Hope for people with Locked-in Syndrome or ALS?

One of the worst things that can happen to a person is something called "Locked-In Syndrome" (see http://en.wikipedia.org/wiki/Locked-In_syndrome). The reason this is so bad is that the person can still think and is conscious but is unable to communicate with the outside world because that part of the nervous system has been destroyed. In a sense, the person is "buried alive" inside their own body. This might happen as a result of a stroke that takes out a significant part of the left hemisphere or part of the brainstem in the pons, for example. People with ALS suffer a similar fate in that they lose the ability to move their muscles and eventually even lose the ability to breathe or keep their airway open and suffocate.

One of the technologies that might offer some hope is something called a Brain-Computer Interface (http://en.wikipedia.org/wiki/Brain_computer_interface). Using such a tool, it might be possible for a person to manipulate a robot arm or computer interface to communicate or otherwise interact with the outside world. It sounds a little science fiction, but recently scientists were able to get a monkey to feed itself using a robot arm that interfaced with the monkey's brain (http://www.nytimes.com/2008/05/29/science/29brain.html). Obviously there must be some limits to this technology and it has not been tried in humans yet. However the monkey and human brain have many similarities that make trying this technology in humans seems very close and I'm sure it is being tried to some extent already using EEGs and fMRI interfaces.

Back from a Holiday weekend

I always like to talk to my classmates after a Holiday weekend (like this past Memorial day 3 day weekend). Everyone is so rested and happy. Even our lecturers seem to have a little extra spring in their step. Soon we will be in exam study mode and year 1 will be over and then we will get a 1 month break. One thing that is clearly helping me is daily workouts. It's been tough working that into my schedule for really no valid reason, but I'm there and I love it. We have learned time and time again how working out helps cardiovascular health, and, most recently, that it has actually been proven to be equivalent to a natural antidepressant and an inducer of brain cell growth development! How about that for motivation to work out. I need every brain cell I can get with all the memorization we need to do.

Neulaw Conference Summary

http://neuro.bcm.edu/eagleman/neurolaw/Home.html

" Baylor College of Medicine’s Initiative on Neuroscience and Law addresses how new discoveries in neuroscience should navigate the way we make laws, punish criminals, and develop rehabilitation. The project brings together a unique collaboration of neurobiologists, legal scholars, ethicists, medical humanists, and policy makers, with the goal of running experiments that will result in modern, evidence-based policy."

Dr. Eagleman in his introduction of Neuroscience and law gave a broad overview of the many ways that neuroscience can explain criminal and other legally interesting behavior. Dr. Eagleman focused mostly on results from science as he explained how Charles Whitman and Phineas Gage were not consciously able to influence their behavior. He gave the example of a man who became interested in sex with children as a result of a tumor and was treated twice and with each surgery was able to regain normal sexuality.

After this, Dr. Hays explained key rulings and issues related to the admissibility of expert testimony (FRE 702. He showed that expert testimony related to neuroscience could be admitted in court if it met a four part test outlined in Daubert v. Merrell Dow 509 U.S.579 if the technique / theory was tested, peer review and published, had a known error rate, and had widespread acceptance within the relevant scientific community. He indicated that actually polygraph tests did very well in determining whether subject were being dishonest and that traditional juries are not well characterized in terms of their ability to assess truthfulness.

Dr. McGuire is very interested in the implications of neuroscience on ethics and law as in the case of participation in imaging research study leading to unexpected discovery of a large tumor by scientists who are not clinicians. She highlighted the many ways in which neuroscience is giving beneficial insights but that results can have uncomfortable implications for patients and research subjects. For example, some of the questions we would really like answers to cannot really be funded for ethical reasons. During the panel discussion she elaborated on this point by explaining that if we studied predictive factors for future criminal behavior based on fMRI imaging of school children, one would be worried about the stigma for children with these predictive factors for criminal behavior and this would outweigh the benefits of perhaps early intervention.

As a neurologist, Dr. Kass was able to go into more detail about how neuroscience can be used to assess individuals. He spoke about how differences in human frontal lobes lead to differences in emotional regulation such as the processing of risk, reward, and ambiguity as well as individual information thresholds for decision making. He spoke about variability in human self-regulatory styles; for example, some people are driven by gain and this leads to eagerness. Others are driven by loss prevention, and this leads to vigilance.

Mr. Dan Goldberg provided an important legal perspective by warning about how application of neuroimaging and related science can be used to mislead juries. In addition to Daubert 509, lawyers can sometimes apply Federal Evidence Rule 403 to neuroimaging because the value of such evidence may not be sufficient compared to the potential undue prejudice that can be caused. For example, in studies, juries that were given a fallacious narrative backed up with a brain imaging study overlooked the errors in the story whereas juries that did not have imaging studies as part of the presentation saw the problems.

Dr. Amir Halevy gave an engaging presentation of the factors in determining brain death and explained that dying is not an event, but rather a process in which a body becomes a corpse. He walked the audience through the history of how death is determined and explained how the coincidental development of technology such as ventilators and organ transplant capabilities led to ethical worries that organ donation might precede death, if not in actual fact, then possibly in a legal sense. He carefully outlined important considerations such as whether the body was at normal body temperature when a determination of death was made as one example to ensure that every appropriate attempt had been made to resuscitate the patient.

Finally Dr. Winslade wrapped up the formal presentation portion of the conference with a careful analysis of voluntary surgical castration for three sex offenders under Texas Law, as for certain non-violent pedophiles . It is important to recognize that this castration procedure is part of a comprehensive therapy that includes intensive counseling and education. Dr. Winslade discussed three cases that showed that it is possible to treat pedophiles so that they can have better control over their impulsivity and other behavior problems even if there is no proven cure for pedophilia.

Neurophysiology and Criminal Behavior

We are gradually wrapping up several weeks of intensive study of neuroanatomy among other things, such as infectious disease. In a few weeks we'll start a round of tests and then we will be out for the summer. A lot of my classmates are feeling pretty burned out. Personally, I have a renewed sense of energy and purpose. I like what I'm studying even if I don't master it fully or forget important points. The information is really very interesting in and of itself. For me neuroanatomy has been a real eye-opener to the mind and brain. It's just amazing how scientists are now able to trace depression to physiological changes in the brain and are beginning to track down the development of Alzheimer's disease for current and future treatment.

One of the more remarkable aspects of this is an effort to trace issues such as criminal behavior to neurophysiology. It has been known for a long time, as in the study of the case of Phinease Gage (http://en.wikipedia.org/wiki/Phineas_Gage) that damage to the frontal lobes can cause behavior that is at best not moral and can evidently become criminal. On Friday many students in our class will be attending a conference on neuroscience and law here at Baylor CM (www.neulaw.org). We hear of considerations from psychiatry and neuroscience in criminal and other aspects of law; here will be our chance to learn about some of the recent developments and their implications. We are still quite far away from being able to implant, say, a chip in the brain of a pedophile to change such a person's thoughts, but we can perhaps learn more about various ways that people can lose judgment and what that means in the legal context.

Professors who make you look forward to practicing medicine

There is a lot to learn and medical school professors are an important part of the equation in the learning process. A good professor presents the material clearly ... but a great one inspires you with their passion for their work. Today we had Dr. Sargent talk about pediatric mental health. I'll say right off, that while this field is interesting, it isn't my passion currently; but that's not important. What's important is that this professor like several other key professors here at BCM have more than semantic information to provide. Specifically Dr. Sargent has a vision for dramatically improving life for many children in our community, which, of course, means that he has a vision for a better future for our community. Here are some specific things that he mentioned:

* Multiystemic therapy uses dollars that are already being spent to keep juveniles in detention and incarceration to provide treatment for kids with various mental. Here is one of several links that can be readily found on this topic: http://www.colorado.edu/cspv/blueprints/model/programs/MST.html

Key reference: Family preservation using multisystemic therapy: An effective alternative to incarcerating serious juvenile offenders.

Henggeler, Scott W.; Melton, Gary B.; Smith, Linda A.

Journal of Consulting and Clinical Psychology. 1992 Dec Vol 60(6) 953-961

* Systems of Hope. This is the organization that Dr. Sargent is involved with. Here is
http://www.systemsofhope.org/

Here is a little bit about the organization that Dr. Sargent is involved with:

Systems of Hope meet the needs of Harris County children and youth with serious mental health needs and their families by creating a collaborative network of community-based services and supports using the systems of care framework. A plan of care is created for each family focusing on their strengths. Systems of Care is more than a program — it is a philosophy of how care should be delivered. It is an approach to services that recognizes the importance of family, school and community, and seeks to promote the full potential of every child and youth by addressing their physical, emotional, intellectual, cultural and social needs.

Making time for fun

Medical school takes a lot of time for the typical person (including me). Sometimes when I'm goofing off doing something fun with the family I wonder if I'm taking too much time away from my studies. Yes, balance is important but if you get behind in keeping up with the material it can be hard to catch up and that creates stress ... thus there is an incentive to work hard all along, at least for me. Yesterday we had a class picnic and I never thought about studying -- probably because there was a lot going on in terms of physical activity. Because of the parking situation I hauled a 40 lb bar-b-que gill about half mile or so and go a pretty good workout even before the picnic really started for me. We ran a lot, played frisbee, volleyball and the like. Usually when I work out, I'm back studying after about an hour. This was a multi-hour deal and that was probably key to unwinding. I was always under the impression that is better to spend time throughout the week to work out or goof off. That usually means its going to be fairly short. The picnic showed me that sometimes you need several hours to completely get your mind off things and refreshed.

Wasting time with marginal software

In a nutshell: The Nero 7.0 Essentials is a timewaster that may or may not work (probably does, but be prepared to spend a long time working with it, especially if you have a lot of data (e.g., 6 GB+) that you want to offload onto DVD).

There are plenty of ways to waste time, and one that I'll cover here in this brief note is dealing with software / computer issues. I bought a new DVD burner because my tablet computer did not have a DVD drive and I needed to install some software. I wanted to also take advantage of the burner to offload some files. The burner comes with the piece-of-junk Nero 7.0 essentials software. I don't normally develop negative feelings toward software, but Nero is an exception, as I have wasted countless hours either attempting to get this software to do its job or to install some "feature" that was breaking the rest of the system in the not too distant past. My memory of this software is a combination of lockups and application crashes. Don't get me wrong ... the software often worked, but it wasn't reliable.

Today was no exception. I went to install the software and it took forever for some reason. It isn't just possible to install a simple burner. It installs all this junk that I don't want but it is what it is. Then it attempts to associate itself with every imaginable media file type -- NO, THANKS. However, the installation was basically a smooth process. It did require a reboot, but that wasn't too bad. After that, I wanted to burn my data to DVD. By default, the software chose a CD-ROM drive insead of the DVD burner ... not a huge issue until I tried to cancel to switch to the correct drive. The program of course locked up and had to be forced to end. After that it wasn't possible to start the Nero software again. I had to reboot my system to start the Nero software once again.

The second time around I was much more careful about setting the drive to use because I knew I would not get a second chance to correct this. I added the directory I wanted to burn and it went fairly smoothly. Then there is a message about "Please wait..." without any explanation of what the software is doing. Who knows if I will ever get that directory burned. With this software it's difficult to tell if its locked up or doing something. Keeping the user informed is apparently an occasional task that Nero may or may not perform. When it does give a message, be prepared for indications such as no progress with no improvement (are we locked up?) or 100% complete but "please wait" (so what exactly does 100% complete mean?). Well, I need to get back to studying. I'll let this software keep try to do its thing in the background.

Pace picking up / It was fun listening to Feigin today

Well, I'm past the mid-point of the first year and things are picking up. We move through material quickly and the expectations of what we are supposed to remember increase in terms of level of detail. All the while, my lectures are mostly empty now (few students go). Most students just watch the lectures on recorded video, which is not a bad idea, actually. I still go to lecture, mostly because I enjoy it. I can tell my memory is getting better with all this practice I'm getting remembering tons of important medical facts.

Today I attended a lecture by Dr. Ralph Feigin. He strongly promoted pediatrics and challenged us to excel in our education. He was very energetic as you would expect of someone with his reputation.