Honoring healthcare

Perhaps the most famous of the deaths this year is that of Senator Edward Kennedy.

As demographics in the U.S. change and as the political tides sway, we have been watching the baton pass from the Old-Guard to the new hopeful brand of grassroots politician.

As the country changes, We The People changes, and so do our leaders.


While Senator Kennedy’s passing is tragic, it was not unexpected. His death highlights how, even with the best of modern Medicine, we are all still victims of fate and mortality. Great strides have been made in the detection and treatment of cancer, yet many succumb yearly to primary and metastatic brain tumors (including glioblastoma multiforme or GBM).

I hope that Kennedy’s death gives us all pause to weigh and consider (on both sides of the aisle) what our goals, expectations, and strategies are for meaningful healthcare reform. The danger is that there will be a rush to pass healthcare reform simply as a tribute to Kennedy and his lifelong goals, without taking careful consideration and reflection to the will of many Americans.

There is genuine fear among many segments of American society concerning the potential hazards in the way of a smooth transition to affordable universal healthcare. While there are many stakeholders, most of whom are not the front-line of medical care (only the patient, care partner and physician are unified in a unbreakable bond of striving for optimal health), we must recognize that the rush to pass a healthcare bill is not in the best interest of the nation.


Yes, healthcare is an urgent matter, but we have waited this long for reform, why do we have to rush to pass it through (without widespread support) now?


- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

info@neurologique.org
www.neurologique.org

Back to the Future: expanding the MS Community

Another day, another drug.

What makes the FDA’s approval of Novartis AG’s (NVSEF) interferon beta-1b (Extavia) important?

Critics may argue that Extavia is exactly the same drug as Bayer’s Betaseron, but this is still a significant step towards further MS treatment development for two reasons:

1. Novartis has been waiting for this approval for some time – it is already available in Europe. There were rumors that the delay was because the FDA was hesitant to open the road to bio-similars (and hence the lack of approval of EMD Serono’s Rebif New Formulation (RNF) [an affiliate of Merck KGaA]). The issue here is that Extavia is 2006 Betaseron – not similar but exact.

2. This is also clear indication that Novartis is staying in the MS market and that (hopefully) FTY720 (Fingolimod) will make it through the approval process (as the second, but thus far, strongest, oral medication for MS disease modification.

This will also be a boost to MS patients as greater competition may lead to lower prices – but even if it doesn’t, Extavia will return us to Betaseron, circa 2006. This means that there will be 15 injections per box and that the injections will be used with the old autoinjector.

Fifteen injections in a box means 12 boxes a year and not 13, this makes more sense intuitively from an every other day point-of-view and means that patients (and insurances) are paying for 12 copays a year, as opposed to 13. Also, many patients prefer the older autoinjector for several reasons:

1. The grip is thinner.

2. Less pressure is needed when holding the injector to the skin (and thus less likely for the needle to go into the muscle).

3. The injection takes less time.

So, what does this all mean?

We will see, but in the meantime -- Welcome Novartis to the MS community!

--
Extavia was approved on 08/14/09 and will be available starting 10/10/09, with a lauch planned for September 2009.


- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

info@neurologique.org
www.neurologique.org

Jakarta and Stream of Consciousness

The Michael Jackson Voodoo death post has been visited by readers as far as Jakarta.

A reader, much closer to home in the US, wrote in with the following post:


A Jacksonian Break:
Did the King of Pop die from a broken heart?


If so, how did it break? Perhaps it was progressive, like other things Jacksonian…

Progressing along an exponential curve: increased stimulation, followed by increased need for numbness, followed by tolerance, and repeat cycle. Chicken is to egg as Jackson’s escapism is to his sensationalism. Or is it vice versa? Extreme emotion propelling a life, which ended in death caused by the agent used to escape the extreme emotion.

Irony.

Was each administration of propofol an inadvertent death wish? Or successive approximations thereof? Perhaps not death in the morbid way it is most often imagined; perhaps he longed for Death as the Great Escape.

{He was the King of Pop, not the King of Emo after all. His colleague, Elliott Smith, made clear his need for escape when he stabbed himself in the heart times 2. Now there’s a sensationalist.}

Perhaps some of Jackson’s graphic/gruesome imagery was born out of his nightly drug-dependent “sleep.” Brandner et al (1997, Anesthesia) reported more memorable/vivid imagery during dream states induced with IV propofol than during those induced with nitrous. Or, again, flipping that coin on its head, maybe the anesthetic was required to tame an inherently active “id,” which visited frequently and without invitation/provocation during sleep. A hyperactive eros-thanatos, fed by fame and fortune.

One could argue that he was chronically deprived of sleep, and thus physically and psychologically unable to sustain the level of vibrancy required for his personal and professional daily living activities. Such a parsimonious explanation so dull in the face of the plethora of more dramatic ideas.

Irregardless of the acute and specific cause of his death, one might argue Jackson’s lifestyle led him down a road untraveled, through the labyrinth of deeply private and public psyches, thus raising the interesting and perhaps more poignant questions: What thrilled Michael? Will a gaze in the mirror truly instigate positive change? Did he look in the mirror, or was his anesthetic addiction a subconsciously-propelled attempt to look away, far far away…


- Elizabeth Adams


Note: Propofol is the generic name of Diprivan.


- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

info@neurologique.org
www.neurologique.org

Death: Manner vs. Cause -- Language of Death

Another unfortunate death (when is death fortunate?) allows us a glimpse into conflicting issues of life and death.

Budd Schulberg died at the age of 95, “of natural causes at his home in Westhampton Beach, on Long Island,” said his wife, Betsy Schulberg, but a family spokesman said that he suffered breathing problems Wednesday afternoon and was rushed from his Westhampton, L.I., home to Peconic Bay Medical Center, where he was pronounced dead. His wife states that, “he was taken to a nearby medical center, where doctors unsuccessfully tried to revive him”.

As a novelist, Oscar-winning screenwriter (On the Waterfront with Marlon Brando) and Hall of Fame boxing correspondent, he would have appreciated the subtlety of language in the exact manner and cause of his death.


Manner of death is how a person died – natural, accidental, suicidal, homicidal, undetermined or unclassified; cause (mode) of death is what is directly related to the death, such as the type of disease state (e.g. severe asthma attack) or type of injury or under what circumstances (e.g. gunshot wound to the head).

It sounds like his manner of death was natural (meaning that it wasn’t caused by an inflicted injury) – but so is any disease that one dies of. Most people think of a “natural” death as one that is to be expected, such as an older person dying of a heart attack, but a young person dying from meningitis is also “natural,” in that it wasn’t caused by something external to one’s own body.

The cause of his death may have been respiratory arrest.

So, the phrase “died of natural causes” is actually a misnomer and should be “died in a natural manner,” however people dying in hospital beds with tubes sticking out of them hardly sounds like a natural manner.


Piecing this together, it sounds as if he had respiratory arrest (possibly from severe asthma or pulmonary embolism,) and he stopped sending oxygenated blood to his brain and to his heart. An ambulance arrived and administered advanced cardiac life support and once he arrived at the hospital this was either continued or he was pronounced “dead on arrival.”


So, where did he die?

We know that he either died at home or in the hospital:

- He stopped breathing at home and if his heart stopped working and he stopped receiving oxygenated blood to his brain, then his death occurred at home and the resuscitation efforts from then on were on a person already dead.

- On the other hand, if he had breathing problems and was rushed to the hospital and was pronounced dead after resuscitation efforts, then his time of death would be when they stopped trying to resuscitate him – and his place of death was the hospital.


So, when did he die?

There are three possibilities:

- Before being picked up by the ambulance.
- On the ambulance.
- In the Emergency Department (ER).


So, how did he die?

Which happened first?

- His heart stopped.
- His brain didn’t receive oxygen and so the nervous system connections to his heart stopped work and his heart stopped pumping.


Just as Budd Schulberg was controversial in life (naming names in the Communist Party, scathing attack on Hollywood by the son of the head of Paramount Pictures), so too, his death, while seeming uncontroversial, carries with it unanswered questions.



Remember:


Questions beget questions.


- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

info@neurologique.org
http://www.neurologique.org/

Rising from the ashes

Another well known person, another death … another opportunity for neurological education.


Frank McCourt, best known as the Pulitzer Prize winning author of Angela’s Ashes, died late last month at the age of 78. According to news reports, he had metastatic melanoma and was “gravely ill” with meningitis.

What was his immediate cause of death – melanoma or meningitis and what was the time course?

Are these two reports by those close to him in agreement, and do they help us in our diagnosis?

1. He was 78, gravely ill with meningitis and recently was treated for melanoma, the deadliest form of skin cancer and the cause of his death, said his publisher, Scribner.

2. We had this big dinner party in Roxbury (Conn.) last month, and he was there," said author Gay Talese, a longtime friend. "I made him a vodka martini, and he didn't look at all like he was going to disappear from the Earth in a month. He was very jovial, as usual."


We know that he had metastatic melanoma, which spreads to the brain 40 - 60% of the time. On autopsy 70 – 90% of people who died of melanoma have intracranial metastases. It is also the most common cause of bleeding (hemorrhage) in the brain from a metastatic cancer. Melanoma may metastasize to the meninges (covering of the brain); other causes of leptomeningeal metastases are cancers of the lung, breast, and GI tract.


So why does the second quote make it sound like he was doing well only a month before? Other reports have stated that he had 2 weeks of meningitis. What type of meningitis was this?

The possible types of meningitis he had were:

1. Carcinomatous meningitis -- cancer spreads to the leptomeninges (the covering of the brain). This causes an inflammatory reaction in the meninges, hence the “–itis.” Although most people think of infectious meningitis, this type is from irritation/inflammation and not infection. Sometimes leptomeningeal carcinomatosis is treated by radiation and intrathecal chemotherapy (chemotherapy into the sac surrounding the brain and spinal cord).

2. Infectious meningitis – bacterial, viral and fungal infections. He may have been immunosuppressed for several reasons: the cancer itself, chemotherapy, steroids to reduce the swelling/edema caused by the cancer. He may have had an opportunistic infection because of his immunosuppression or he may have had reactivation of a previous infection (e.g. syphilis).

3. Aseptic meningitis – a rare cause is ibuprofen (and other analgesic) use.

4. Chemical meningitis – from procedures that may irritate the meninges (e.g. putting chemotherapy, dye or anesthesia into the thecal sac).

5. Granulomatous/vasculitis – there is no reason to think that he had a separate condition, such as sarcoidosis, Wegener granulomatosis, Behcet disease, vasculitis or Vogt-Kayanagi-Harada disease.

6. Unknown -- in a third of people, no cause is found.


So, can we reconcile him dying from melanoma or dying from meningitis?

Yes.


The melanoma was probably ultimately responsible for the meningitis (either through leptomeningeal involvement or from infection due to immunosuppression). If he died from the meningitis, then melanoma is the underlying or proximate cause of death and meningitis is the immediate or dependent cause (or mode) of death.

Alternatively, the carcinomatous meningitis could have been a sign that the melanoma was metastatic to many other parts of his body – and then the immediate cause of death will remain a mystery.

Sound familiar?

- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique

info@neurologique.org
http://www.neurologique.org/