Please take five minutes...

and follow along this gorgeous piece of music!! so beautifully written, every note is perfectly placed. perfectly timed

brain repair after stroke

Here is a very interesting grand rounds at UCSD about brain repair after stroke


principles of brain repair from grand rounds

1. brain repair is time sensitive - stroke physiology is a sequence of cellular events, have to time treatments accordingly (sequence growth factors, or if give NMDA blockers early kill recovery)
2. brain repair is experience dependent - need exposure to the lost function, task specific rehabilitation + repitition that leads to increase in behavioral recovery
3. have to optimize patient selection type, many therapies are $$, and there are many variables that modify outcome (age, handedness, genetics, medications, timing of events...)
4.value of domain specific endpoints - less global endpoints may be needed to understand repair issues because global recovery may be too broad to measure whats working

List of all neuro programs

This link was taken from student doctor network, it is a google map with every neurology program listed, nice to get a bird's eye view. Thanks to Dandelionwine for making it

original link

American Academy of Neurology practice bulletin regarding prescription of "neuroenhancement" in well adults

practice of medicine traditional goals or obligations

1. prevent and diagnose disease or injury

2. cure/treat the disease or injury

3. reduce suffering

4. educate

5. help patients die in peace and dignity

6. reassure the well

ethically more complicated behaviors

1. participating in executions

2. participating in interrogations

i add these

3. use of medicine as a direct coercive force

4. research and experimentation with complicated ethical questions

5. profit motivated medicine

role is divided into

core domain

-these are obligatory

secondary domain

-considered ethically permissible

AAN describes prescribing medication for the purpose of neuroenhancement at best to fall into the category of secondary domain and at worst ethically impermissible

reasons prescribing for enhancement may be considered permissible

-improves well being (similarly to plastic surgery)

-benefits > risks

issues worth considering before prescribing-

-prescriptions will be "off-label" until medications are specifically designed and approved for the purpose of enhancement

-"off label" use should be based on

1. plausible rationale

2. based on available evidence

3. consistent w/standard of care (unfortunately very little clinical evidence to inform this use)

-before prescribing must inform patient

1. not FDA approved for this use

2. side effects

3. risks (short term and long term)

4. alternatives to not taking the medication

Ethical considerations before prescribing

-Thorough assessment of patient

e.g. - just because a patient is requesting neuroenhancement does not mean they are well, have to do a full work up for existing pathology. the request itself may be evidence of existing condition or the patient's interpretation of their symptoms

thus the request for neuroenhancement is still a "chief complaint"

-Beneficence and nonmaleficence

the putative benefits of enhancement (increased competitiveness, intelligence etc) are difficult to quantify and thus difficult to compare to the risks of treatment. thus clearly stating treatment goals will help the physician

-Distributive justice

drugs unlikely to be covered by third party payers, will remain in the domain of the rich, so consider the effects of limited access on society.

-conflict of interest

"avoid financial arrangements that influence patient care", inform patients of conflict of interest (stock, financial incentives etc...)

-Liability

courts will probably analyze injury claims for neuroenhancement similarly as they do other cosmetic procedures - courts may or may not be more aggressive

case: Zalazar v Vercimack - expert witness testimony is not needed to prove causation for cases involving informed consent elective medical procedures because "there is no medical issue that requires explanation for the jury".

refrain from guaranteeing an outcome

The following are a couple of selected key practice guidelines put forth by the AAN

1. prescriptions of meds for "neuroenhancement" are not legally obligatory, not prohibited and legally permissible in the US

2. prescriptions of meds for "neuroenhancment" are not ethically obligatory or prohibited and therefore are permissible

3. there is limited evidence of efficacy and safety info for these agents

4. liability is uncertain and may favor the plaintiff

5. refusal to prescribe is both ethically and legally permissible

6. informed consent applies for the prescription of "neuroenhancing" meds

7. ending prescriptions for "neuroenhancement" after they have been initiated is both legally and ethically permissible

Reference:

Larriviere D, Williams M, Rizzo M, Bonnie R. "Responding to requests from adult patients for neuroenhancments, Guidance of the Ethics, Law and Humanities Committee" 2009. American Academy of Neurology. www.neurology.org

The macula speaks softly but carries a big stick.

In the OR today I saw a vitrectomy- the removal of the vitreous fluid from the posterior chamber of the eye, a surgical treatment for retinal detachment. As I observed this surgery and saw the macula live and very clearly for the first time something hit me (not a scalpel). It is surprising how humble a structure the macula is, especially considering how powerful it is. It is a square centimeter or so (no bigger than your pinky nail) but it receives all the light from the world that will eventually be processed into "sight". Without the macula one is essentially blind (peripheral vision will be spared, but try crossing the street using only your peripheral vision). It is really so small and so simple appearing, at least grossly, it almost looks indistinguishable any square centimeter of tissue, but it is oh so much more talented! As I was looking at this through the ophthalmologist lens, I found it amazing to consider that this little bit of mild mannered tissue catches light! Not only that it transforms it into a patterned electrical signal. How marvelous! This little bit, this tiny tiny bit of tissue can even sort wavelengths of light, weigh and average the intensity of the inputs and send it off in a ordered pattern that will eventually be critical for survival. Think about what that means in the most basic sense, electromagnetic fields can be sensed by carbon based tissues. How gorgeous! Even more so to consider that this little piece tissue came about organically, spontaneously. It is fun to speculate how this came about, why should sensing light matter to ocean life (where photoreceptors have been presumed to originate)? Theories abound, but the truth remains unknown. So it is that a structure appearing so small to the naked eye makes it possible to view the ends of the cosmos. There is lesson in there somewhere...

ophtho notes last day

glaucoma (cannot be prevented, but goal is to prevent losing eyesight within their lifetime)

epi

2nd most common cause of blindness in world (cataract #1)

asymptomatic!! like htn

glaucoma - no longer just increased intraocular pressure, need nerve damage now for definition

look for donut hole in optic nerve

sensitivity of IOP w/pressure of >21mmHg is 50%!!!!

narrow angle

pressure lowering drug - acetazolamide, timolol

laser iridotomy - putting a hole in the iris to assist in aqueous flow

open angle treatment

-prostaglandins, beta blocker, alpha agonist.

-drainage shunts can be placed

exfoliative glaucoma is when the iris sheds cells and pigment (during pupillary constriction/dilation) and blockes aqueous outflow.

family history

sibling odds ration 3.7

parents odds ratio 2.2

nasal field defect can clue you in to glaucoma because very rare to find neurological cause of nasal field defect