 2012

SSRIs Associated With Intracranial Hemorrhage

Recently I was talking about how skewed my views of some therapies are as a specialist; how, despite intellectually knowing the studies and the benefits certain drugs hold, I have a near visceral reaction to them because I largely only see complications associated with them. If I ever had to go and practice primary care I would be terrible:

Me: “Hmm…you were just discharged following an MI with this new stent that Dr. Peters put in. I see you’re now on Plavix. I don’t know about that…I’m really worried you may fall and bleed in your head.

And so, I always appreciate it when new studies raise my angst a little bit. A literature review and meta analysis published recently in Neurology finds that SSRI use is associated with an increased risk of spontaneous intracranial hemorrhage.

Intracerebral hemorrhage was also associated with SSRI exposure in both unadjusted (RR 1.68, 95% CI 1.46–1.91) and adjusted (RR 1.42, 95% CI 1.23–1.65) analyses

I am trying to be a better doctor and internalize fully what I already know; that out in the real world of medicine most drugs I fear do far more harm than good and the complications I see are a relatively rare event. I don’t think I’m going to add SSRIs to the list of pressing questions I ask every new patient or family with ICH.

Me: “Does he take any medications? Are you sure he isn’t on anything that would thin his blood such as aspirin, Plavix or Coumadin? Are you sure he isn’t taking an antidepressant such as Celexa, Lexapro or Paxil? Are you sure?

Wednesday, September 26th 2012

Lost In The Monotony

Residency is a period of survival, even in the age of duty hour restrictions. It is a period of sometimes putting your head down and going one day to the next which, can often, run together. And depending on how the call schedule comes together it can be difficult to recall fully your responsibilities. Am I on call today or tomorrow? This weekend? So I know I’m not alone in showing up to one of the hospitals we cover yesterday promptly at 4 pm to take overnight call and realizing to my embarrassment that I was 24 hours early.

Once when I was a medical student doing a general surgery rotation I stayed overnight for “call” and then went home in the morning at about 10am. I quickly fell asleep. I woke up to the sun on the horizon from my bedroom window and a bedside clock that read “7.” I jumped up, forwent a shower and raced to the hospital. Out of breath, at the end of the stairs I found the team’s work room empty. Frantically I dialed my fellow medical student on the service to ask her if the team was already on the floors rounding only to learn she was at home making dinner and I was twelve hours early. I had mistaken 7 pm for 7 am. That truly would’ve been a feat to sleep 20 hours straight instead of the actual 8 hour nap I had pulled.

Shift work does this to you I suppose.