Living with Motor Neurone Disease: “Where there is life, there is hope”

 There's an old Yiddish saying that goes:  "Listen to the patient, not the doctor."

In The House of God we are given some laws.  Law IV is:

THE PATIENT IS THE ONE WITH THE DISEASE.

Since this is a commandment, we should listen to our patients.

When Sarah Ezekiel received a diagnosis of motor neurone disease, she became deeply depressed. Seventeen years later, she describes what helped her regain hope.  Her essay for the BMJ is profound and helpful.

 Link to BMJ essay.

A Bedside Conversation with Wilder Penfield

Alan Blum is a professor of Family Medicine at the University of Alabama School of Medicine at Tuscaloosa  He and I have met in cyberspace through our mutual friend, Dr. Dileep Bal of Kapaa, Hawaii.  I was researching the great neurosurgeon, Wilder Penfield, when I came across an article by Alan Blum in the Canadian Medical Association Journal in 2011. "A Bedside Conversation with Wilder Penfield."

Blum writes, "Recently, I came across six prescription-size pages of handwritten notes from an hour-long conversation I had with the [Montreal] Institute’s founder, Dr. Wilder Penfield on the morning of Apr. 3, 1976, when he was a patient in the Ross Pavillion at the Royal Vic. Having hoped to meet him since the start of my training, I stopped off at my room after completing night-call and sign-out to muster the courage to introduce myself and to pick up my copy of The Torch, his novel about Hippocrates’ battle to lay the foundations of medicine."

 Among other things, Alan Blum is a talented illustrator.  We have featured his drawings on Cell 2 Soul in 2010.  His recollection of meeting Penfield shortly before the latter's death is moving and worth reading.

The Steeper Obstacles Faced by Women in Medicine

by Dhruv Khullar

Happy medical residents are all alike. Every unhappy resident would take a long time to count.

A new study in JAMA Internal Medicine suggests yes.* Dr. Constance Guille and colleagues analyzed the mental health of more than 3,100 newly minted doctors at 44 hospitals across the country. Before starting residency, men and women had similar levels of depressive symptoms. After six months on the job, both genders experienced a sharp rise in depression scores — but the effect was much more pronounced for women. A major reason: work-family conflict, which accounted for more than a third of the disparity.

The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties. 

This article is worth reading by all trainees, prospective physicians, and practicing doctors.

Someday, this may be the reality

 *  Work-Family Conflict and the Sex Difference in Depression Among Training Physicians. Constance Guille, etl a.  JAMA Intern Med. 2017;177(12):1766-1772. doi:10.1001/jamainternmed.2017.5138  

Conclusions and Relevance:  This study demonstrates that depressive symptoms increase substantially during the internship year for men and women, but that this increase is greater for women. The study also identifies work-family conflict as an important potentially modifiable factor that is associated with elevated depressive symptoms in training physicians. Systemic modifications to alleviate conflict between work and family life may improve physician mental health and reduce the disproportionate depression disease burden for female physicians. Given that depression among physicians is associated with poor patient care and career attrition, efforts to alleviate depression among physicians has the potential to reduce the negative consequences associated with this disease.

I thought I wasn’t thin enough to be anorexic

BMJ 2017;359:j5378

Caitlin S, 17, and her mother, Sally, talk about what helped, and what didn’t help, when Caitlin developed anorexia

Comment by Brian Maurer, PA-C

This piece highlights the issue of the distorted body image that patients with anorexia nervosa manifest.  Although this adolescent dropped her weight by 10 Kg, she didn't recognize that she had developed AN because (1) her BMI remained at an acceptable level, and (2) her perception of a desirable body habitus was reinforced by social media.

It is interesting to note that this adolescent started to buy into the fact that she was sick after her doctors and caretakers educated her about her eating disorder and supported the diagnosis with facts.  Many patients suffering from AN forcibly push back against the diagnosis, as they continue to perceive their distorted body habitus as normal and desirable.

This case also raises the issue of how a patient with a body image disorder might relate better to a clinician/counselor/caretaker of the same sex, particularly when the patient is an adolescent female.

Widespread use of social media among young people has resulted in an uptick of anxiety, depression, cyberbullying, and suicide in this age group.  Clinicians who care for adolescents need to be aware of these influences as they evaluate and care for patients who suffer from eating disorders, mental illness, suicidal ideation and abuse.

BTW, the latest eating disorder to hit the DSM-V is ARFID, avoidant/restrictive food intake disorder. While similar to AN, patients with ARFID lack the distorted body image component.  We follow a handful of kids who meet the criteria for ARFID in the practice.

Prions Discovered in Skin of Patients With Creutzfeldt-Jacob Disease

Abnormal Proteins Discovered in Skin of Patients With Rare Brain Disease

By Denise Grady

NY Times Nov. 22, 2017  NY Times Link.

Finding so-called prions in skin samples may lead to early diagnosis of Creutzfeldt-Jakob disease. But the discovery also hints at possible risks from surgery.

The discovery suggests that skin samples might be used to improve detection of the disorder, Creutzfeldt-Jakob disease, which now is usually diagnosed with much more difficult procedures, like brain biopsies or autopsies.

The researchers said that although the disease had been transmitted decades ago by corneal transplants and certain neurosurgical procedures, there was no definitive evidence that other types of surgery had ever spread it. And the levels found in skin are far lower than those in the brain.

Creutzfeldt-Jakob is the most common member of a family of disorders that affect people and animals called transmissible spongiform encephalopathies. The diseases eat holes in the brain, leaving it looking like a sponge (hence the name). The other human ailments include kuru, fatal familial insomnia and Gerstmann-Straussler-Scheinker disease.

Principal Investigator, Wen-Quan Zou, M.D., PHD, CJD Foundation.

Prions from BSE in green (from NY Times article)

What if You Knew Alzheimer’s Was Coming for You?

Simple blood tests may soon be able to deliver alarming news about your cognitive health.

By Pagan Kennedy

NY Times, Nov. 17, 2017

This profound and thought-provoking article appeared in the Sunday Review. You may find it to be worth reading.

What if You Knew Alzheimer’s Was Coming for You?

Comments:

Arrogance

Franz J. Ingelfinger
N Engl J Med. 1980 Dec 25;303(26):1507-11.
This is a classic article; well worth studying.
FULL TEXT:

Franz Joseph Ingelfinger  (August 20, 1910 – March 27, 1980) was a German-American physician. He served as Chief of Gastroenterology at Evans Memorial Department of Clinical Research, part of Boston University School of Medicine. He also served as Editor of the New England Journal of Medicine (NEJM) from 1967 to 1976.[1] His work was influential in the field of science journalism.

Notes from Arrobance.

FJI Obituary in BMJ