Age Before Beauty

There was shocking and disturbing news at the recent American Stroke Association conference-strokes rates have risen dramatically between 1994-5 and 2006-7 but only in the younger populations!  While there are many explanations for the data (51% rise in 15-34 year old males, for example) but certainly in part, this is related to the obesity crisis coming home to haunt.  Strokes are sad because:

1. Even with early warning signs and advanced medical therapeutics, strokes remain devastating in terms of quality of life-they less often kill than maim
2. Stroke rates can be dramatically impacted by lifestyle decisions-obesity, smoking, sedentary lifestyle, etc.

This study should serve as the shot across the bow-we can no longer ignore the dangerous health trends in this country-a FAST FOOD NATION is doomed to egregious health outcomes, stroke being a prime example.  Each one of us has to commit to trying to live healthier lives and help others to do so as well,

I have long been an exercise enthusiast and have been proud of my locavore/healthy cooking style.  Nonetheless, like many 50-somethings, found my weight had crept to dangerous levels.  I have made further adjustments and am proud to say, have dropped 25 pounds over the last 6 months.  But then I decided to take an even greater step and try to turn my new awareness to greater purpose.  I have set a challenge in both of my offices related to sustainable weight loss.  I decided that as a physician I have to both walk the walk AND talk the talk.  I hope everyone will try and think of at least one thing you can do in your own life or for those you love to help reverse these dangerous trends.

All my Lovin'

To all my family and dear friends,

While Hallmark and Hershey's have tried to drag Valentine's Day over the edge (I won't even mention Victoria's Secret), I still think of today as a day to smile and give thanks for all those I love.  Today, I send out special love to one dear friend in particular-Glenda, this is for you.

Forgive me, I should have called sooner

There is no excuse, no rational cause

You were on my mind, I sensed you in need

And I always tell others-now, do it now!

I wish you were nearer, I would be of more use

I would love to bring you soup

Rub your back, brush your hair

Or just sit by quietly at your side

There are no words I know I can say

You have paid your dues twice and again and again

You deserve better after all you have given others

Just know we are here, will do all we can

Be proud of all you have done and will do

One has grown tall and will make you so overjoyed

Another has stood by your side, with love you share

And countless who have gazed at your historical visions

For me, I can say you no better friend there is

From days long ago in the lab to right now

We have shared our hopes, fears and struggles

I am honored to call you dear friend.

Exciting Progress

This week there was exciting news published in the New England Journal of Medicine about the potential benefits of intrauterine surgery on a fetus with spina bifida (see also Spina Bifida Association).  In the past, similar approaches have resulted in unacceptable risks to the mother and complications of the pregnancy.  With advances in technology and technique, these risks have been limited and in fact no additional risk to the mothers were found.  Dramatic positive results included (full text at NEJM link above):

• The first primary outcome, fetal or neonatal death or the need for a cerebrospinal fluid shunt by the age of 12 months, occurred in 68% of infants in the prenatal-surgery group and in 98% in the postnatal-surgery group (relative risk, 0.70; 97.7% confidence interval [CI], 0.58 to 0.84; P<0.001) 
• The second primary outcome — a score derived from the Bayley Mental Development Index and the difference between the functional and the anatomical level of the lesion at 30 months — was significantly better in the prenatal-surgery group than in the postnatal-surgery group (P=0.007). 
• In post hoc analyses, infants in the prenatal-surgery group were more likely to have a level of function that was two or more levels better than expected according to the anatomical level (32% vs. 12%, P=0.005) and less likely to have a level of function that was two or more levels worse than the expected level (13% vs. 28%, P=0.03) than were infants in the postnatal-surgery group. 

The New York Times hailed the research as opening the door to the great potential for fetal surgery.  Many days I have happy to be a neurosurgeon, some days I feel GREAT to be a neurosurgeon.  Reading the results of this study, as someone who has spent many hours with these patients and their families, I am thrilled!

The Social History

A  49 year old woman came to my office last week with 5 years of debilitating headaches.  Her neurological evaluation included an MRI which  revealed a pineal region cyst.  After several years getting interval MRIs focusing on this benign cyst until she took her care into her hands and sought the opinion of a neurosurgeon.  I looked through her extensive catalogue of MRIs and could confidently reassure her that this cyst was not a worry and not the source of her headaches.  She was relieved but asked the expected question, "Then what is causing my headaches?"  I think I know but before I answer let me divert for a moment...
Pain-in its many forms and expressions-is probably the greatest challenge for physicians.  You can't see it or touch it, there are no tests that reliably predict it or measure it (there are scales that are used but they remain completely subjective), and it is always a "symptom" rather than a diagnosis (think appendicitis as diagnosis/right lower abdominal pain as symptom OR brain tumor as diagnosis/headaches as symptom).  Despite all this, pain is always real-one might complain more than another or let it interfere with life more but anyone who comes to my office complaining of pain IS REALLY experiencing pain.  Because pain is the end product expression of many factors and modulations-both physical and psychological.  And to date, science has failed us miserably in understanding the real mechanics of pain.  Sure I could enumerate molecular knowledge about receptors, agonists, antagonists, signal transduction and the like but in the end, it wouldn't get any of us closer to understanding how and why patients suffer, how stress can bring on a headache or aggravate back pain, or how a wedding can temporarily halt longstanding cancer pain (as just a few examples of a myriad of pain enigmas).

Early in my career, I learned an invaluable lesson from an enormously gifted and talented plastic surgeon (who I count as both friend and mentor), Dr. Jane Petro.  We were jointly running a peripheral nerve clinic and had to evaluate a patient with RSD (Reflex Sympathetic Dystrophy as it was known then, now referred to as Complex Regional Pain Syndrone-CRPS).  After the patient left, she engaged the team in a discussion of a striking paper that demonstrated the very high correlation of RSD with abuse (both child and spousal abuse) (References below).  The clear implication was that our life events clearly impact our response to injury and disease in ways that remain unknown to us.  But while we may not understand the mechanism, it is evident that all health care providers have to more closely attend to understanding the lives of our patients in order to administer to their medical needs.
Which brings me to the Social History-probably the most under-rated component of a patient's history (beyond the perfunctory smoking, alcohol, and drug history).  Despite the pressures and my role as a sub-specialist, I always ask a few questions about home, employment and background.  At the least, I know a few things about my patient and it helps me view them as people (fathers, sisters, colleagues, etc.).  And sometimes the information turns out to be critical for successful outcomes or interventions.  For example, I recently performed a spinal fusion on a woman who was clearly in a threatening marriage and based on that information, I made sure she went to rehab post-op, even though she was likely medically well enough to go directly home.
So how does this all relate to my headache patient? Well, by just asking one simple question, she revealed a recent divorce after several years of a nasty separation.  Clearly, her headaches were temporally related to the onset of marital strife.   Trust me, this woman truly suffers from terrible headaches-they are real and life-altering, neither imagined nor exaggerated.  How? I don't know. Why headaches and not some other complaint? I don't know.  What is the best intervention now for this woman? I don't know.
But I do know, taking the Social History remains a critical component of understanding and providing the best care to our patients.

References:
Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence. - Wuest J - Pain Med - 01-MAY-2009; 10(4): 739-47

Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain. - Balousek S - J Gen Intern Med - 01-SEP-2007; 22(9): 1268-73

Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis. - Ciccone DS - Clin J Pain - 01-SEP-2005; 21(5): 378-86

Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence. - Feliu MH -Clin J Pain - 01-MAR-2010; 26(3): 258-63

Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed.; CHAPTER 82 - Domestic Violence

Katz: Comprehensive Gynecology, 5th ed.; Chapter 10 - Rape, Incest, and Domestic Violence

Sport Related Head Injury

This has got to hurt!

Super Bowl is just days away and I am as big a fan an ANYONE (see my blog sidebar for evidence!) but I do admit that as a neurosurgeon, I find it increasingly difficult to watch the players heads bounce off the ground with resultant concussions or worse.  I recently presented an educational radio program for my community that I thought I would share.  No cool pictures-just me talking!

Aaron Rodgers "New" helmut (after several concussions)