Why neurology
Sorry for not blogging in a while. I've been working on this one, and it has taken me a while, as you'll see...
I’d like to respond to a recent blog of a friend of mine about a subject close to my heart, which you can find here:
First, I’d like to say thanks to Phil for giving such nice consideration to the field of neurology.
Phil also expresses some of his reservations about the field, which I think are common misperceptions about neurology. I’d like to respond to some of these if I can, though bear in mind that I am definitely biased as a neurologist-to-be. At the very least, maybe you can get an idea of why I chose neurology.
The criticism: In neurology, you can diagnose things, but don’t have many treatment options.
This is probably the most common misperception about neurology. In Texas, I’ve often heard it referred to as the “Diagnose and Adios” field. While that’s funny, I still don’t think it’s completely accurate. The total number of treatment options for most areas of neurology is quite limited when compared to the rest of general internal medicine, but I think the key is comparing apples to apples. In diseases like ALS, there is virtually nothing in the way of treatment, but it would be unfair to compare this to the treatment of hypertension. ALS is a degenerative disease, so how about comparing it to another degenerative disease like an inherited dilated cardiomyopathy. How much is there to do for that? The difference is, unfortunately, that neurology has a disproportionately high number of degenerative diseases, which are very difficult to treat across the board. For diseases like epilepsy, there are many antiepileptics available, and this would be fair to compare with hypertension, though it is still true that there are more antihypertensives available. So the criticism of limited total number of therapeutic options is valid, though how good or bad this truly is in choosing a career will be debated further below.
However, if by not having many treatment options, there is the implication that there are not EFFECTIVE treatment options, then I would beg to differ. Consider an autoinflammatory neurologic disease like MS. There are MS-specific immunosuppressive therapies available that are quite effective. Compare that to therapeutic options for lupus or RA. At best there are “disease-modifying” agents that still have a fair bit of systemic toxicity and aren’t altogether effective. How many times have you had a patient with SLE or RA living a relatively symptom-free life. I've actually had well-controlled MS patients who report almost no symptoms on meds. It is the same with Parkinson's, where I've had a number of asymptomatic patients on medications. The bottom line is that most therapy in neurology is focused on symptom control, but so is most medical therapy in the rest of internal medicine. So we don't cure MS or cure Parkinson's. But when is the last time you cured hypertension or diabetes? Meds in those cases ALSO just control the symptoms, as we certainly see when our hypertensive and diabetic patients stop taking their meds.
So if you equate a person with normal blood pressure on anti-hypertensives with a person with no tremor/bradykinesia on a dopamine agonist, where does the misperception that there are no good neurologic therapeutic options come from? Most residents/students encounter neurologic diseases like Parkinson’s or MS in the ER/hospital setting, where they are either being diagnosed for the first time or are poorly controlled at home. The same is true for hypertensive urgency or new onset diabetes. The difference is that all residents/students also rotate in outpatient clinics where they have the opportunity to see well-controlled diabetes and hypertension. Most do not rotate through outpatient neurology clinics where they can see well-controlled MS, Parkinson’s, migraines, epilepsy, and more.
Then, is it even so bad if we can't cure all these diseases? For me, it helps me to keep a healthy humble approach to medicine instead of thinking that I'm out there saving everyone’s life, since even if I do, it's not through any power of my own anyway. Also, for me neurology is MORE exciting since less is known. It means there is lots of work to be done, and I honestly think that in my lifetime the major breakthroughs in all of medicine will be in neurology. Just look at the percentage of grants and new studies that are in neurological fields of study. I think that many older doctors who have been in practice a while tend to fall back on all the therapies they’ve been using forever instead of keeping up with all the newest, most innovative treatments. If there are constantly new treatments becoming available (like in neurology), it forces you to keep up, and I like that. But I’m even comfortable in acknowledging that we will likely never know all that there is to know about how the brain works. For me, there is a certain beautiful mystery to the human brain that reminds me of its creator. To me, it is God’s most intricate and amazing creation, and I am humbled just to be able to study it and to serve others who have problems with it. That’s why I chose neurology.
I’d like to respond to a recent blog of a friend of mine about a subject close to my heart, which you can find here:
First, I’d like to say thanks to Phil for giving such nice consideration to the field of neurology.
Phil also expresses some of his reservations about the field, which I think are common misperceptions about neurology. I’d like to respond to some of these if I can, though bear in mind that I am definitely biased as a neurologist-to-be. At the very least, maybe you can get an idea of why I chose neurology.
The criticism: In neurology, you can diagnose things, but don’t have many treatment options.
This is probably the most common misperception about neurology. In Texas, I’ve often heard it referred to as the “Diagnose and Adios” field. While that’s funny, I still don’t think it’s completely accurate. The total number of treatment options for most areas of neurology is quite limited when compared to the rest of general internal medicine, but I think the key is comparing apples to apples. In diseases like ALS, there is virtually nothing in the way of treatment, but it would be unfair to compare this to the treatment of hypertension. ALS is a degenerative disease, so how about comparing it to another degenerative disease like an inherited dilated cardiomyopathy. How much is there to do for that? The difference is, unfortunately, that neurology has a disproportionately high number of degenerative diseases, which are very difficult to treat across the board. For diseases like epilepsy, there are many antiepileptics available, and this would be fair to compare with hypertension, though it is still true that there are more antihypertensives available. So the criticism of limited total number of therapeutic options is valid, though how good or bad this truly is in choosing a career will be debated further below.
However, if by not having many treatment options, there is the implication that there are not EFFECTIVE treatment options, then I would beg to differ. Consider an autoinflammatory neurologic disease like MS. There are MS-specific immunosuppressive therapies available that are quite effective. Compare that to therapeutic options for lupus or RA. At best there are “disease-modifying” agents that still have a fair bit of systemic toxicity and aren’t altogether effective. How many times have you had a patient with SLE or RA living a relatively symptom-free life. I've actually had well-controlled MS patients who report almost no symptoms on meds. It is the same with Parkinson's, where I've had a number of asymptomatic patients on medications. The bottom line is that most therapy in neurology is focused on symptom control, but so is most medical therapy in the rest of internal medicine. So we don't cure MS or cure Parkinson's. But when is the last time you cured hypertension or diabetes? Meds in those cases ALSO just control the symptoms, as we certainly see when our hypertensive and diabetic patients stop taking their meds.
So if you equate a person with normal blood pressure on anti-hypertensives with a person with no tremor/bradykinesia on a dopamine agonist, where does the misperception that there are no good neurologic therapeutic options come from? Most residents/students encounter neurologic diseases like Parkinson’s or MS in the ER/hospital setting, where they are either being diagnosed for the first time or are poorly controlled at home. The same is true for hypertensive urgency or new onset diabetes. The difference is that all residents/students also rotate in outpatient clinics where they have the opportunity to see well-controlled diabetes and hypertension. Most do not rotate through outpatient neurology clinics where they can see well-controlled MS, Parkinson’s, migraines, epilepsy, and more.
Then, is it even so bad if we can't cure all these diseases? For me, it helps me to keep a healthy humble approach to medicine instead of thinking that I'm out there saving everyone’s life, since even if I do, it's not through any power of my own anyway. Also, for me neurology is MORE exciting since less is known. It means there is lots of work to be done, and I honestly think that in my lifetime the major breakthroughs in all of medicine will be in neurology. Just look at the percentage of grants and new studies that are in neurological fields of study. I think that many older doctors who have been in practice a while tend to fall back on all the therapies they’ve been using forever instead of keeping up with all the newest, most innovative treatments. If there are constantly new treatments becoming available (like in neurology), it forces you to keep up, and I like that. But I’m even comfortable in acknowledging that we will likely never know all that there is to know about how the brain works. For me, there is a certain beautiful mystery to the human brain that reminds me of its creator. To me, it is God’s most intricate and amazing creation, and I am humbled just to be able to study it and to serve others who have problems with it. That’s why I chose neurology.
posted by Victor | 10:57 PM
6 Comments:
Great post, Victor. I picked neuroscience for the mystery. It's fascinating, isn't it? I am hoping to contribute to one very small part of our growing understanding of the brain myself. Hopefully my basic research will translate to your clinical work within our lifetime. That would be a wonderful thing to see, professionally.
I think it's very important that you are cognizant of the forever-changing and growing discipline of medicine. We have a ton of older docs out there who stand hard-and-fast to the tried-and-true. It's not to say that there isn't value among much of that, but to deny the possibilities of technology and growth in sciences over even the last decade would be potentially a severe disservice to one's patients.
Sorry for the long comment!
Victor, I'd like to thank you for such an inspiring post. I am a 3rd year med student down in Mobile, AL. I have a very strong interest in neurology, but I can't help but be affected by the criticism I get from residents and attendings when I inform them of this interest. You make some excellent points in your post, and the comparisons with other medicine treatment options are very accurate. In the end, I've found that the one topic I've enjoyed learning about most throughout med school is neuroscience. I am also looking forward to a career that offers continuing breakthroughs, and makes my education a lifelong endeavor.
While some MS patients who have had the liberation therapy are reporting long-term benefits from having the procedure, there are just as many for whom the ‘liberation therapy’ has failed as an effective therapeutic intervention. This doesn’t mean that these patients didn’t have some immediate benefits once the neck veins were opened; most did, but over time the veins restenosed again and their MS symptoms returned. In fact, having seen their MS symptoms almost totally disappear however briefly once their veins were cleared, patients who have restenosed want it done over again, as many times as necessary in some cases. However, there is now a new and growing subset of MS patients who have had vein widening venoplasty multiple times, usually to less beneficial effect each time, leading to the later discovery of so much intraluminal scar tissue by the second, third, or fourth attempt at re-opening the veins that the procedure cannot be performed again.For more information on the combination therapy protocol and study email to apply@ccsviclinic.ca or call 888-468-1554. http://www.ccsviclinic.ca/?p=1071
http://www.youtube.com/watch?v=ysFiW26MHfQ&feature=player_embedded
Topical amongst this group are: vascular grafts, bioprosthetics with autologous source endothelialization, pig’s veins, etc. The need to remove jugular veins and implant new vessels because they are so occluded, indicates the possibility that there was ‘overtreatment’ of the veins during the initial venoplasty procedure that eventually led to the formation of scar tissue (that is, if they didn’t occlude with thrombin build-up (clots) immediately post-procedure). It’s well-known that once balloons are expanded in those narrowed areas of the diseased neck veins, tearing and abrasion (desquamation) occurs intraluminally causing inflammation and bleeding. And healing within venous lumen damaged due to venoplasty typically takes many months and leaves lasting, lumen-choking scars. Lumen diameters are permanently decreased. The recent self-reporting of an alarming number of permanently blocked neck veins certainly begs the question to be asked as to what additional medical interventions need to be developed to avoid this kind of catastrophic damage.
Because the definite risk exists that veins will become blocked as a result of the liberation therapy, this further indicates that there may not be recognition by the surgeons of the fragility of the neck vein structure, especially in patients that already have diagnosed venous disease (CCSVI), even though the procedure is considered to be ‘minimally invasive’. No additional steps in the current liberation therapy protocol have either been taken or proposed by Interventional Radiologists performing the vein dilation to eliminate the risk of restenosis. To date the approach amongst the Interventional Radiologists who are performing this therapy on an outpatient basis has been: ‘whatever happens, happens’, post-procedure. It is incorrectly assumed that restenosis will always be ‘correctable’ in subsequent therapies if necessary. This is now clearly proving to be the wrong assumption.For more information on the combination therapy protocol and study email to apply@ccsviclinic.ca or call 888-468-1554. http://www.ccsviclinic.ca/?p=1071
http://www.youtube.com/watch?v=ysFiW26MHfQ&feature=player_embedded
Therefore performing additional effective therapeutic modalities that will avoid the normal cascade of healing events and consequential scarring in support the liberation therapy is vitally important to restore and maintain optimal central nervous system (CNS) drainage once the abnormal veins have been widened. Preliminary evidence from CCSVI Clinic patient case reports indicates that stromal cells injected through the catheter at the time of the venoplasty and applied directly to the damaged vein avoid the formation of both thrombin and scar tissue intraluminally, and that the veins heal very quickly with no evidence of scar tissue. After over a year of treating patients’ veins with stem cells at the time of the liberation therapy, it may be hypothesized that the stem cells work to create more stable, stronger and more enduring veins resulting in long-term patency (optimal blood flow) and the subsequent avoidance of additional venoplasty procedures. Case studies on each patient treated with the combination therapy are now underway.
David Summers of Murfreesboro, TN is one such MS patient now being case studied. David came to the CCSVI Clinic as a paraplegic MS patient evaluated at 8.0 on the Kurtzke EDSS scale. His MS had become secondary progressive and his rate of deterioration had increased dramatically by late 2011. In April of 2012, David was treated at CCSVI Clinic with the combination liberation/autologous stem cell therapy protocol developed by researchers at Regenetek Cellular Technologies. Liberation therapy was first performed and adult autologous stem cells were implanted into David’s jugular veins at the time of his vein expansion. Four days later, a clinical dose of mesenchymal stem cells (MSCs), enhanced in vitro from the original autologous marrow source was implanted back into David’s CNS via lumbar puncture. (Stem cells multiplied from an autologous source not only ensures that patients are receiving their own DNA, but studies have shown there is no risk of cell mutation resulting in the formation of cancerous cells).For more information on the combination therapy protocol and study email to apply@ccsviclinic.ca or call 888-468-1554. http://www.ccsviclinic.ca/?p=1071
http://www.youtube.com/watch?v=ysFiW26MHfQ&feature=player_embedded
David’s MS symptoms not only began to improve immediately, but within four hours of his implantation, he began to feel sensation below the waist. This did not happen the first time he had his liberation therapy in 2010, nor in the 90 days following that procedure, the length of time that he said he had received some benefit as a result.
Following the combination of stem cell implants at CCSVI Clinic, disappearance of his MS symptoms could possibly be explained by the liberation therapy, but his subsequent nerve and muscle regeneration over the last several months can only be accounted for by the rebuilding of the myelin and axonal fibers within the CNS. Only the implantation of pluripotent MSCs that can differentiate into neuroprogenitor cells can do this. Furthermore following his therapy, his frequent attacks of MS completely stopped, another known benefit of MSCs which express chemicals that ‘turn off’ the proteins expressed by the over-aggressive immune system attacking the CNS.
In the six months following his combination therapy at CCSVI Clinic, David began to walk and workout more frequently. At 108 days post-procedure he entered a formal physiotherapy program to improve his walking ability, balance and physical endurance. He has not had an MS attack since his therapies in April of 2012 and most of his MS symptoms have disappeared or reduced dramatically. His EDSS score has moved from an 8.0 to approximately 3.0 and he continues to improve.
Other MS patients not nearly as disabled as David was, having been treated at CCSVI Clinic, are now reporting dramatic improvement and many are now asymptomatic. This combination therapy protocol, meticulously researched and based on various clinical studies on autologous stem cell transplantation, has now been taken from the bench to the bedside for the first time. So far David Summers is one of dozens for whom the outcomes are producing therapeutically what the clinical studies have confirmed. More case study data is being produced and will make up the Prospective Cohort Study to be published later next year.
For more information on the combination therapy protocol and study email to apply@ccsviclinic.ca or call 888-468-1554.
http://www.ccsviclinic.ca/?p=1071
http://www.youtube.com/watch?v=ysFiW26MHfQ&feature=player_embedded
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