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Electro - Neuro -Diagnostics ( END )
The purpose of this site is to provide a collaboration of information, opinions and experiences in the field of Electroneurodiagnostics.What is Electroneurodiagnostics?
Electroneurodiagnostic [END] technology is the allied health care profession that analyzes and monitors nervous system function to promote the effective treatment of neuropathological conditions. Technologists record electrical activity arising from the brain, spinal cord, peripheral nerves, somatosensory or motor nerve systems using a variety of techniques and instruments.
Serum prolactin in seizure diagnosis,
postictal levels of serum prolactin as a way to separate epileptic from nonepileptic seizuresGlass half-full or half-empty?
Robert S. Fisher, MD, PhD
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See the article "Diagnostic value of serum prolactin levels in PNES in the epilepsy monitoring unit" in volume 6 on page 116.
Since the initial paper by Trimble in 19781 highlighting postictal levels of serum prolactin as a way to separate epileptic from nonepileptic seizures, PubMed has logged approximately 300 articles retrievable by the search terms “epilepsy” and “prolactin.” Despite this considerable body of work, the role of serum prolactin in diagnosis of seizures remains uncertain. In this issue of Neurology® Clinical Practice, Abubakr and Wambacq2 evaluated serum prolactin levels 20 minutes after a behavioral seizure–like event in 200 patients undergoing video-EEG recordings in an epilepsy monitoring unit. Using the video-EEG as the “gold standard,” they found prolactin to be elevated in all 22 patients with tonic-clonic seizures, 27 of 32 patients with complex partial seizures, and 42 of 146 patients with psychogenic seizures. For tonic-clonic seizures sensitivity was 100% and for complex partial seizures sensitivity was 84.4%. Overall, elevated prolactin occurred in 84.4% of patients with epileptic events and 28.8% of patients with nonepileptic events. Sensitivity and specificity in this study were comparable to the pooled sensitivity (52.6%) and specificity (92.8%) for all epileptic seizures in a previously published American Academy of Neurology Therapeutics and Technology Assessment Subcommittee review of 10 studies.3
Because the present study includes a large number of patients evaluated at a single center, it provides useful new information on the utility of serum prolactin as a marker for seizures. Certain study limitations need to be considered. As the authors indicate, the study was retrospective and was performed in a selected population of patients referred to an epilepsy monitoring unit. Obtaining prolactin assay 20 minutes after a seizure in the outpatient setting is difficult, although possible by a finger-stick method.4 Some conditions that can elevate serum prolactin, such as syncope,5 are not well represented in video-EEG monitoring populations. The criterion used in this study for identifying elevated serum prolactin is debatable, because different studies3 require either a doubling over baseline or elevation above some absolute value ranging from 16.5 to 45 ng/mL. The absolute value matters; for example, a doubling of serum prolactin from 1 to 2 ng/mL would not represent an impressive increase. My own view is that prolactin should at least double and achieve a minimum value of 15 ng/mL in order to meet criteria for marking an epileptic seizure. Conditions that affect baseline serum prolactin, such as dopaminergic or neuroleptic medications, pregnancy, or pituitary abnormalities, should be excluded.
The main debatable issue with the findings of this study is the conclusion that “serum prolactin levels do not provide any additional support for distinguishing psychogenic nonepileptic seizures from epileptic seizures.” This is an interpretive matter of glass half-full or half-empty. This gloomy interpretation is not supported by the sensitivity and specificity reported in the study. In an epilepsy monitoring unit, prolactin does not provide useful additional information, because the diagnosis is provided (usually) by the video-EEG recording. In other settings, the positive predictive value of a prolactin elevation depends on the a priori likelihood of underlying epilepsy. In certain circumstances, therefore, prolactin measurements might be helpful. One such example would be a negative postevent prolactin elevation in an outpatient with apparent tonic-clonic seizures. In less clear circumstances, prolactin values would simply be a piece of the diagnostic puzzle. A diagnosis of epilepsy or seizures primarily depends on history and clinical impression. Every laboratory test, with the possible exception of video-EEG monitoring (and even that is not perfect), is adjunctive, with false-negatives and false-positives. This study provides cautionary information, but it does not rule out a useful contribution by serum prolactin measurements in a suitable clinical context.
Trickle Down Medicine
ByMarilia GarciaAugust 16, 2017
When looking at annual reports, one could not help to notice the business attitude of healthcare companies in the United States. We spent 3.2 trillion dollars on healthcare last year alone; this is almost three times as Italy’s National budget. The medical industry’s commercialization is growing every year, money increasingly dictates where our health resources are placed. Families are forced to pay an enormous amount of bills when leaving a hospital for a life-threatening emergency. Hence, patients often avoid going to see a doctor because of the fear of overpriced treatments. Commercialized healthcare has made the medicinal world less healing and more destructive. It has affected many aspects like the quality of care, the research being conducted, and the amount of duplicated drugs in the market.
The foundation of medicine is no longer built on saving lives but, rather, bankrolling them.
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In today’s world, patients are lucky their doctor studies their symptoms for more than five minutes. Physicians are given a tremendous amount of cases everyday, which decreases the quality of care each individual receives. Caregivers often view patients as a lead way to their paycheck and not as human beings who desire to be cured. This behavior damages the doctor patient relationship in the healthcare system. According to Roni Caryn Rabin from PBS, the less communication a patient receives, the more likely they are to leave the practice confused or angry. Usually, a doctor that is pressured by time does not listen to every concern the patient has, as a result, these repeated cycles could often lead to medical malpractice. An oncologist in Michigan, was accused of administering chemotherapy to patients with a zero survival rate in order to charge their corresponding insurance (Youn, CNN, 2013). This incident clearly depicts one of the many faults of the subsidized medicine in the United States.
A study performed in 1999, encountered that physicians would only allow the patient to speak for 23 seconds before deflecting them onto another subject, and only one in four patients were able to complete their phrase ( Rabin, PBS, 2014). Doctors are given substantial amounts of cases to review in short periods of time, which could make mindful diagnosing close to impossible. If the caregiver is not listening to the patient’s concerns, this may impair his or her ability to gain awareness to what is going on. From working in a medical practice, I have discovered that patients are often scheduled between 5-10 minute intervals. There are cases that tend to be more complex and therefore slows down the consultation. As a doctor, when patients are in a room, you move your wrist to see the time and realize you are more than ten minutes late. Therefore, they start speeding the process in order to be able to finish on time. In many areas of work, people hurry to finish the last task on their desk, but the main difference here is that these aren’t files to be put in a cabinet, but someone’s life that is at stake.
“As a physician you are not only avoiding mortality but aiding morbidity” As Laura Lacquer, a Harvard MD graduate describes, medicine is not always about saving a life but improving the quality of it as well. Trusting a physician is one of the main aspects of health care, but once this relationship occurs in a commercialized environment, the patient should be filled with doubt. When a person being treated believes she is just a number, her trust can quickly dissolve. Who has not heard the allegations that doctors only want your money? This complaint comes directly from people who are under a system that involves subsidized medicine, in which they are often treated as a statistic.
Research is the overlooked blueprint of the medicinal world, commercialization of medicine as a whole, deeply affects the research being conducted. For instance, Stem cell research is currently at its peak of popularity, which provides a perfect ground for commercialization to take place. Therefore, the funds are given to study only the elements of Stem cell than could be easily distributed to the general population. Company executives will usually pressure scientists to follow their agenda for more profitable products and thus skew the research conducted. The powerful companies funding the research are not looking for breakthroughs, but are more determined to market the findings afterwards. The companies that provide the capital lead academic institutions to focus on a specific product. There has even been evidence found of data withholding when commercialized research takes place. This is, perhaps, the most alarming part of it all, research data is hidden from the public because it just is not profitable.
A news entry from S.Z Berg, a journalist from the Huffington post, followed a family with a daughter that suffered from a rare disease called Sanfillipo Syndrome- Type A. The family went to extreme lengths to find funding for their daughter’s rare disease, since government funding would not cover it. According to Berg’s article, there are more than 6,000 unexplained diseases that affect anywhere from 20 to 30 million people. These diseases do not acquire government funding because the treatments would not be lucrative. These are millions of families left with no explanation or cure to their loved one’s sickness. Medicine should not be driven on quantity basis. We all have the same body, but the way our bodies react is always different. There is not a formula that will fix any human being therefore, why are we treating people based on quantity?
The pharmaceutical sector in commercialized medicine is perhaps the most troubling. A drug needed for life-threatening purposes could be increased, in price, any percentage a company would want. In an article by Mathew Herper, a Forbes journalist, the false inflation of a drug’s price in the U.S is shown after seeing the same drug being sold at a steady price all around the globe. The article sets its focus on a steroid called deflazacort, the steroid is used to treat children with muscular dystrophy. Deflazacort contains fewer side effects than other steroids in the market. The drug was sold initially from 1,000 to 2,000 dollars a year, and was increased to 89,000 USD after being FDA approved. Only 7 to 8 percent of the people had access to the drug as a result of the price increase. These price increases would make the drugs unattainable for many low-income families. There were many times that my dad, a chronic gout sufferer, would obtain his pain management medicine from Cuba, simply because the price in the U.S was out of his reach. This overpricing also leads to duplication of drugs in the market, which can create an adverse situation. Many of the duplicate drugs are not well regulated and can cause dangerous side effects.
A lot of the medication prescribed is often due to courtship provided from drug companies to medical practices. In my experience, working in a pediatric office, lunch was provided from these companies and they would hold presentations with the doctors regarding the drugs. Some companies would visit more often, which meant that we used their drugs more frequently. This was always kind of concerning to me, how is it that they are lobbying medication? In many instances they were doing just that. I would notice that after these meetings there was an increase in these drugs being prescribed.
Admittedly, there are also some benefits to commercializing medicine, the research that is profitable will in fact be able to help some patients. Therefore, patients are at least being treated by a physician, even if they are not receiving the best care. Some patients will not need more than 5-10 minutes with a doctor. Furthermore, the increase in the price of pharmaceuticals will still reach a percentage of patients and duplicate drugs, are there as an optional route? Yet, I would argue that the negative outweighs the positive in this situation. The healthcare industry should not commercialize people’s health. It is very dangerous to bring in a business in which corresponds to saving people’s lives. Quantity doesn’t wave quality in this instance. Money playing a major role in medicine could cause unethical outcomes in which human beings are seen as currency (McCormick, 2010).
The future state of healthcare in the US seems to keep declining, even though there is an awareness of the problem with commercializing medicine, the infrastructures of the capitalist system keep encouraging this behavior. The amount of revenue does not reflect success within the medical field, but rather, the loss of humanized care. Commercializing healthcare not only affects the quality of care the patient receives, but the research being conducted to better morbidity. The relationship between a patient and their doctor should be as honest as it can be to avoid malpractice and distrust. All three sectors of medicine should be held to the same transparent standards. Spreading awareness of this issue, will help make the future of medicine brighter. Patients deserve to hold certainty that their caregiver is trying everything in their power to aid them.