Tuesday, March 24, 2015

Quality of life

A colleague was once to take part in a "care" conference for a quadriplegic man who had had one hospitalization after another, evidently due to frequent problems with infection.  Some of the participants were clearly going to take the "enough is enough" stance.  So he asked his colleagues to rate their own quality of life on a 1-10 scale.  A resident or fellow gave himself a 6.  My colleague found this puzzling; he was a physician, a married man, he was intelligent and in good health.  Why a 6?  Others gave themselves somewhat higher scores.  When he asked the quadriplegic man the same question, his answer was 9.  He took off one point only because of his current illness

Think of the many possibilities

Home transcranial stimulation
The Smart Pill
Easy to Swallow: The Smart Pill
A tiny ingestible sensor by Proteus Digital Health "is a game changer for medication compliance," David Lee Scher, MD, told Medscape. "The sensor, which costs less than a penny, is placed on a pill. It gets activated by stomach juices when it's ingested. A digital signal is then sent to a Band-Aid®–like monitor worn on the patient's arm." The sensor records when the medication is ingested, as well as the patient's heart rate, body temperature and position, and rest and activity patterns. "You view these data in the context of how effective a given pill is," Dr Scher says. "For example, if someone is taking a heart medicine that you want to decrease their heart rate, you can tell whether the rate is slow with activity because the medication is working or because the patient is inactive." The data are wirelessly transmitted to a smartphone app, which then sends it to a provider, caregiver, or family member. "Patients receive text message reminders if they don't take their pills," Dr Scher adds.

A BraiNet® for every patient.
Anytime. Anywhere.

EEG needs to be available to patients 24 hours per day 7 days per week. Waiting until the next "work day" to do the EEG is not fast enough for good patient management. Often, EEG is not available around the clock, 7 days/week and even when there is an "on call tech" the time it takes to get to the hospital and perform the procedure can take several hours. The BraiNet® makes EEG set up possible for a healthcare professional "on site" to apply the electrodes.

The BraiNet® is designed to be used for any EEG – the "stat" EEG in the ICU or ER or other area of the hospital as well as for the routine EEG in the Neurodiagnostic Lab or Neurofeedback office. It is ideal for long-term monitoring and can stay on the patients head for several days – in the epilepsy monitoring unit (EMU) – in any intensive care unit (ICU/NICU/PICU/NNCU) or for ambulatory EEG (AEEG). Our NEW Sleep BraiNet® is perfect for overnight polysomnography in the sleep lab or in the patient's home.

All BraiNet® Templates slip on the head in seconds.

Imagine your patients having access to BraiNet for home use! Lots of viewable EEG for all those ambiguous episodes that never seem to happen in the monitoring unit.

A colleague wrote in response to the above: 
Hello Galen! Possibilities, indeed. Some of them perhaps even good or neutral.

I remember once a mentor paying rapt (but supposedly platonic) attention to an ambulatory EEG that happened to overlap a couple's intercourse. As I recall, that segment exhibited lots of muscle and movement artifact but no obvious alteration in the background rhythm, providing anecdotal support to our concept that sex may be largely a subcortical activity. Duh.

Thursday, March 19, 2015


"Kirsch says it’s not quite correct for reporters to interpret his work by saying that antidepressants don’t work. It’s that he’s concluded they don’t work by rebalancing serotonin. Instead, they appear to work primarily through the placebo effect."

See:  http://www.forbes.com/sites/fayeflam/2015/03/18/a-psychologist-explains-how-not-to-be-fooled-by-the-placebo-effect/

Thursday, March 12, 2015

A life worth living

In the past, I sent the following to the child-neuro listserve: 
I saw a 1.7 kg 36 weeks gestation female neonate, now 3 weeks of age, with Wolf-Hirschhorn syndrome. She was alert and energetic. After her diagnosis was established at 2 weeks of age, her parents, having received appropriate information regarding Wolf-Hirschhorn syndrome, made the decision that a life with Wolf-Hirschhorn syndrome is not a life worth living.  After ethics consultation, a decision has been made to allow her to feed orally as much as she can, but to do no more. To date, she feeds modestly, but does not experience overt dysphagia. Presumably, oral feeding will be inadequate and inanition will begin with palliative pomp and circumstance. I am revulsed by this situation.
My consultation note indicates, "As noted above, the parents have decided regarding their daughter, that a life with Wolf-Hirchhorn syndrome is not a life worth living (slightly edited)."
More recently, the parents have considered further pediatric neurology evaluation for their daughter.  Mother requested that this be by a different provider.

Lethal parasomnia

Credit to Tim Feyma for this one.


Sunday, March 8, 2015

Why is diagnosing brain death so confusing?

See:  http://yaledailynews.com/blog/2015/03/03/hospitals-should-adopt-uniform-brain-death-standards-article-argues/ 

Ghoshal S, Greer DM. Why is diagnosing brain death so confusing? Curr Opin
Crit Care. 2015 Apr;21(2):107-12.

Although detailed practice parameters have been developed to help guide physicians in brain death determination, guidelines based on these parameters widely vary. The recent case of Jahi McMath not only highlights social misconceptions but also serves as a call to action to decrease medical variability and confusion regarding brain death determination. This review discusses common sources of variations in brain death determination - we divide these sources into before, during, and after brain death declaration.
We use four key studies to elucidate variable practice in brain death determination. Poor training of examiners and patient qualifications for brain death examination prior to testing, incomplete apnea testing, repeat examinations during testing, and the sometimes unjustified use of ancillary testing are highlighted as main areas for improvement. Improved physician training and certification, as well as better standardization of hospital protocols, may be answers to more universal practice.
Diagnosing brain death is confusing because of numerous variations in practice, but this variation can be improved. Improved and standardized physician training can help create a formal certification process for examiners and help create uniformity in brain death determination. National standards will also help decrease variability of practice.

Tuesday, March 3, 2015

Minnesota medical marijuana

Can you imagine.  A patient is diagnosed with epilepsy.  The patient is then sent to a pharmacist to decide whether the patient should get valproate, carbamazepine, primidone, etc.  A patient is diagnosed with hypertension.  The patient is then sent to a pharmacist to decide whether furosemide, hydrochlorothiazide, etc.  Has the world gone nuts? 

From: Timothy Feyma
Sent: Monday, March 02, 2015 7:32 AM
Subject: Minnesota Medical Cannabis 


At the Epilepsy Foundation meeting over the weekend, we were treated to a discussion regarding the particulars known to date about the plan to allow medical access to cannabis in MN.  Thomas Arneson MD (http://www.health.state.mn.us/news/pressrel/2014/cannabis100214.html ) led the discussion. I would like to share a very brief summary of what was discussed.  This will likely be redundant in ways to some, but the specifics of how a prescription gets filled should be interesting to most.  As most are aware, the state plans to have access available by 7/1/15 for patients!

The Minnesota law allows for medical use only of cannabis.  Recreational use is not allowed under the law.  There will be no smoked form allowed.  A liquid, oil, and seemingly vaporized form will be available. 

Conditions that will qualify include:

- Cancer

- Glaucoma

- HIV and AIDS with active symptomatic disease

- Tourette Syndrome


- Seizures ("including those characteristic of epilepsy")

- Muscle spasms possible due to multiple sclerosis

- Crohn's

- Terminal illnesses with life expectancy <1 year and pain/n/v/cachexia 

These conditions were decided upon as allowable based upon legislative decision.  For many of the issues, a parent group or lobbying group pushed for inclusion.  It is not clear that physicians helped to devise the list. 

As for producers, there are two approved growers made up of Life line Labs (http://www.leaflinelabs.com/ ) and Minnesota Medical Solutions (http://minnesotamedicalsolutions.com/ ).  There will be 4 distribution centers opened.  There will be no reciprocity between our distribution centers and other states allowing cannabis prescriptions.

As for the process of obtaining medical cannabis, patients will have to follow this algorithm:

1) A patient must visit a certified health care provider (NP, PA, MD, DO)  to see if they will qualify for access given defined definitions of qualifying criteria. Health care provider requests for certification will begin in a few months and entail state run training yet to be detailed fully, anyone can volunteer and no additional DEA certification needed. Physicians will be re-verified on an annual basis.  The recertification process is aimed to try and ensure 90% of cannabis approvals are not completed by a small group of physicians that allow free access with minimal medical investigation, understood?

2) A cannabis certified health care practitioner will certify that a patient meets criteria 

3) The patient then submits an application with fee to the state after they are certified. 

4) The state reviews the documents and then approves the patient for cannabis prescription 

5) The patient then goes to a dispensary and consults with a pharmacist to decide which formulation of cannabis they will receive.  Some will be given strains higher in THC, while others will receive strains comparatively higher in CBD depending on the disease and pharmacist discretion.  Only 30 day supplies can be filled at a time and each return visit to obtain more from the pharmacy will include a review of med benefits / side effects to perform a degree of clinical surveillance. 

Medicaid and Medicare won't reimburse costs which will likely be $100's per month, but a patient assistance program is being developed. 

There are many more details to be defined, but these are the basics presented over the weekend.