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Neurology

Smooth Operator

by Laura McFarland, Communications Director

According to a 2008 survey, operating room staff play music during about two thirds of surgeries, as reported in this year’s British Medical Journal’s Christmas issue, which reviews the history of music in the operating room.

Aside from a more general effect on health, numerous data specifically support music for patients having surgery under local or general anaesthesia. BMJ notes that in a randomised trial of 372 patients having elective surgery, relaxing melodies (60-80 bpm, mimicking the resting heart rate) proved to be superior to midazolam as a pre-anaesthetic anxiolytic. Combined data suggest that this calming effect is maintained before, during (when awake), and after surgery, with music faring better than noise blocking devices alone. For patients requiring further respiratory support postoperatively, music’s ability to reduce anxiety, heart rate, and respiratory rate extends even to ventilated patients in intensive care.

My son, delivered by C-section, was born to the sounds of Loverboy, “Working for the Weekend.” Personally I would have preferred something a little more classical, which is apparently the preferred genre. Its popularity may be in part due to the lack of lyrics, which alas rules out holiday carols. The Journal offers a number of suggestions and some understandable don’ts (REM’s “Everybody Hurts,” for instance) if readers find themselves needing to make a selection.

MCN wishes a joyful holiday season to all of our readers. We will be closed on Thursday, December 25th and Thursday, January 1st. To meet the needs of our clients, MCN is open during regular business hours throughout the rest of the season. Our 26 offices nationwide, including operational centers in Tampa, FL, Long Island, NY, Chicago, IL, and Seattle, WA, are seamlessly connected through one fully integrated database. Whatever the weather, MCN staff are available to answer client questions, receive referrals, and review and deliver reports from 8 am – 8 pm EST.

More on the PTSD-Military Conundrum

By Brian Grant, MD

The in-depth article, “Mind Field: PTSD & the Military,” from Seattle Weekly was impressive in its nuanced tone. The reader is left with more questions than answers, as befits such a complex topic. Themes include the impact of systems on behavior, the nature of psychiatric diagnosis, the impact of combat, how media exposure may impact others including family members of those traumatized, politics and partisanship and more.

The author of the article, Keegan Hamilton, wryly notes: “While noble in its intent, the monetization of PTSD diagnosis has created a classic catch-22.” One should ask whether veterans are better served with treatment upon diagnosis or compensation, and if the impact of a minimum of a 50% disability rating upon diagnosis serves the veteran and society? How often, once awarded a disability pension, does meaningful treatment occur and benefits reduced after such treatment? What is the impact upon treatment if it is tied into economic factors?

Every case should be addressed based upon individual facts, but it would be naive to suggest that the basic assumptions and economics of the veterans’ compensation and pension system do not significantly impact individual and group behaviors and outcomes. Passions and politics are inflamed. To frame the issue another way, we should ask ourselves under what circumstances in society do individuals actively desire a medical or psychiatric diagnosis, rather than strongly hope for a finding of good health or at least a short-term malady? PTSD is real. It is also treatable. The diagnosis is fairly easy to make based upon the criteria and a diagnosis does not equal impairment. We have written on this topic recently in previous posts, “Military Psychiatrists Under Fire for Doing Their Jobs,” and “Madigan Commander Reinstated After Army Investigates PTSD Diagnosis.”

The article also makes note of “secondary PTSD”. This is not a recognized diagnosis, but would appear to be an interesting social construct, perhaps reflecting the all too frequent drive to create medical diagnoses for the bad things that happen to people and societies in the course of life. Anyone who witnessed the constant televised replays of the Twin Towers collapse in the days following September 11, 2001 was traumatized, upset, and perhaps depressed. They may even have had many of the diagnostic criteria required for PTSD.  Many avoided flying, were fearful of individuals who reminded them of the bombers, felt numbness and estrangement from others, psychic numbing, and a variety of autonomic symptoms upon certain cues. Life in the U.S. changed tangibly, along with our group psyche. When the abnormal becomes normal, does it warrant a medical diagnosis or literary and journalistic treatment?

The Causation Conundrum & Commentary On Who Should Perform Causation Analysis

by Brian L. Grant, MD

A core component on independent assessment and review is determination of causation. Such determinations should be evidence based. Evidence stands on its own merits. It is not a function of the degree of the expert or the opinion of a judge, legislator, advocate or journalist.

Examples abound of such errors in causation. These include Mild Traumatic Brain Injury (MTBI). Scientific evidence is lacking to prove a relationship between MTBI and permanent impairment. Similarly, legal and administrative pronouncements that presume a relationship between hypertension and law enforcement are unsupported by solid science. The media is awash with assumed links between military service and MTBI and PTSD at alarming rates, suggesting either a slippage of criteria, or a profound change in the nature of warriors or the nature of war. Just typing the prior sentence causes this writer anxiety, lest I be accused by advocates of demeaning military service.

Psychiatrists in Washington at Madigan Army Medical Center know all too well the dangers of exercising scrutiny in the politically fraught world or military PTSD. See the accompanying blog post that addresses this.

An expert expressing an opinion is just expressing an opinion – UNLESS the opinion is supported by solid evidence and scientific facts.

The book Guides to the Evaluation of Disease and Injury Causation addresses the challenge of causation determination in-depth as well as proper protocol to determine cause. Among other insights, it discusses the challenge of relatedness; that an event preceding a complaint does not establish causation but may, in the absence of specific evidence, constitute false reasoning.

The protocol to establish causation is a six step process:

1 – Definitely establishing a diagnosis

2 – Applying relevant findings from epidemiological science to the individual case

3 – Obtain and assess the evidence of exposure

4 – Consider other relevant factors

5 – Scrutinizing the Validity of the Evidence

6 – Evaluation of the results from all of the above steps, and generation of conclusions

The above points and much more are from a seminal article, “Determining Injury-Relatedness, Work-Relatedness, and Claim Relatedness” by Robert J Barth, Ph.D. (BarthRJ. Determining Injury-Relatedness, Work-Relatedness, and Claim Relatedness. AMA Guides Newsletter.May/June 2012: 1-10.) 

As of this writing, the issue of the newsletter is not yet listed on the AMA site, but presumably it will be soon and may be accessed by calling them at (800) 621-8335.

Barth is perhaps the foremost thinker and writer on this and many other related topics. The cited article is copyrighted and as such can’t be attached, but is well worth acquiring. In our opinion it is a must read and must own for anyone involved in medical or legal work involving medical causation.

We must quote another pearl from the above article that challenges the bias equation that is often applied to independent evaluators as opposed to treating clinicians:

“As is the case for any forensic work, a causation analysis should be conducted in an independent context. Treating clinicians face considerable financial and social conflicts of interest if they attempt to engage in any forensic activity (such as causation analysis) in regard to their patients. In contrast, independent evaluations minimize the evaluator’s conflicts of interest. Therefore, treating clinicians should refrain from engaging in any forensic work that involves their patients (including refraining from causation discussions).”

Clinicians not involved in the treatment of a particular claim may not be free of bias if they allow themselves to be swayed by requestors of their services. But in our experience the majority of those desiring evaluations are not overly invested in a particular outcome and more likely seek a realistic assessment of the truth, causation and related matters, in one of many cases they are managing at a given time. Contrast this to the considerable pressures that may be experienced in a treatment relationship where the emotional and economic stakes are very high for a patient, who may cause pressure to be felt by the treating clinician and impair objectivity as a result. Regardless of whether one is treating or evaluating, the same rigorous principles of causation analysis as well as other aspects of assessment, diagnosis and treatment must apply.

Mental Illness Hit 1 in 5 U.S. Adults in Past Year

Per this Bloomberg article, a new survey finds that 20 percent of U.S. adults—over 45 million people— experienced mental illness in the past year. The survey, which included 67,500 adults nationwide, was released by the Substance Abuse and Mental Health Services Administration (SAMHSA).

“The consequences for individuals, families and communities can be devastating. If left untreated mental illnesses can result in disability, substance abuse, suicides, lost productivity, and family discord. Through health care reform and the Mental Health Parity and Addiction Equity Act we can help far more people get needed treatment for behavioral health problems,” noted SAMHSA Administrator Pamela S. Hyde. Read more…

Silk Brain Implant Could Aid Spinal Injuries, Epilepsy

Reuters posted a very compelling article about a silk chip that adheres to the brain that has the potential to help people with epilepsy or spinal cord injuries. The water-soluble silk dissolves onto the brain leaving only the electrodes behind. Going forward, this technology could have the potential to help other disorders like Parkinson’s Disease and Multiple Sclerosis.