Category Archives: Uncategorized

Determination of Brain Death by Neurologic Criteria

Wish I were here

This is for my personal use. Not for my typical readers. From the World Brain Death Project:

Abstract

Importance

There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

Objective

To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

Process

Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

Evidence Synthesis Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

Recommendations

Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

Conclusions and Relevance

This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

Source: Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project | Critical Care Medicine | JAMA | JAMA Network

COVID-19: Do Lock-Downs Work?

artist's rendition of coronavirus
Artist’s rendition of Coronavirus

If you’re looking for evidence that stay-at-home orders and business closures don’t help control COVID-19, here it is:

In summary, we fail to find strong evidence supporting a role for more restrictive non-pharmacological interventions in the control of COVID in early 2020. We do not question the role of all public health interventions, or of coordinated communications about the epidemic, but we fail to find an additional benefit of stay-at-home orders and business closures.

– John P.A. Ioannidis, et al.

Melatonin for Insomnia

sleep, sleeping, girl, young woman
Dr. Emily Deans says if you need an alarm clock to wake up, you’re probably not getting enough sleep

I often get pages from hospital nurses regarding a patient’s request for a sleeping pill. (Or is the request really from the nurse because a sleeping patient is less hassle? LOL.) My hospital’s formulary limits me to ambien, restoril, trazodone, benadryl, and melatonin. Of those, melatonin seems to be the safest. But does it work?

Dr Harriet Hall over at SBM writes this:

The evidence is mixed and weak. There is some positive evidence for melatonin, and side effects are mild. I wouldn’t discourage anyone who wants to give it a try, but I think good sleep hygiene measures would be a better first step for treating insomnia.

Furthermore…

The optimum dosage has not been established. In studies, the doses have ranged from 1 to 12 mg. Supplements typically contain 1-3 mg. Dosages between 1 and 10 mg can raise melatonin levels to 3-60 times the levels normally found in the body.

Caution is advisable, since quality control is a documented problem. 71% of products did not contain within 10% of the labelled amount of melatonin, with variations ranging from -83% to +478%, lot-to-lot variability was as high as 465%, and the discrepancies were not correlated to any manufacturer or product type. To make matters worse, 8 out of 31 products were contaminated with the neurotransmitter serotonin.

If melatonin works by placebo effect alone, it will help ~10% of users, almost always without adverse effects. I dose it at 1.5 mg, with a repeat dose an hour later if needed.

Steve Parker, M.D.

Feds Blame Walmart for Contributing to Opioid Crisis

Photo by freestocks.org on Pexels.com

From New4Nashville:

The Justice Department alleges Walmart violated federal law by selling thousands of prescriptions for controlled substances that its pharmacists “knew were invalid,” said Jeffrey Clark, the acting assistant attorney general in charge of the Justice Department’s civil division.

Federal law required Walmart to spot suspicious orders for controlled substances and report those to the Drug Enforcement Administration, but prosecutors charge the company didn’t do that. 

This could get interesting. Questions immediately arise:

  • Are the Feds trying to deflect blame from themselves?
  • Did Walmart fail to make adequate political contributions and/or bribes?
  • Pharmacists, not pharmacies, are supposed to be on the lookout for illegitimate prescriptions. Where do they stand in this?
  • Will the customers or “patients” be let off the hook?
  • Is this just a bold career move by a stagnant Justice Department bureaucrat?
  • Are the Feds trying to extort Walmart to help reduce the federal deficit?

Are you addicted to opioids and want to tape off and quit? Click for one method.

Steve Parker, M.D.

h/t Knuckledraggin My Life Away

h/t Knuckledraggin My Life Away

Vitamin D Seems to Play a Role in Preventing Severe Illness and Death From #COVID19 #Coronavirus

intubation, mechanical ventilation, ventilator
If you have to be on a life-support breathing machine (ventilator), this qualifies as severe COVID-19 disease. Ventilator is at the bedside out of the picture. To tolerate the tube in your throat, you’ll be in the “medically-induced coma” you read about in the news.

From Northwestern Now:

After studying global data from the novel coronavirus (COVID-19) pandemic, researchers have discovered a strong correlation between severe vitamin D deficiency [based on blood levels] and mortality rates.

Led by Northwestern University, the research team conducted a statistical analysis of data from hospitals and clinics across China, France, Germany, Italy, Iran, South Korea, Spain, Switzerland, the United Kingdom (UK) and the United States.

The researchers noted that patients from countries with high COVID-19 mortality rates, such as Italy, Spain and the UK, had lower levels of vitamin D compared to patients in countries that were not as severely affected.

Our bodies have two source of vitamin D. Our skin can make it if given sufficient exposure to sunlight, or we can ingest it. Many folks don’t swallow and/or absorb enough of it, or don’t get enough sun exposure.

I’ve never been to Europe and readily confess I don’t know much about it. I figured the UK doesn’t get much sunlight, but Spain and Italy do (at least southern Italy). Maybe the heavy air pollution in northern Italy—e.g., Lombardi—blocks out the sun.

trees, forest, sunlight
Not a lot of sunlight penetrating through this forest

The researchers say that vitamin D keeps the immune system from over-reacting to the virus infection. A hyperactive immune system response causes widespread inflammation, which in turn damages various body tissues, leading to severe illness and sometimes death. This is the “cytokine storm” you may have heard about. That’s the theory anyway.

I never knew vitamin D was involved in the immune system, or if I did, I forgot. Like most physicians, my interest in vitamin D relates to calcium metabolism and bone health/fracture prevention.

Professor Backman is quoted in the article:

It is hard to say which dose [of vitamin D supplement] is most beneficial for COVID-19,” Backman said. “However, it is clear that vitamin D deficiency is harmful, and it can be easily addressed with appropriate supplementation. This might be another key to helping protect vulnerable populations, such as African-American and elderly patients, who have a prevalence of vitamin D deficiency.

Clicking this link may take you to the prepublication original research report.

A few days ago, CNN reported that black people are four times more likely to die from COVID-19 than are whites. Here in the U.S., we’ve seen disproportionately high fatalities among blacks living in Chicago, New Orleans, and Milwaukee County, Milwaukee. I’m not the first to wonder if vitamin D deficiency is a contributing factor. I mentioned earlier that our skin makes vitamin D when exposed to sufficient sunlight. But that process is less efficient in darker skin. And folks at more northern latitudes tend to get less sun exposure, particularly in winter. (Lack of sunlight shouldn’t be a problem in New Orleans). We’ve know for years that U.S. blacks have “sub-optimal” vitamin D blood levels. Click for even more reading on this issue if you’re crazy; it’s complicated. Despite low blood levels of 25-hydroxyvitamin D, blacks are not prone to thin-bone osteoporotic fractures like whites and east asians. Some experts suggest that higher rates of diabetes and hypertension in U.S. blacks is related to low vitamin D levels.

What we don’t know is:

  • If you have COVID-19 and try to augment your vitamin D level with a supplement, will you have a better outcome?
  • If you are deficient in vitamin D now but take measures to raise your blood level (via food or supplementation), will you be less likely to contract COVID-19 and able to avoid serious illness if you do get sick?
  • Would the answers to the first two questions depend on whether you have black, brown, white, pink, or polka-dotted skin?

Hey, doc. Tell me something concrete I can do now to improve my odds of surviving this pandemic!

If you’re black of otherwise dark-skinned, I don’t know what to tell you.

If you qualify as a vulnerable person, why not ask your doctor to order a vitamin D blood level (called 25-OH-vitamin D)? If that’s not possible, ask your doc if 1,000 units of vitamin D3/day (cholecalciferol) by mouth is a good idea.

     Steve Parker, M.D.

PS: About a week ago I ran across a study finding that pre-sickness use of vitamin D supplements was linked to worse outcomes in COVID-19. I tried to find it a few days later but couldn’t. I’m sorry if this perplexes you. Welcome to the scientific literature and nature of medical practice.

The Electoral College Declares the President-Elect, Not the Mainstream Media

I’m neither a Republican nor Democrat and this is not a political blog. However I do have at least a little concern that the recent U.S. presidential election was influenced by fraudulent “voting.” Investigations are underway and maybe we’ll have an answer by Dec 14, 2020, the deadline for the electoral college to declare a clear and legal winner. I’m reproducing these tweets here, hoping that they’ll be preserved even if Twitter decides to censor and delete them. Twitter would not allow me to copy one of President Trump’s tweets of Nov 7.

On a lighter note, here’s a pic of a jade plant started from a clipping from an outdoors jade plant from Oceanside, CA, from summer of 2019. It has tripled size since then, but does not do well in 100+ degree heat.

Dr Craig Wax Wants Hospital Price Transparency

Which is less expensive?

The following excerpt was in a letter by Craig Wax to U.S. News and World Report. The final paragraph may be news to you.

IN THE CURRENT DAY [2017], when health insurance and health care delivery are not only regulated, but mandatory for citizens to buy, patients as consumers must know costs. U.S. News & World Report’s annual listing of “Best Hospitals,” based on your rating scales, needs to include hospital service and procedure costs.

Consumer Reports monthly periodical is one such example; it not only reports their definition of quality rating scales but also costs. This is vital for consumers of any product or service to compare all variables, when able. Although, on some health care instances, such as emergencies, you cannot compare when your life or limb may be at risk. However, patients can compare hospitals and other providers of health care service at most other times. In this way, they can develop an understanding of the variables and have a general understanding and preference for facility.

Let’s take the so-called top three children’s hospital pricing schemes.

Most hospitals are designated nonprofit, as are the top three pediatric hospitals in the article. This seems to sound like they are operating at minimal reimbursement margins, but the reverse is true. They set, “chargemaster,” pie-in-the-sky prices but will accept various insurance contract prices as payment in full. Nonprofit is merely a tax designation to dodge business, state and federal taxes, while at the same time, hospitals actively solicit state taxpayer funds and private donations. They seldom offer direct care cash prices due to federal government Medicare health care price fixing.

Please understand that due to federal government Medicare law, that cash prices cheaper than Medicare rates may not be formally offered or posted. The federal government considers it illegal to offer a quality product at a cash discount over Medicare mandated rates.

Source: U.S. News Hospital Rankings Should Include Retail Procedure Costs | Letters | US News

Steve Parker, M.D.

PS: Avoid the medical-industrial complex by getting and staying as healthy as possible. Let me help.

President Trump’s Healthcare Reform Proposals

Somewhere in the Southwest?

Washington Examiner has an opinion piece on Pres. Trump’s proposed (or initiated/) healthcare reforms:

“Patient choice and control are at the heart of Trump’s plan. It includes alternative forms of coverage, such as association health plans and short-term limited duration plans. It invests in telehealth services, which have been critical for patients during the COVID-19 pandemic. It gives major discounts to seniors for their prescription drugs. The plan increases access to direct primary care, which all but eliminates the insurance bureaucracy that decides what patients will and won’t get.

Perhaps most importantly, it requires price transparency, so patients know what services and procedures cost before they are forced to pay for them. It tips the scales in favor of patients to lower premiums and the cost of care. There will be no more surprise billing bankrupting families.”

Click for the President’s September 2020 executive order. I haven’t read it yet.

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet
http://amazon.com/author/steveparkermd Click the link to purchase at Amazon.com. E-book versions also available at Smashwords. com.

What Happened to the Tomatoes of My Youth?

Chicken salad on a bed of greens plus tomatoes

From Appalachian Magazine:

Big, soft, juicy and sweet, America’s tomatoes of yesteryear were culinary delights that were as beloved as any candy.

Whether sliced and heavily salted, slapped betwixt two pieces of bread with mayonnaise, or eaten raw, these tomatoes were nothing short of pure ecstasy and children craved these garden treats!

Fast-forward a handful of generations and American school children are throwing away tomatoes faster than the lunchroom cafeteria workers can slap them onto a tray.

What happened?  Why have America’s youngest fallen out of love with what was once its beloved fruit?

The answer may not surprise you all that much: It’s not that our children have changed, it’s that tomatoes have changed.

Source: A Generation That’s Never Tasted a Real Tomato | Appalachian Magazine

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

Legalized Recreational #Marijuana Increases Traffic Fatality Rates

“By analyzing additional experimental states over a more recent time period, we have provided additional data that legalization of recreational marijuana is associated with increased traffic fatality rates. Applying these results to national driving statistics, nationwide legalization would be associated with 6800 (95% CI, 4200-9700) excess roadway deaths each year. Despite certain methodological differences, we found an increase similar to that reported by Aydelotte et al. They reported an increase of 1.8 fatal crashes (equivalent to 2.0 fatalities) per BVMT. We concur with their opinion that changes may not be detected immediately after legalization but only after a longer time period or after commercial sales begin.”

Source: Change in Traffic Fatality Rates in the First 4 States to Legalize Recreational Marijuana | Emergency Medicine | JAMA Internal Medicine | JAMA Network

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.