Nitric oxide is synthesized from what amino acid?

Arginine

Notric oxide acts as a prominent second messenger

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If I was a cardiologist or a primary care physician or a neurologist I might love Plavix. As a neurosurgery resident I have a decidedly different view.

We know that anticoagulation therapy is associated with larger intracranial bleeds in trauma as well as worse outcomes. And we should have no doubt that antiplatelet therapy carries a similar risk. Indeed, Plavix is probably associated with worse outcomes in traumatic brain injury, although the data is scarcer for a drug like Plavix as compared to say warfarin.

Don’t get me wrong, cerebrally I know that the data supports its use whole heartedly. These are, typically, patients whom Plavix has helped save from further heart or brain attacks. The risk they face from such far outweighs the risk of an intracranial bleed. That said, it is hard to put aside what I see everyday; that is trauma patients with large bleeds associated with antiplatelet or anticoagulant use.

Well, Plavix, one of my largest scourges, is coming off patent.

The drug is set to lose its patent protection on Thursday. Faced with an expected influx of cheaper generic alternatives, Bristol-Myers Squibb, which sells Plavix in the United States under a partnership with Sanofi-Aventis, has said it no longer plans to actively promote the drug.

“This is one of the behemoth drugs that really defined the drug industry in the ’90s,” said Catherine J. Arnold, an analyst for Credit Suisse.

I’ll take comfort in the fact that the cheaper costs of generics typically does not actually lead to increased use of a drug. For me that would be a horror scenario. And I’ll keep telling myself that, despite my very limited view point, these are drugs that actually do far more good than harm.

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This is an incredible story out of the United Kingdom. A family is claiming malpractice over a little girl’s death from tuberculous. The most sensational stuff is some of the etiologies some of the physicians tried to ascribe to the girl’s symptoms.

An inquest heard that her GP, Dr Sharad Shripadrao Pandit, accused her parents of “mollycoddling” her.

Shockingly, he even claimed her symptoms were brought on because she was ‘lovesick’.

Inappropriate to judge stories of malpractice out of a newspaper. But if even a modicum of truth is in the transcripts out of the Coroner’s Court are true then this is a horror. My thoughts are with her family.

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The gene locus responsible for NF-2 is located on which chromosome and arm?

22q11.1

A number of other disorders have deletions on 22q11, including DiGeorge with the locus at 22q11.2

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Based on this H&E photomicrograph the diagnosis of this intracranial pathology is?

Glioblastoma multiforme

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I love patient blogs. I love the personal narrative as a patient, hearing patients tell their stories. Especially concerning sudden, acute life altering health issues. It’s not watching a train wreck; it is uplifting and motivational. I once heard Jill Taylor speak and while I was underwhelmed with the performance as a public speaker (no offense) I did enjoy her book talking about her experience recognizing she was having a stroke to being a patient to recovering.

Senator Mark Kirk, the man who followed Roland Burris who followed Barack Obama in the United States Senate, details his similar experience as a stroke patient in the Chicago Tribune.

The medical team at Northwestern, in consultation with my family, decided to operate. Sunday evening, Dr. Fessler and his surgical team removed a 4-by-8-inch section of my skull to relieve the swelling. I am told that I woke up on Monday morning and asked for my BlackBerry, although I have no recollection of that now.

Over the next two days, the swelling in my brain did not go down, and Dr. Fessler and Dr. H. Hunt Batjer operated again, removing the dead portion of my brain as well as more bone to allow for more swelling. Since that second surgery, I have been on a steady course of recovery. Two weeks later, the removed section of my skull was replaced and my head was back in one piece. A week after that, I transferred out of Northwestern’s intensive care unit and moved into the Rehabilitation Institute of Chicago, just a few blocks away. For the past two months, I have been working for hours each day to regain my ability to walk and other motor functions.

I was very fortunate that the stroke affected the right side of my brain. While I could not at first move the left side of my body, my cognitive and speech functions were not impaired. With a lot of work and a lot of help, I have been slowly regaining movement on the left side of my body.

Throughout this time, I have been blessed with great care from some of the finest health care workers in the world. Jesserine, “Jazz,” one of my nurses at RIC, has become a great friend. I do not know what I would have done without her skills and professionalism. Jazz and her colleagues saved my life and have facilitated my recovery in more ways than I could list.

Not the most personal of memoirs but a good read.

I’m a little surprised the Senator got such an aggressive and early decompression. There is good evidence for aggressive, early hemicraniectomy in large non-dominant middle cerebral artery strokes to circumvent the effects of swelling, see here and here. The thing that surprises me, just inferred from his own piece in the Tribune, it seems like he was awake and talky leading up to the surgery. If that’s the case certainly not a patient, at that point, suffering from a malignant MCA stroke. Then again the fact they went back to the operating room for further decompression days later…

I guess all to take away is I should play physician from afar and based on a 1000 word article in the newspaper. We all remember this.

But you should read Senator Kirk’s piece and remember, as he employs, remember American Stroke Month.

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Neurosurgery loses a lot of MRI. It uses a lot of MRI in the urgent setting. Care of the central nervous system is where MR has altered care the most and where quick and efficient access to MR for acute issues has become widely available; rightly. Patients with symptoms of stroke, SCI, cauda equina injury, intracranial mass lesions with herniation syndromes. These are situations where stat access to MRI has proven invaluable and nowadays is essentially standard of care.

And so I am surprised by the number of patients I see who have symptoms that would dictate stat MR scans but who have contraindications to MRI. Patients with ICDs or pacemakers or SCS or other implants or who are claustrophobic or who are morbidly obese and won’t fit on the table. Running into this problem often, I’m excited about a prospective study looking at MRI use in patient’s with supposedly non-compatible pacemakers, the Magnasafe Registry.

This group gave an oral presentation of early results at the Heart Rhythm Society meeting. As the Medscape write up notes,

Among 500 patients undergoing scans, there were no deaths, device failures, generator-lead replacements, losses of capture, ventricular arrhythmias, or electrical resets, according to Debra Doud, MD, of the Scripps Clinic in La Jolla, Calif.

[...]

Current guidelines state that MRI is contraindicated in patients with cardiac devices, and Medicare has not reimbursed for MRI scans performed in patients who have a device in place. Doud noted that Medicare has since begun reimbursing for such scans as long as the patient is enrolled in the registry.

Considering the large number of patients with cardiac devices, the aging of the population, the increasing indications for cardiac devices, and the strengths of MRI in examining soft tissue, “the availability of being able to perform these exams in this patient population is extremely important,” Doud said in an interview.

I’m interested for this study to complete. The idea that implantable devices should limit access to such a now important medical technology, especially in this day and age.

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All of the following are afferent tracts through the inferior cerebellar peduncle except?

A. Corticopontocerebellar
B. Vestibulocerebellar
C. Dorsal spinocerebellar
D. Olivocerebellar
E. Reticulocerebellar

Cotrticopontocerebellar

The corticopontocerebellar is a tract of the middle cerebellar peduncle

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There has been somewhat of a recent, increasingly popular, move to promote discussion about the length of medical education. Particularly a discussion of the merits of the fourth year of medical school. Medical school breaks down like this, with some minor variations between schools: You spend the first eighteen months to two years in the classroom and then the third year doing a set of core clinical rotations. The fourth year however is less clearly defined, more amorphous. You do elective clinical rotations. For some students, doing particularly competitive specialties a good chunk of fourth year can be spent doing elective in that specialty, boosting their experience and credentials. And for some students who are not sure, at the start of fourth year, what they want to do the beginning of fourth year provides an opportunity to do electives that help decide what these students want to do for their training. But even in such cases a good chunk of fourth year is essentially spent doing peripheral elective rotations often that are, unwanted by the students themselves, and a waste of time.

It is becoming more than a discussion, but a slow reality, for medical schools to start compressing the education timeline.

In the last five years, at least four schools have initiated or are developing three-year programs:

• Mercer will begin its three-year track at its Savannah campus in June.
• Lake Erie College of Osteopathic Medicine in Erie, Pa., started its program in 2007 and launched a second three-year track in July 2011 for certified physician assistants who want to become doctors.
• Texas Tech University Health Sciences Center School of Medicine in Lubbock began its three-year program with nine students in 2011.
• Louisiana State University School of Medicine is developing a three-year program at its campus in Lafayette. The first class is projected to start in 2014 or 2015, said Sam McClugage, PhD, the medical school’s associate dean for admissions.

Personally, while I enjoyed the free time during fourth year as I prepared for the rigors of residency, essentially all but three months of that year for me were wasted. I did no particularly memorable rotations outside of my neurosurgery ones. I think compressing medical school is a worthwhile idea. It will make becoming a physician more economically viable by reducing the costs of school and it will also make the decision easier as the time committment to a career will be reduced.

Beyond getting rid of fourth year, the first two years can also readily, in many school’s experience, be compressed into eighteen months. Three years is a reasonable goal for medical school. Ideally, as in countries other than the U.S. and Canada, I would love for medical education to be something to pursue as undergraduate work, indepdendent of a complete college degree. It is true most medical schools require only a set of prerequisites and not a formal degree. However, I think there is some bias against students who apply without completing their undergraduate work. That should change. Two years of college, three years of medical school and into resident by 23 or 24 for a traditional student would be an ideal way of training the next generation of physicians.

I think the trend is certainly towards shorter, which is not worse.

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What are the two most common organisms grown in hospital acquired bacteremia?

1. Coag-negative staphylococcus
2. Enterococcus

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