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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.
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.
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.
Patients are hooked up to Sedasys and sedated intravenously. While connected, a patient’s condition is monitored by the machine. It measures oxygen levels, for instance. If there is a problem, the machine alerts the physician, and is supposed to take action, such as increasing the oxygen supply and stopping the anesthesia, and resumes only if the patient’s condition normalizes.
Patients also wear an earpiece, in case they drift into too deep a level of sedation and need to be awakened. As a doctor or nurse would do, the machine would, through the earpiece, tell the patient to wake up.
If even our most prominent and well-connected citizens can’t get the best evidence-guided care, where does that leave the rest of us? Though doctors are some of the most hypereducated professionals around, they frequently don’t deliver care that has stood up to the most rigorous research.
I would argue though that often times patients don’t want evidence-guided care however. They want the hi-tech and most informative care; the care they saw on television.
Evidence-based care is for the population as a whole. If you do it for everyone the population sized outcomes will be better. But patients are individuals and they have trouble understanding in terms of such epidemiological measures.
No that cardiac CT scan likely won’t change our individual outcome and there are low risks. But we want to know what it shows and what it adds to the prognosis and in the off chance we’re one of the unique where it finds something.
No this microdiskectomy with two weeks of pain won’t lead to a better outcome at a few months compared to being conservative but we want the chance of relief now.
I’m not sure that sometimes it’s a matter of better informed consent or communication with patients. Not just sometimes but perhaps often patients perceive more as better and no office visit or computerized informed consent it going to disuade that.
In short he reports poor communication and planning with several physicians who appeared to hold a relatively poor opinion for his wife’s future with recurrent NSCLC.
It sounds like really terrible communication between multiple physicians and his family.
He promised to discuss the biopsy options with my wife’s oncologist the next day and call us with the “game plan.” The doctor never called us back.
He reports his wife is improving back on a tyrosine kinase inhibitor, despite some of the physicians they saw seemingly having reluctance about further treatment.
But I’m not sure their anecdote speaks to a failure based on bias. I would argue what comes across as a bias in this story is really physicians doing their job. Here is what he says about the ordeal,
Physicians need to be aware of the fact that they both bring pre-existing attitudes and biases to the office visit…and check them at the door. These attitudes and beliefs color the decisions clinicians make.
Lung cancer that presents as a bad cough is like a red flag to a bull. It invokes a whole set of assumptions about…the person’s odds of survival – slim to none.
You have to wonder how many people’s lives are cut short or whose care is not what it should be simply because their doctor jumped to the wrong conclusions.
But physicians are supposed to prognosticate and that’s supposed to help drive the discussion. Advanced, recurrent adeno does have a poor prognosis. It seems to me a thoracic surgeon should seriously question the utility of a risky, painful, invasive procedure and have a discussion on the merits of such. Similarly for an oncologist discussing chemotherapy; even chemotherapy as comparatively well tolerated as erlotinib. These discussions don’t appear to have happened appropriately and that seems to be the failure of the story. Prognostication is imperfect but I don’t think though that represents a bias or something inappropriate in these settings.
Beyond “people’s lives…cut short” by “wrong conclusions” plenty of cancer patients in this country get aggressive treatments that offer extremely poor chances of contributing to their survival or quality of life. These treatments often have side effects and consequences including hastening death if by no other means than by lowering functional status (which is something strongly associated with survival). I would argue in my neurooncology experience probably far more people get unnecessary, overtreatment than don’t get the care they should based on biases.
Don’t listen to Lombardi. Practice eventually makes people good at a skill. Even over practicing. I used to have this impression in surgical training that the learning curve was steep but then tapered off. That perhaps, once you reached a relatively low threshold that improvement beyond that would happen but be marginal. That perhaps there wasn’t much of a difference between the 100th brain tumor and the 500th brain tumor from the same approach for a medical system – the surgeon and the OR staff and the nursing caring for the patients.
I don’t believe that anymore.
Some of the most important questions you can ask a proceduralist are how many of your type of surgery he’s done (being specific) and how often he performs them at whatever hospital or surgical center you’re going to be at.
Just more evidence for such in the NEJM. For six index surgeries,
Hospitals with high surgical volume and low surgical mortality have lower rates of surgical readmission than other hospitals.
Kind’ve obvious but worth reminding. The literature is full of evidence that volume makes better outcomes whether it’s in heart attacks or colon surgery.
Often times as neurosurgical residents we’re asked by faculty why we would (or wouldn’t) operate on patients. Therapies for cancer can have different goals. You, hopefully, don’t operate just because a brain tumor is there. Often times, surgery for malignant tumors that cannot be “completely” resected – in which a gross total resection cannot be achieved – has limited influence on cure or survival rates. I’m not a big fan of the idea of cytotoxic reduction.
In general then surgery can have any of three goals. It can have an oncological goal – if the tumor can be resected to a degree to influence survival. It can have a palliative goal – if debulking the tumor will relieve symptoms. It can have a diagnostic goal – if getting tissue will identify the tumor so that other treatments can be initiated.
Non-invasive therapies, such as chemotherapy or radiation therapy, can similarly have either an oncological or palliative goal.
All of these therapies can have significant morbidity and side effects and so the decision to undergo therapies merely as a matter of palliation should not be taken lightly. In many cases you can exchange current symptoms for other symptoms or increased risks associated with therapies.
Such makes a study published in the Journal of Clinical Oncology even more discouraging. In the study more than 380 patients with essentially terminal lung cancer with neuro or bony metastasis were surveyed as they underwent radiation therapy. The radiation therapy was solely a palliative therapy to relieve symptoms. And yet,
Seventy-eight percent of patients believed that RT was very or somewhat likely to help them live longer
The therapy was only palliative and had no oncologic goals and no hope of improving survival.
Twenty percent of the patients expected radiation treatments were “very likely” to cure their cancer
Its tough to relate these complex ideas to patients when there is such a disparity in information. Often times, in my experience, prognosis is discussed in vague terms. “This is not a curable disease,” or things along those lines without discussion that this is actually going to be fatal or discussion of numbers in terms of survival or what progressive symptoms and quality of life are likely to look like. Difficult discussions no doubt. But without such discussion it seems impossible to fully explain things like palliative therapy.
I know its just me but it seems the summer of Naegleria Fowleri, the “brain eating” amoeba, that each year makes headlines in the American south. In short order there have been at least three cases I can think of that have gotten significant media attention. It seems more prevalent in the news than I remember it in previous years. And yet the disease remains as rare as ever. Perhaps its just the coverage of Kali Hardig, the first survivor of the meningoencephalitis caused by the amoeba in decades.
I will say she looks remarkably non-devastated neurologically for having gone through this infection.
N. Fowleri enters the brain through the nose. It lives in warm, shallow, still, fresh water.
The symptoms of its meningitis occur within a week of infection. Rare cases of survival are probably related to early diagnosis. Mainstay treatments are highly ineffective but center on amphotericin B plus or minus steroids. The CDC is handing out miltefosine this summer as a new possible treatment for amoebic meningoencephalitis. But all three of the cases I know about got it and two of them didn’t survive. Not a massive shift in prognosis but considering where we’re starting from any other therapy options are probably welcomed.
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.
Injury to the brain continues to be a unique thing in medicine. These injuries are scary and unfamiliar to many health care providers. There is a finality to them. Their consequences are hidden a little bit; the asystole is easy to figure in the emergency room but the suppression and brain death isn’t something so easily recognized.
They’re what you might imagine, along with polytrauma, as poster child conditions for tertiarization and transfer to a higher level of care.
In truly catastrophic injury to the brain however, I’m not sure that’s a good thing.
My institution has had a small discussion lately on just what ethics and the law requires of us as a place with full neuro specialty coverage.
I’ll make up an example:
A 61 year old man comes into a small community hospital’s emergency room. He was found down at home by his wife and last seen normal four hours previously. He wouldn’t wake up and he was breathing slowly and shallowly. The ambulance crew intubated him. In the emergency room his pupils are large and don’t react to light and he doesn’t do anything when the doctor hurts him. He’s in a very deep coma. If the physician working the emergency room felt comfortable doing a brain death exam, which he doesn’t, the patient might have some very primitive reflexes left but his condition is very serious.
A CT scan of the head is performed and shows a large bleed within the brain.
The bleed was probably caused by high blood pressure. In reality however, the patient’s condition is essentially terminal and the cause of the bleed isn’t important at this point.
The small hospital has an intensive care unit and an open bed. It however has no neurosurgeons, nor indeed even neurologists who round at the hospital. And so the physician in the emergency room starts trying to transfer the patient to a hospital where a neurosurgeon can see the patient.
There are really two issues here. The first is a legal issue concerning a law called EMTALA. EMTALA is a law that dictates transfers for higher care amongst hospitals that accept Medicare (virtually all hospitals). In very broad terms it puts responsibilities and requirements on both the hospital trying to transfer the patient and the hospital that might accept the patient. The former has a responsibility to stabilize a patient. They cannot refuse care in an emergency as a matter of lack of payment or inquire about payment prior to treatment to stabilize. Nor can they transfer a patient after stabilization merely as a matter of lack of ability to pay. The latter has a non-discrimination requirement, that specifically reads,
A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the secretary in regulation) shall
not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.
Case law on the non-discrimination provision is scarce but in catastrophic injury, where no specialized intervention will alter the course of the patient’s condition, I would argue that the patient doesn’t require specialized care. And not merely cases where the patient is brain dead at the time of the transfer request but also in situations where brain death is inevitable or the condition is otherwise not survivable. The patient and family can proceed to comfort measures at any hospital, there is no specialization about such care.
The second issue is an ethical one. Do hospitals with specialized capabilities owe something to patients and families to transfer as a matter of finality and closure. In that we’re saying, “Watch, we did everything we could…”?
While I’m somewhat empathetic to such an argument I have trouble with it. I think it reflects a problem in both the expectations we have of health care as patients and how physicians are trained to deal with end of life. Really it is a shame for physicians to come out of training without basic palliative and communication skills. Even the physician in the small rural emergency room should have such a skill set. The capability to have an end of life discussion with families, even if the medical issue falls somewhat outside their scope of specialty.
I’m also somewhat disappointed in how some referring physicians appear to place priority in getting the patient off their hands over the patient’s well being. I’ve had cases where even after discussion with the consulting physician at an outside hospital and having seen the films and described in no uncertain terms to the other doc that the injury is not survivable that they continue to press for transfer.
I may be wearing blinders here but, and I think much of this is subconscious, I can only draw a single conclusion from such arguing. The continued pressure to accept the patient in transfer, after I’ve explained there is nothing to do for them, is a condemnation of my analysis of the situation. They’re basically calling into question my competency; my faculty’s compentency.
And I’m okay with that in the sense that I’m not going to take offense. What I have trouble with is they’re now trying to transfer their patient to a consultant who they don’t think is competent.
I don’t know how they can have the patient’s best interests in mind and work to transfer them to another physician they’ve basically said they don’t trust.
The issue gets more complex of course and I could continue writing. What if the patient was 6 months old instead of 61 years but the situation, in terms of the finality of the condition, remained the same? How many physicians on the line at the accepting hospital are literally too lazy to accept the transfer and work for any reason not to?
In general however, in an honest physician-to-physician phone call, with terminal conditions, where nothing will be done at the accepting hospital, no matter the patient’s age, I’m not sure transfer is a good thing. It significantly contributes to costs, provides false hope and contributes to our societal expectations at the end of life.