Monday, April 24, 2017

Sometimes It’s Better Not To Know





“I don’t know if I’m looking forward to being 98.”

My 97-year-old patient revealed this to me during our first meeting in my clinic examination room.

He had just moved to an assisted living facility in Cleveland to be near his son and daughter-in-law, who also sat in the room.

They were quiet as they watched us interact.

“What do you mean?” I asked.

He rested both forearms on the high arms of his wheelchair, which caused his shoulders to hunch and gave the impression that he was about to spring into action.

He spoke deliberately, choosing his words carefully. His eyes were rheumy but sharply focused, commanding my attention. I got the impression he was used to being in charge.

“I don’t want to end up… you know, blotto,” he said, quickly pantomiming a person slouched to one side of his chair, mouth open.

His son and daughter-in-law glanced at each other and then at me as they arched their eyebrows in surprise.

“Why do you think that might happen?” I asked.

“Because of my medical condition, or whatever you’re going to recommend I treat it with,” he answered, matter-of-factly.


He had abnormal blood counts, but no established diagnosis.

He was anemic, requiring a blood transfusion every two months, just often enough to be a nuisance for anybody.

His platelets were low, but not low enough to put him at risk for bleeding or to require platelet transfusions.

And his white blood cell count was decreased, though again, not enough to render him prone to infections.

I had already pulled up his labs on the computer and had walked him through the results.

Given his age and these laboratory values, it seemed likely that he had a condition called myelodysplastic syndromes, a group of cancers in which the bone marrow fails to make enough healthy blood cells.

The only way to be sure of the diagnosis was to perform a bone marrow biopsy. For that, we would have to stick a needle into the flat part of his pelvis, just below his spine, and remove a sample of marrow from deep within the bone, to be analyzed by a pathologist.

Bone marrow biopsies have been used to evaluate diseases of the blood for over a century.

The contemporary biopsy needle, invented by the Iranian hematologist Dr. Khosrow Jamshidi in 1973, is almost comically long, long enough to reach the bone that is sometimes buried deep beneath the skin. It looks like a prop for a movie mad scientist.

A few years ago, I probably forfeited any “parent of the year aspirations I may have had by pulling one out at my son’s elementary school during a lesson to his classmates on how blood was made. Not surprisingly, they recoiled at the sight of it.

Patients can have the same reaction. An alternative to the needle is a drill that was shown in one study to be just as effective at obtaining bone marrow specimens.

Though some patients have told me they feel less pain with the drill, others say it gives them even more anxiety, telling me it evokes the sounds they normally hear emanating from the dentist’s office.

I wondered whether I really needed to make my patient go through this procedure just to establish his diagnosis.

His blood counts had been low for some time, implying a chronic condition that didn’t appear to be worsening anytime soon.

Even if I did diagnose a bone marrow cancer such as myelodysplastic syndromes, I wouldn’t treat it, as the therapies I might suggest would necessitate even more frequent trips to the doctor’s office for him and wouldn’t fix the underlying problem.

More important, he had already told me that he didn’t want to be incapacitated by his disease, or by its treatment. He valued his quality of life. I worried that if we went down this path, I might make that worse.

“To really figure out what’s going on with your blood counts, we would have to put you through a bone marrow biopsy…” I started to say.

He waved his hand impatiently, cutting me off.

“I don’t want it,” he said. “I don’t want to go through it.”

I met his gaze for a few seconds and nodded in agreement, as did his son.

“I’m O.K. not knowing if you’re O.K. not knowing,” I told him. This time he nodded.

“See you back in a month,” he replied, finishing the doctor visit. He had put an end to our encounter. On his terms.

Source:     NY Times

‘Pacemaker’ for the Brain Can Help Memory, Study Finds



The right hemisphere of a study participant’s brain. The electrodes are overlaid in blue and the one researchers targeted for stimulation is toward the right, highlighted in yellow. CreditYoussef Ezzyat

 
Well-timed pulses from electrodes implanted in the brain can enhance memory in some people, scientists reported on Thursday, in the most rigorous demonstration to date of how a pacemaker-like approach might help reduce symptoms of dementia, head injuries and other conditions.

The report is the result of decades of work decoding brain signals, helped along in recent years by large Department of Defense grants intended to develop novel treatments for people with traumatic brain injuries, a signature wound of the Iraq and Afghanistan wars.

The research, led by a team at the University of Pennsylvania, is published in the journal Current Biology.

Previous attempts to stimulate human memory with implanted electrodes had produced mixed results:

Some experiments seemed to sharpen memory, but others muddled it. The new paper resolves this confusion by demonstrating that the timing of the stimulation is crucial.

Zapping memory areas when they are functioning poorly improves the brain’s encoding of new information. But doing so when those areas are operating well — as they do for stretches of the day in most everyone, including those with deficits — impairs the process.

“We all have good days and bad days, times when we’re foggy, or when we’re sharp,” said Michael Kahana, who with Youssef Ezzyat led the research team. “We found that jostling the system when it’s in a low-functioning state can jump it to a high-functioning one.”
Researchers cautioned that implantation is a delicate procedure and that the reported improvements may not apply broadly.

The study was of epilepsy patients; scientists still have much work to do to determine whether this approach has the same potential in people with other conditions, and if so how best to apply it.

But in establishing the importance of timing, the field seems to have turned a corner, experts said.

Experts said the new report gives scientists a needed blueprint for so-called closed-loop cognitive stimulation: implanted electrodes that both monitor the functional state of memory areas, moment to moment, and deliver pulses only in the very microseconds when they’re helpful.

The hope is that such sensitive, timed implants could bolster thinking and memory in a range of conditions, including Alzheimer’s and other dementias, as well as deficits from brain injury.

“The cool thing about this paper is that they showed why stimulation works in some conditions, and why it doesn’t in others,” said Bradley Voytek, an assistant professor of cognitive science and neuroscience at the University of California, San Diego, who was not involved in the work. “It gives us a blueprint for moving forward.”

Justin Sanchez, director of the biotechnologies office at the Pentagon’s Defense Advanced Research Projects Agency, which has doled out some $77 million to advance cognitive stimulation, said: “To me, this paper is one of the breakthrough moments on this problem, to find locations in the brain to stimulate in this particular way to boost performance.”

The new study is the latest chapter in an extraordinary, decades-long collaboration among cognitive scientists, brain surgeons and people with severe epilepsy being evaluated for an operation.

The preoperative “evaluation” is a fishing expedition of sorts, in which doctors sink an array of electrodes through the top of the skull and wait for a seizure to occur, to see whether it’s operable.

Many of the electrodes sit in or near memory areas, and the wait can take weeks in the hospital.

Cognitive scientists use this opportunity, with patients’ consent, to present memory tests and take recordings.

This approach — called direct neural recording, and piggybacking entirely on the clinical placement of the electrodes — has become the leading edge of research into the biology of human memory.

This study used data from 150 patients, and had 20 collaborators from institutions around the country, including Emory University, the University of Washington, the Mayo Clinic and the University of California, San Francisco.

In a series of experiments, the researchers had patients memorize lists of words and later, after a distraction, asked them to freely recall as many of the words as they could.

All the while, the scientists monitored a handful of “hot spots” in the brain which, previous work had shown, were strongly related to memory encoding.

Before the stimulation tests, the team determined the precise settings for each patient’s high- and low-functioning states.

Each participant carried out the word-memorization tests repeatedly, with different words every time; some lists were memorized with brain stimulation, and other lists with no stimulation, which served as a control.

The authors then examined memory performance based on whether stimulation arrived during low- compared with high-functioning brain states.

The team then statistically analyzed the results and found that people scored slightly higher than usual on words when stimulation arrived during a low or foggy state — and worse, when the pulse arrived in a high state. “The average enhancement effect was about 12 to 13 percent,” Dr. Kahana said. “And when stimulation arrived in a good state, the average was about 15 to 20 percent worse than usual.”

Dr. Doris Greenblatt, a psychiatrist who participated in the trial at Emory, said she sought the surgery because her epilepsy had long caused memory problems. “Each seizure I had tore at the fabric of memory, and it was as if my memories weren’t attached to anything,” Dr. Greenblatt said.

She agreed to the memory testing for the study. “It was a little humiliating, to be honest,” she said of the testing. “I would remember one or two items from a list of objects in a kitchen, for instance, then think, ‘Oh no, what else was there?’ ”

She said she had no idea whether the electrodes in her brain were stimulating or not. “All I can say is that it was exhausting, and I worried about how I was doing.” She had the surgery for her epilepsy a year ago, with Dr. Robert Gross, and has not had a seizure since; her memory is also improved, she said.

The timed component in this study represented a clear break from previous approaches. In 2014 the Defense Department had funded another group testing stimulation in epilepsy patients — directly to a brain area near the hippocampus, which is crucial to memory formation.

That approach did not take into account brain states, the high and low function, and it was not successful.

“To me,” said Dr. Voytek, the new approach “is a clear demarcation that the era of dumb stimulators is over.”

Source:     NY Times

Friday, April 7, 2017

April 7 - World Health Day: Depression, Let's Talk


Every year on the 7th of April, the World Health Day is celebrated.

Each year comes with its own theme and this year (2017) the theme is "Depression - Let's Talk"


 And this theme could not have been more apt, especially in Nigeria where the suicide rate in the past one month has jumped to 55% from a mere 2% before then.

What is Depression

Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings, and sense of well-being.

People with a depressed mood can feel 

- sad
- hopeless
- helpless
- guilty
- irritable
- angry
- ashamed
- or restless.

They may
- lose interest in activities that were once pleasurable
- experience loss of appetite or overeating,
- have problems concentrating, remembering details or making decisions,
- experience relationship difficulties
- and may contemplate, attempt or commit suicide. 

aches
pains
digestive problems
or reduced energy may also be present

Depressed mood is a feature of some psychiatric syndromes such as major depressive disorder, but it may also be a normal temporary reaction to life events such as bereavement, a symptom of some bodily ailments or a side effect of some drugs and medical treatments.

A DSM diagnosis distinguishes an episode (or 'state') of depression from the habitual (or 'trait') depressive symptoms someone can experience as part of their personality.

People who pursue long term courses tend to have more symptoms of depression than those who pursue short term courses e.g Medical Students

People who are constantly under stress and pressure tend to be more depressed than the general population e.g. Medical Doctors

Blacks in the USA tend to be more depressed than Whites

Women tend to be more depressed than men but men tend to have more suicide tendencies as a result of depression then women

Causes:

1.      Life events

Adversity in childhood, such as bereavement, neglect, mental abuse, physical abuse, sexual abuse, and unequal parental treatment of siblings can contribute to depression in adulthood.

Childhood physical or sexual abuse in particular significantly correlates with the likelihood of experiencing depression over the life course.

Life events and changes that may precipitate depressed mood include

- financial difficulties
- unemployment
- work stress
- a medical diagnosis (cancer, HIV, etc.)
-bullying
- loss of a loved one
- rape
- relationship troubles
- jealousy
- separation

Adolescents may be especially prone to experiencing depressed mood following social rejection, peer pressure and bullying.

2.      Personality

High scores on the personality domain neuroticism make the development of depressive symptoms as well as all kinds of depression diagnoses more likely, and depression is associated with low extraversion.

3.      Medical treatments

Depression may also be iatrogenic (the result of healthcare), such as drug induced depression.

Therapies associated with depression include interferon therapy, beta-blockers, Isotretinoin, contraceptives, cardiac agents, anticonvulsants, antimigraine drugs, antipsychotics, and hormonal agents such as gonadotropin-releasing hormone agonist.

4.      Substance-induced

Several drugs of abuse can cause or exacerbate depression, whether in intoxication, withdrawal, and from chronic use.

These include

sedatives (including prescription benzodiazepines)
and illicit drugs like heroin),
stimulants (such as cocaine and amphetamines)

5.      Non-psychiatric illnesses

Depressed mood can be the result of a number of infectious diseases, 
neurological conditions 

and physiological problems
including hypoandrogenism (in men)
and cancer.

6.      Psychiatric syndromes

A number of psychiatric syndromes feature depressed mood as a main symptom.

The mood disorders are a group of disorders considered to be primary disturbances of mood.

These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode.

Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated mood, cognition and energy levels, but may also involve one or more episodes of depression.

When the course of depressive episodes follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be described as a seasonal affective disorder.

Outside the mood disorders: borderline personality disorder often features an extremely intense depressive mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioral symptoms are significant but do not meet the criteria for a major depressive episode: and post traumatic stress disorder, an anxiety disorder that sometimes follows trauma, is commonly accompanied by depressed mood.

Depression is sometimes associated with substance use disorder.

Both legal and illegal drugs can cause substance use disorder.

Assessment

Mental Health Providers use questionnaires and check lists to detect and assess the severity of depression

Treatment

Depressed mood may not require professional treatment, and may be a normal temporary reaction to life events, a symptom of some medical condition, or a side effect of some drugs or medical treatments.

A prolonged depressed mood, especially in combination with other symptoms, may lead to a diagnosis of a psychiatric or medical condition which may benefit from treatment.

Different sub-divisions of depression have different treatment approaches.

In the United States, it has been estimated that two thirds of people with depression do not actively seek treatment.

The World Health Organisation (WHO) has predicted that by 2030, depression will account for the highest level of disability accorded any physical or mental disorder in the world (WHO, 2008).

Source:     Wikipedia