Physician-Assisted Suicide and the Hippocratic Oath

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Physician-assisted suicide is sometimes called physician-assisted death.

Physician-assisted suicide is sometimes called physician-assisted death. Suicide is the more accurate word. It is not voluntary active euthanasia. This means a patient asks a physician to kill him or her with a lethal injection. In physician-assisted suicide, the physician’s act is necessary but not sufficient for the patient’s death, whereas in active euthanasia, the act of the physician is both necessary and sufficient. Active euthanasia is not legal in the United States. Physician-assisted death is legal in 6 states and DC, comprising 20% of US citizens. Opponents of physician-assisted death are fearful that it will lead to voluntary active euthanasia, as has occurred in the Netherlands and in Belgium. There, active euthanasia is done more frequently than physician-assisted-death. Furthermore, in the Netherlands, as in the United States, patients who have chronic and nonterminal diseases, including psychiatric diseases, can receive either physician-assisted death or active euthanasia.

 

In the United States, patients must be terminally ill, which is defined as a fatal disease with prognosis of 6 months or less to live. Do the Dutch value life less than Americans do? Are they less religious? Or do they believe that physicians have a duty to respect patients’ autonomy and the right to determine what constitutes their best outcome? This approach obviously conflicts with the Hippocratic Oath, which simply says do no harm.

 

In many cases, suffering, both physical and emotional, can be reduced by symptom palliation and treatment of depression. These measures would not, however, solve the problems of a patient’s financial worries, pressure from family members, health insurers, and hospitals.

 

It goes without saying that some physicians’ religious beliefs preclude them from participating, and indeed, in all states, participation is voluntary, and the American Medical Association and American College of Physicians are opposed to legalizing physician-assisted death. The American Academy of Neurology is formulating a policy, not yet available.

 

See Neurology, 2017, volume 88, an editorial with lead author Bernat. Also see the wonderful novel by Ian McEwan called Amsterdam. It is also distinguished by being short and safe to drop on your foot.

Long-Term Recovery From Traumatic Brain Injury In Children

Traumatic Brain Injury In Children
Traumatic Brain Injury In Children

A study from Cincinnati Children’s Hospital about traumatic brain injury in children followed these children up to 7 years. For mild to moderate TBI, attentional problems are twice as common. For severe TBI, they are 5 times as common and appear similar to ADHD.

 

Importantly, the home environment modifies these results. Children from disadvantaged or chaotic homes often demonstrate persistent problems, whereas those in optimal environment generally do not.

 

With effective parenting, impairment of skills that can affect social functioning might be avoided. These include information processing speed, inhibition as opposed to impulsivity, and reasoning.

 

The results of this study are important, as more than 630,000 children and teens have traumatic brain injury sufficiently severe to be seen in emergency rooms in the United States each year.

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“Chemobrain” Is Real

Chemobrain is real.

The concept of chemobrain has never been well defined. Are anxiety and depression the cause? Who is more likely to get it? Which treatments increase the risk?

 

A new study tried to answer these questions. It was published in Journal of Clinical Oncology, December 28, 2016, with lead author Janelsins. Five hundred and eighty-one patients with stage I-IIIC breast cancer with mean age of 53 years were tested before and after scheduled chemotherapy and 6 months later. Assessed were cognitive impairment, perceived cognitive abilities, the impact of cognitive impairment on the quality of life, and cognitive impairment perceived by others. Three hundred and sixty-four age-matched people without cancer served as controls. A weakness of the study is that the controls were not people with breast cancer who did not receive chemotherapy.

 

Results were that patients treated with chemotherapy reported significantly more impairment in the 4 measures described above than the controls compared to their prechemotherapy status in the immediate posttreatment period as well as 6 months later. Risk factors were higher baseline anxiety and depression and decreased cognitive reserve. The type of chemotherapy regimen or endocrine therapy or radiation therapy did not influence the scores.

 

Unfortunately, no specific therapy is available for chemobrain. Further, the risk factors identified above are so common that they cannot be used to “stratify” patients regarding a specific treatment.

 

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Your Neurologist in Orange County.
Your Neurologist in Orange County.

 

The Most Important Sense?

The blind would argue that hearing is more important than vision. The deaf may say otherwise. But what it’s like not to have a sense of touch?

Touch sense
What it’s like not to have a sense of touch?

Neurologists often see patients who have profound proprioceptive deficits in their arms and legs. The usual causes are chemotherapy induced neuropathy or autoimmune acute sensory neuronopathy, which may or may not be associated with a malignancy. Neuronopathy syndrome can be devastating. We can empathize with these patients, understand how disabling their disorder is, but we usually do not ask what it’s like to live without touch.

 

Jonathan Cole recently explored all of this in a book titled “Losing Touch: A Man Without His Body.” It was written in collaboration with Ian Waterman, who contracted acute sensory neuronopathy, presumed to be viral, in 1971 at the age of 19 and never recovered. He noted that for the first 12 years of his illness, no medical professional asked how it felt. One must use vision to compensate for the loss of sensory feedback. This can be mentally exhausting. For most people, walking is effortless and a wonderful time to think and reflect. Ian Waterman says, “I don’t get lost in walking. I concentrate all the way through. If I daydream, I would fall over.” If he moves his arm, he is able to return at the original position in only one of two ways: Looking at or finding the relatively warm spot where his arm was initially resting. He can feel hot and cold but is unaware of the position of his limbs. He must sleep with the lights on, and in a power outage, he is completely helpless.

 

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Your Neurologist in Orange County.
Your Neurologist in Orange County.

Still Another Reason To Lose Weight – Migraine

Obesity has been recognized for many years to be a risk factor for cardiovascular disease and stroke. More recent studies have concluded that obesity in the teens increases the risk of developing multiple sclerosis.

Another reason to lose weight - Migraine.
Another reason to lose weight – Migraine.

Migraine now joins this list. Obesity is an important risk factor in converting from episodic migraine, meaning less than 15 headache days a month, to chronic migraine, meaning 15 or more headache days a month. Patients with chronic migraine have much more disability, utilize medical resources more, have a poorer quality of life, are more difficult to treat, and have higher rates of depression.

 

Why this should be so probably relates to the fact that fat cells are proinflammatory, secreting adipokines and other deleterious cytokines. Other risk factors in converting episodic to chronic migraine include inadequate treatment of individual attacks of migraine, lower socioeconomic status, smoking, and snoring. Likely, the increased risk with snoring relates to obesity.

 

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Your Neurologist in Orange County.

 

 

 

 

Clinical Trials – A Cautionary Tale

clinical trilas fullerton neurology center
Clinical Trials Tales

This was big news several months ago. A phase I drug Clinical Trials in France resulted in a death in 1 healthy volunteer and neurological deficits in 3 others. The details were published in the New England Journal of Medicine, November 3, 2016. The drug was considered to be an analgesic, anti-inflammatory, and possibly effective for neuropathic pain. It targeted the endocannabinoid system. The manufacturer was Bial, a pharmaceutical company based in Portugal.

 

The medication seemed safe in animal testing, and this led to a phase I trial, which is designed to test safety and not efficacy in humans. Bial went ahead with the study even though other drug companies had tested molecules that were similar and seemed ineffective.

 

This trial started in January 2016, with 8 volunteers. Two received placebo and six a 50 mg dose of the medication. All 6 of the treated patients were hospitalized with adverse effects, starting on the fifth day of drug administration. Nevertheless, the researchers continued to treat the other patients.

 

The toxicity was neurological. MRI showed hyperintense lesions, mainly in the brainstem and hippocampal areas.

 

Lessons are obvious. Researchers should know when to stop. The dosing should have been staggered rather than all patients being treated at the same time.

 

Volunteers in phase I trials have no possibility of benefit from the trial, unlike patients in phase II and phase III trials. They do so largely because they are being compensated. Several years ago The New Yorker published an article explaining that there is a group of young men for whom clinical trials are their livelihood. Phase I trials are essential in development of medications. They are ethical as long as there is true informed consent and appropriate safeguards are in place.

 

See Neurology Today, December 8, 2016.

 

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How Often Is Syncope Caused By Pulmonary Embolism?

According to a study in the October 20, 2016, issue of the New England Journal of Medicine, surprisingly so, specifically 1 out of every 6 patients admitted for first-time syncope. It was found in 24% of patients who presented with syncope when no other cause was found and even 13% among those who had another potential cause.

 

Keep in mind that in the study of 560 patients most were older than 75 years. They were screened with a D-dimer blood test, and the diagnosis was confirmed with a CT angiogram of the chest or V/Q scanning.

 

Patients were identified at 11 hospitals in Italy over a 4-year period. Lead author is Paolo Prandoni. Comments by several experts varied from great skepticism to a feeling of being validated for similarly held beliefs. If the results can be validated, they will likely change clinical practice for elderly patients with syncope. Benefits of anticoagulation would outweigh risks of CT angiography.

 

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Fullerton, Neurology, Headache, Treatment, Center
Fullerton Neurology and Headache Center

 

 

Supplements May Do More Harm Than Good

An important analysis termed “Trends in Dietary Supplement Use Among US Adults From 1999-2012” by lead author Kantor was published in JAMA, October 11, 2016. An editorial was written by Dr P.A. Cohen.

FDA-Approved Anti-Epileptic Drugs For Monotherapy
Supplements may do more harm than good.

The main finding is that about 50% of adults in the United States used supplements within the last 30 days, and this proportion was unchanged from 1999-2000 compared to 2011-2012. This is despite the fact that multiple studies have yielded mainly disappointing results about potential health benefits, and there is more and more evidence of harm.

 

The Dietary Supplement Health and Education Act of 1994 is an important reason for continued widespread use. This act states that supplements are presumed to be safe until the FDA detects evidence of harm, which usually occurs only after extensive use and exposure to many consumers. For example, supplements containing Ephedra were linked to serious adverse effects, including myocardial infarctions, seizures, strokes, sudden deaths. Beta-carotene supplements were found to actually increase the risk of lung cancer among smokers. The National Institutes of Health has invested 250 to 300 million dollars per year in dietary supplement research. They found that echinacea does not treat the common cold, St. John’s wort does not treat major depression, vitamin E does not prevent prostate cancer, glucosamine and chondroitin do not treat arthritis, and that ginkgo biloba does not improve cognition.

 

Use of some supplements can be justified, including treatment of vitamin and mineral deficiencies, used for early age-related macular degeneration, vitamin D for multiple sclerosis, and perhaps probiotics for various disorders.

 

Why do consumers continue this widespread use given this knowledge? Perhaps they are not aware of these negative results. Perhaps they do not have faith in the scientific process and in fact believe there is a conspiracy by the “established” healthcare system. Most researchers believe that perceived benefits are largely placebo effects.

 

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A Blood-Based Biomarker May Be Able To Predict Alzheimer’s Disease

A Blood-Based Biomarker May Be Able To Predict Alzheimer’s Disease
A recent study describes a simple blood-based signature that reflects neocortical beta-amyloid burden.

Detecting Alzheimer’s disease by a relatively inexpensive blood test could greatly reduce the cost of population screening and recruitment for clinical trials. This is especially relevant given the hope that monoclonal antibodies directed at amyloid prove to modify the disease course.

 

A recent study published in Neurology, September 13, 2016, lead author Burnham, describes a simple blood-based signature that reflects neocortical beta-amyloid burden. It is a profile of 4 individual blood makers, specifically amyloid beta 1-42, CXCL-13, IgM-1, IL-17, PPY, and VCAM-1. Individually, they did not have significant predictive power but did in combination.

 

Specifically, the 12% of healthy controls that had high estimated beta-amyloid burden progressed in comparison to the 5% who had a low burden. Forty percent of subjects with mild cognitive impairment with a high burden progressed in comparison to 5% of those with MCI who did not. These ratios are similar to those utilizing Pittsburgh compound B-PET scan. They outperformed the cerebrospinal fluid amyloid-tau profile, which obviously requires an invasive lumbar puncture, as well as outperformed in measures of hippocampal volume on brain MRI. Keep in mind that there was marked overlap of confidence intervals in analyzing all of these markers.

 

If findings are confirmed in a large group of patients, this profile would likely come into widespread use. It appears that there are commercially available kits to measure each component.

 

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Race And Ethnicity In Multiple Sclerosis

Race and ethnicity are not the same. People of the same race share distinctive physical traits and ancestry. Ethnicity, on the other hand, is a shared experience, specifically cultural. DNA varies by less than 0.1% in any two people chosen at random. Further, at least 85% of the 350,000 known genes are present in all people.

 

African Americans in fact have higher incidence of MS than whites / Caucasians. Hispanic Americans seem to have lower incidence. People who migrate from a high risk to a low risk area in first two decades of life carry the high risk. This is more likely secondary to environmental factors, specifically vitamin D, and viral infections rather than genetic factors. Another important risk factor is obesity, especially in adolescent girls.

 

African Americans are older at onset and have a more severe course with resultant greater disability.

 

A Hispanic person can be of any race. In Hispanic Americans, age of onset appears to be younger than white but neuromyelitis optica much higher, with a prevalence of 19%, comparable to those in Asians. In whites, this disorder is seen in only 2% to 3%. Why should this be so? Likely, there is Asian ancestry in Hispanics from Central and South America.

 

Treatment of MS is greatly affected by race and ethnicity. African Americans are probably less responsive to interferons than whites. On the other hand, Tysabri may be effective in this group, as in Hispanic patients. B-cell therapies may be especially beneficial to African Americans because they have higher IgG index in their cerebrospinal fluid than whites. This, however, has never been tested adequately.

 

Access to healthcare is less in African Americans and Hispanics, especially low-income groups. About a third of patients in MS who are covered by Medicaid / Medi-Cal had never seen an MS specialist and were not receiving treatment-modifying drugs. Factors include mistrust of the healthcare delivery system (recall the Tuskegee syphilis study), less access to health insurance, greater belief in natural remedies, or as language and cultural barriers.

 

Tailoring treatment to a diverse group is a poorly met challenge at this time.

 

See Science of MS Management, summer 2016.

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