A touch of MS: therapeutic mislabeling.

When psychogenic symptomatology is at play, a spectrum of ethical problems and considerations arise when patients want, and at times, insist on being given an inaccurate neurologic diagnosis. We use the example of multiple sclerosis (MS) to highlight the value considerations for clinicians when they face these types of cases. Given the ambiguities involved in its diagnosis and the significant risks of its treatment, MS represents a rich case study. This discussion highlights the potential harms of mislabeling such patients with MS when the neurologist is confident they do not have MS and offers suggestions about how to approach and manage these patients. Despite being expedient and well-intentioned, labeling psychogenic symptoms with a medically inaccurate diagnosis, such as a "touch of MS," constitutes a "therapeutic mislabeling" and sacrifices ethically important values incommensurate with the benefits gained.

Ethics consultations in stroke and neurological disease: a 7-year retrospective review.

BACKGROUND AND PURPOSE: To describe the reasons for and methods of resolution of ethics consultations conducted in neurological and neurointensive care units affiliated with a single health care facility. METHODS: We performed a retrospective review of all ethics consultations contained in the Cleveland Clinic Ethics Database from 1998 to 2004 involving patients from neurosurgical and neurological units. Forty-nine eligible consultations were identified and all patients had primary neurological or neurosurgical diagnoses. Primary outcome measures were reasons for ethics consultations and the methods for resolution. RESULTS: The most common diagnoses of patients who received an ethics consultation were stroke (total 26; ischemic stroke 12, intracerebral hemorrhage 10; subarachnoid hemorrhage 4) and brain tumor (7). The most frequent reasons for consultations were withdrawal of life support/futility (15), conflict (8), and capacity evaluations (7). The main reasons for consults were not statistically different in stroke versus non-stroke patients. However, a subgroup analysis of withdrawal of ventilatory support/futility reasons found significant differences between the groups (P = 0.0003, Fisher's exact), particularly in the frequency of issues related to death by neurological criteria (DNC) and requests for aggressive medical care despite poor prognoses. In 53% of consultations, the consultant organized and led meetings with family members, half of which were attended by the primary attending staff. CONCLUSION: Although there may be a role for ethics consultations in neurological practice, future studies are needed to better clarify how to optimize their use.

Multiple sclerosis symptom management.

Multiple sclerosis (MS) is the most common cause of nontraumatic disability in young adults. The increasing emphasis on early treatment with disease-modifying therapies has the goal of preventing long-term disability. However, current disease treatments are only partially effective, and most patients experience a variety of neurologic symptoms at various times during their disease course. Because these symptoms often have a profound impact on social, occupational and physical performance, effective symptom management is an important component of therapy to maintain quality of life. Effective symptom management often requires a multidisciplinary team approach. This review outlines general principles of the management of MS symptoms.

Neurointensivists' opinions about death by neurological criteria and organ donation.

INTRODUCTION: Neurointensivists are at the front line of treatment of patients who progress to death by neurological criteria (DNC). Although some of these patients will become organ donors, there has not been a systematic evaluation of the opinions and resources available to neurointensivists in regard to these important issues. METHODS: We conducted a survey of neurointensivists regarding controversial issues in the declaration of DNC, procedures for discussing death and approaching donor families, and participation in donation after cardiac death (DCD). RESULTS: The majority of centers described by the respondents had all five most commonly accepted ancillary tests to determine DNC (61%). Radionuclide blood flow studies are the most frequently reported test used (64%). Younger physicians are more likely to use trans-cranial Doppler exams (TCD) than their older counterparts (41% versus 28%, p<0.001). Discussions about DNC with the family are most often presided by the attending physician, and donation requests are most commonly initiated by organ procurement organization (OPO) representatives, but there is significant variation from center to center. Nine out of 10 physicians in our survey reported that they are likely to participate in DCD. CONCLUSION: Despite this enthusiasm, there is no clear consensus on many of the issues surrounding DCD, including how long after cardiac cessation recovery should begin. We believe that this study will serve as a springboard for more discussion about the diagnosis of DNC, the role of physicians in organ requests and donor management, and the procurement of organs through DCD.

Excellent outcome in infants and small children with thrombophilias undergoing kidney transplantation.

One of the most common causes of early graft failure in children undergoing renal transplantation is vascular thrombosis. Numerous risk factors for graft thrombosis have been previously described. Children with various types of thrombophilias such as protein C, protein S and factor V Leiden deficiencies are at an increased risk for vascular thrombosis. Infants and small children with these disorders undergoing renal transplantation have not been well documented in the literature. We reviewed our experience in the diagnosis, peri-operative management and follow up of these patients at our institution. A retrospective analysis of all children undergoing renal transplantation at our institution, using data obtained from the Pediatric Transplant Registry at our institution since May 2000 was performed. The indications for renal transplant included focal segmental glomerulosclerosis, renal dysplasia and reflux nephropathy. One patient had factor V Leiden mutation and two patients had protein S deficiency. Patients were anticoagulated in the peri-operative and post-transplant period. All index transplants were performed with living donor kidneys. There were no adverse outcomes in children with thrombophilias despite having significantly lower weight at the time of transplant vs. children without thrombophilia. The incidence of graft thrombosis in the pediatric renal transplant recipients is high. We identify a potential cause of thrombosis in children not well documented in the literature. A high index of suspicion combined with preoperative screening and diagnosis of thrombophilias and an appropriate treatment plan may decrease the incidence of graft thrombosis in infants and small children undergoing renal transplantation.

Dual-kidney transplants: long-term results.

BACKGROUND: Dual-kidney transplantation, where two usually aged adult kidneys are placed into an adult recipient, is one way to help alleviate the continuing disparity between the number of patients on the kidney transplant waiting list and those who receive kidney transplants each year. The Dual Kidney Registry was developed to analyze donor and recipient data and outcomes at several centers. METHODS: Two hundred eighty-seven patients who have undergone transplantation since 1994 have been entered into the relational database. The patients were followed yearly after initial entry into the database. RESULTS: The mean donor age was 58+/-13 years and the mean terminal creatinine clearance was 77+/-40 mL/min. The mean glomerular sclerosis on procurement biopsy was 16+/-13%. Delayed graft function (DGF), defined as dialysis in the first 7 days after transplantation, was a predictor of poor outcome, and increased cold storage time was a predictor of DGF. The overall incidence of DGF was 27%. In recipients with prompt graft function (PGF), the mean cold storage time was 22+/-9 hr versus 29+/-10 hr in recipients with DGF (P<0.001). The overall 1- and 5-year graft survival was 86% and 69%, respectively. The 1- and 5-year graft survival rates were significantly better in recipients with PGF (90% and 74%) versus DGF (79% and 54%) (P<0.002). CONCLUSIONS: Cold storage time and DGF have a significant impact on the 1- and 5-year graft survival in recipients of dual-kidney transplants. The 5-year graft survival in recipients of dual-kidney transplants is excellent.