10 Conditions Parents Often Misdiagnose

The article below was sent to me by the staff at the National Nannies website and per their request, I have decided to feature part of it here because I thought that some of the points are well-made.

One of the roles we play as parents on occasion is that of family physician. Recognizing and treating minor ailments and then deciding whether a doctor visit might be in order is all in a day’s work for most moms and dads. That’s not to say our diagnoses are always right; we do get it wrong on occasion too, and here are some common illnesses and ailments that trip us up. The following is a list of the 10 most misdiagnosed kids’ ailments by parents:

1. ADHD – Parents will often interpret the signs of this disease as being indicative of a disruptive or unruly child. It is necessary to conduct testing to ascertain that the child is indeed suffering from Attention Deficit Hyperactivity Disorder.
2. Asperger’s Syndrome – Parents of children with Asperger’s Syndrome will frequently confuse the symptoms with autism. Naturally, either case requires a professional diagnosis, but initial tendency is for parents to lean towards their child having autism unless proven otherwise.
3. Bacterial Meningitis – Sharing many of the same symptoms of the flu such as fever and headaches, bacterial meningitis is often mistaken for the more common flu. Light sensitivity, seizures and skin rashes may also accompany those symptoms.
4. Vocal Cord Dysfunction (VCD) –This illness is characterized by sudden, abnormal narrowing of the vocal cords, which results in obstructed airflow and a wheezing sound during breathing. This is frequently misdiagnosed by parents and doctors alike as asthma.

For more, see the original version is at this link.

The Mickey Mouse Sign in Medicine: part 4

Today is the fourth and last example of the Mickey Mouse sign in the field of medicine. The image below comes from a 63-year-old man with diabetes mellitus who underwent ultrasound scanning of the femoral arteries (types of arteries in the legs). The picture below (presented in this article) shows a Mickey Mouse appearance formed by the presence of a blood clot in the legs.  Such blood clots are not always associated with symptoms and can be deadly. The presence of the Mickey Mouse sign on such scans helps identify such blood clots much easier. Be sure to check out the first, second, and third examples of the Mickey Mouse sign. The image below is copyrighted by BMJ Publishing Group Ltd & the British Association for Accident and Emergency Medicine.

The Mickey Mouse Sign in Medicine: part 3

The third way in which the Mickey Mouse sign can show up in medicine is via ultrasound scanning in the detection of anencephaly. Anencephaly is the absence of a large part of the brain and the skull. It is the most common abnormality affecting the central nervous system (brain and spine). Most babies born with this condition do not survive birth. The picture below (copyrighted by Wiley from this article) shows the appearance of a Mickey Mouse face on the ultrasound. In reality, it is showing a large amount of protruding, abnormally developed brain tissue. The sign was first identified in 1994 and its presence helps diagnose anencephaly early in pregnancy. Be sure to check out the first Mickey Mouse sign, the second Mickey Mouse sign, and the fourth Mickey Mouse sign.

The Mickey Mouse Sign in Medicine: Part 2

Today is the 2nd example of The Mickey Mouse sign in the field of medicine. What you will see in the picture below is an image from a coronary angiography of a 58-year-old man presented in this article. An angiography is a technique that produces a picture of the inside structure of blood vessels. You will see two large black circles shaped like Mickey Mouse ears, which is an aneurysm. An aneurysm is a balloon-like expansion of a blood vessel due to weakening of the blood vessel walls. Be sure to also see part one, part three, and part four of the Mickey Mouse sign.The image below is copyrighted by the American Heart Association.

The Mickey Mouse Sign in Medicine: Part 1

Mickey Mouse was created by Walt Disney in 1928. His impact has been felt all over the world, including the field of medicine. If you have children, your pediatrician’s office likely has pictures of Mickey to make it more comforting. For the same reason, pediatric nurses often wear Mickey on their clothes, children are sometimes given Mickey Mouse stickers, and Mickey Mouse cartoons may be playing in the waiting room. But beyond the obvious use of Mickey Mouse in pediatric medicine, Mickey Mouse has managed to show up in various images of the body, all of which are referred to as Mickey Mouse signs. In the next four blog entries (excepting the MedFriendly Blog contest over the weekend), I will provide four examples of the Mickey Mouse sign in medicine.

Case 1 involves a 55-year-old woman with breast cancer who underwent a bone scan to determine if the cancer had spread to the bones. In the picture of the spinal area below, the Mickey Mouse sign is the black area seen in the 2nd lumbar vertebrae (lower back). The black pattern of three dots shows areas in which the injected radiotracer was absorbed by the bone. The finding was consistent with Paget’s disease, which is a form of chronic bone inflammation and rapid bone destruction that distorts the bone structure. As a result, unusual patterns can present on bone scan images, including the Mickey Mouse sign. Come back tomorrow to see another Mickey Mouse sign. The image below was featured in this free article and is copyrighted by the Society of Nuclear Medicine. Be sure to see part two, part three, and part four of the Mickey Mouse sign.

Why Kermit the Frog Rules

Kermit the Frog is the undisputed leader of the Muppets and his presence dates back to 1955. He’s the only Muppet to be featured prominently of The Muppet Show and Sesame Street. Kermit the Frog is used here as a symbol for all sorts of frogs (and toads), which play an important role in medical science. If you think back to middle school or high school, you likely had to dissect a frog in science class to learn about different parts of the body. For many children, this spurred further interest in the inner workings of the body and turned many on to the biological sciences.  

Observations of frog deaths and body malformations in frogs have been taken by some to be warnings of possible environmental effects on humans. Scientists have also genetically engineered headless tadpoles, which led to speculation that headless people may be genetically created in the future for organ donation harvest. Frogs have been used to study the effects of space flight, which include changes in the lungs, tails, growth, and behavior. Although frogs may sound like perpetual victims (it’s not easy being green), they are actually a resilient species, being one of the unexpected survivors from the Mt. St. Helens volcanic eruption. In fact, the western toad experienced a population boom there because they fed of the algae that resulted from the lack of lakeshore trees and because their predators (snakes and birds) had not yet recovered. The findings helped ecologists better understand the resilience of some species and ways that some species can survive natural disasters. Yes, folks, Kermit the Frog truly rules and science owes him a lot.

If you liked this entry, you may also like Cookie Monster is Not Autsitic

Reference: Am J Med Genet. 2001 Nov 22;104(2):99-100. Is Kermit the frog in trouble? Cohen MM Jr

10 Ways to Mismanage Your Patient's Heallthcare

Below is a satirical and easy to follow recipe to quickly and easily mismanage your patient’s healthcare. By following these steps, you too will be able to conceptualize cases improperly, misdiagnose people, and order improper treatments.



STEP 1: Overbook your patients: Schedule so many patients each day that you cannot possibly spend ample time with them or see them back for timely follow-ups. This step is not essential, but doing so allows the next steps to occur more easily.

STEP 2: Do not take a thorough history: Although a patient’s history usually provides essential clues to properly conceptualize cases, ignoring important aspects of the history such as family medical/psychiatric history, personal psychiatric history, history of substance abuse, and history of trauma helps get the interviews done faster so you can move on to the next patient. These topics are the easiest to discard because they are the most uncomfortable to discuss, despite the potential value they provide in understanding the current patient presentation. Do not obtain the patient’s medical records because this takes too much time as opposed to only relying on self-report.

STEP 3: Do not use any objective criteria for diagnosis: The diagnostic process is much faster and easier when relying purely on clinical intuition as opposed to a combination of intuition with objective diagnostic criteria. Doing so requires no standard and allows you to diagnose all sorts of conditions purely because you say so. This step also allows you to make up your own name for some medical conditions.

STEP 4: Prescribe unproven treatments: With no solid foundation for a proper diagnosis, you are now ready to move on to the step which involves prescribing medications, therapies, and use of various medical devices and techniques that have little to no scientifically validated evidence to support their use. If a proven treatment is available, ignore that and use the unproven one.

STEP 5: Do not coordinate care with other medical providers: If your patient is followed by multiple physicians, make no attempt to account for the patient’s numerous medications and the ways in which taking one can interfere with another or cause various adverse reactions.

STEP 6: Make no attempt to objectively measure treatment progress: Once the treatment is selected, keep it ongoing indefinitely and do not use objective measures it to check if it is successful. Simply rely on patient self-report and maintain the same general treatment approach if symptoms are still endorsed. Having no criteria for discharge is a bonus here.

STEP 7: Never alter case conceptualization: Once an initial diagnosis is settled upon (see step 3) do not alter it even if symptoms are reported indefinitely. Do not try to gather new information to figure out why this is happening but if new information arises, simply ignore it if it does not comport with the original diagnosis. Continue with the prior steps.

STEP 8: Do not refer to specialists: Since you already know the diagnosis and proper treatment, do not send the patient for evaluation by a specialist for a second opinion. This is the worst thing you can do because it may lead to an altered case conceptualization or different treatment approach. This is especially true if the specialist uses objective scientific approaches to patient care. The only exception to this rule is if you know of a specialist(s) who always agrees with you.

STEP 9: Make no attempt to measure symptom validity: Trust all subjective symptoms as accurate and make no attempt to measure (or refer to someone who can measure) symptom under-reporting or over-reporting in cases where the context would indicate it is appropriate to do so. Thus, if a patient has a severe medical problem but denies significant symptoms and wants to be released for certain activities, do this without considering reasons for why this may be the case (e.g., poor insight in a possible dementia case; desire to be normal again). Similarly, if a patient suffered a mild medical problem but reports severe symptoms grossly disproportionate to the event, make no attempt to assess for (or refer to someone who can assess for) why this may be the case (e.g., exaggeration to obtain medication and/or compensation benefits).

STEP 10: Do not keep up with the scientific literature or just ignore it: This step allows you to remain unaware of new scientific developments and maintain one’s accustomed way of doing things. If you become aware of research that suggests you should consider a different diagnostic and treatment approach, ignore it and continue with the old approach.

More Medical School Secrets Revealed

March Madness, Syracuse vs UNC Asheville, & the Science of Referee Bias

Tonight, during March Madness, the main story was about the game between the #1 seed in the East (Syracuse) and the #16 team, UNC Asheville. As a disclaimer, I am a HUGE Syracuse fan (LET’S GO ORANGE). Besides the possibility of the near upset that took place, the biggest aspect of the story was several calls by the referee that went against UNC Asheville that helped Syracuse.


This included a no goal tending call when goal tending seemed to take place, a lane violation call towards the end of the game that actually was correct, and the referees giving the ball back to UNC Asheville after the ball bounced off of Syracuse player, Brandon Triche, followed by a UNC Asheville player hitting into him. There was some question as to whether Triche was fouled before the ball went off of him, causing him to go out of bounds.

Ok, so what does all of this have to do with anything medical you ask? Good question. Nothing. But MedFriendly is a site that not only explores medical topics but psychological topics as well. Part of psychology is the study of bias. Some UNC Asheville fans believe that the officials were biased against them, which is what resulted in the calls above.

So, I tried to see if anyone had explored the notion of officiating bias scientifically in college basketball. I found one study, performed in 2009. The study examined officiating bias (in terms of foul calls) in 365 NCAA basketball games during the 2004-2005 season. Results indicated that officials are more likely to call fouls on the team with the fewest fouls, making it likely that the number of fouls will tend to even out during the game. The greater the difference of fouls between the two teams, the higher the probability that a foul would be called against the team with fewer fouls. The researchers found a significant bias towards officials calling more fouls on the visiting team (probability as high as 70%), and a bias towards foul calls on the team that is leading.

All in all, the evidence indicates that there was not bias against UNC Asheville by the referees because they met all conditions in the study by which one would expect bias to be in their favor as opposed to Syracuse. That is, they were losing at the time, had less fouls (Syracuse was in the bonus), and technically were considered the visiting team on a neutral court due to their lower seed and greater distance from their home geographical location. Ok Syracuse. Now go beat K-State!

American Idol, Coca-Cola, and Obesity

So, I am sitting at home and the popular show American Idol is on. Randy Jackson has a red shirt on, which is color coordinated with a large red Coca-cola cup. J-Lo is sitting by his side, also with a red Coca-Cola cup. Same with Steven Tyler.  When one of the artists takes the stage, there is a large red moving video banner promoting Coca-Cola. It’s called product placement and it has been going on for decades on television and the movies. There is nothing wrong with it of course, but in the case of Coca-Cola, the situation gets a little more interesting because some worry that such advertising may be contributing to the obesity problem in children.

In 2011, researchers from the Rudd Center for Food Policy and Obesity in New Haven, CT, published a study examining the number of food, beverage, and restaurant brand appearances within shows during prime-time programming examined by Nielsen in 2008. Items were analyzed by product category and company as well as exposure to children adolescents, and adults. They found that food, beverage, and restaurant brands appeared 35,000 times prime-time TV programming (60% of which were energy/sports drinks). It was noted that young people were rarely exposed to this type of advertising with on exception…

“Coca-Cola products were seen 198 times by the average child and 269 times by the average adolescent during prime-time shows over the year, accounting for 70% of child exposure and 61% of adolescent exposure to brand appearances. One show, American Idol, accounted for more than 95% of these exposures… Coca-Cola has pledged to refrain from advertising to children, yet the average child views almost four Coke appearances on prime-time TV every week. This analysis reveals a substantial, potential loophole in current food industry self-regulatory pledges to advertise only better-for-you foods to children.”

While this may make it sound like Coca-Cola has violated their pledge, they really have not when you read their pledge carefully. Here is the relevant section:

 “…we are committed not to directly market messages for any of our beverages to children under 12. We have historically not placed – and continue the practice today of not placing – advertising for any of our beverages on any media that is primarily directed to, and has an audience of 50% or more, children under the age of 12.”

First, as you can see, it is not correct to say that Coca-Cola has pledged to not advertise to “children.” Rather they pledged not to directly market their products to children under 12 with a specific audience make-up.  Secondly, I do not see how one can make the argument that a few Coca-Cola cups and a Coca-Cola banner on American Idol would be directly marketing to children. Direct marketing to children would be showing Bert and Ernie chugging down a Coca-Cola after singing the alphabet or Sponge Bob and Patrick singing about how good Coca-Cola tastes when paired with a Krabby Patty.

Third, American Idol, which was singled out in the study, gets about 25 million viewers. Of these, about 2 million are estimated to be in the 2-11 age range. That’s 12.5% in that age range which is far from the 50% number in the Coca-Cola pledge. Lastly, for other prime time TV shows, young children will not make up more than 50% of the demographic group because the shows are on too late at night. This is why children’s programming is predominant in the morning and the day. All in all, it seems to me that Coca-Cola has maintained their pledge and has not exploited any type of loophole.

March Madness Associated Deep Vein Thrombosis

March Madness officially started last night. In fact, as I am typing this I am watching Iona take on BYU (great comeback BYU!). This is a great time of year for any college basketball fan because you have several days in which most of the time is taken up with continuous games. This means lots of opportunity to sit or lay down for prolonged time periods. Remaining immobile for long time periods, however, can cause deep vein thrombosis (DVT), which is clot formation in a deep vein. If this clot dislodges, it can be fatal in about 3% of cases in which the clot came from the lower extremity.

While DVT formation can be caused by any form of prolonged inactivity, one group of clinicians at Walter Reed Army Medical Center reported a case of March Madness associated DVT formation in an 83-year-old man. One of the signs of a DVT is edema (swelling), which was first noticed in this man after a full day of sitting and watching March Madness. He had recurrent prostate cancer which was felt to be contributory to the DVT, but that prolonged sitting from watching March Madness was a significant contributory factor to clot formation. Patients with a hypercoaguable state (blood disorder leading to clot formation) increases the risk further. The authors recommended the following steps to prevent DVT formation: decreased alcohol and caffeine intake, drinking a liberal amount of water and fluids, and standing at regular intervals to stretch and promote circulation.

Reference: South Med J. 2005;98(3):396. March madness-associated deep vein thrombosis. Wilson RL, Ritter JB, Roy MJ

MedFriendly Website Recommendation #1: The Khan Academy

Tonight I stumbled across a very cool non-profit educational website that I wanted to share with you. It’s called The Khan Academy. Although it may sound like a place you send someone to learn karate, it is actually a website filled with thousands of micro lectures via video tutorials. The topics are very broad and include healthcare, medicine, biology, chemistry, and organic chemistry.

Examples of lectures in healthcare and medicine include one on diabetes, normal colon tissue, colon cancer, vitamin C, and drug pricing. There are many other topics covered outside of healthcare as well including math, the humanities (e.g., history, finances), and much more. The site is funded by donations, such as from Google and the Bill and Melinda Gates Foundation. So check out the site and I think you will find it a worthy bookmark.

Daylights Savings Time & Fatal Car Accidents

This weekend was daylights savings time, the one everyone dreads because you lose an hour of sleep. Sometimes, daylights savings time comes as a surprise to people who forgot about it or who did not realize it was coming.

Some people may know it is coming and adjust their clocks appropriately, but still wake up late because their bodies have yet to adjust. One potential risks of sleep disruption from spring daylights savings time is fatal car accidents. In the fall, you gain the much beloved one extra hour of sleep. There is some evidence for increased and decreased numbers of car accidents after fall daylights savings time. Increased car accidents after fall daylights savings time may be due to staying up longer than usual. Decreased car accidents after fall daylights savings time may be due to some people sleeping an extra hour that night.

An interesting study was performed in 2001 to examine the association between daylights savings time and fatal car accidents in more detail. The researchers examined data from 21 years of United States' fatal automobile accidents. The average number of accidents on the days at the time of daylights saving time shifts (Saturday, Sunday and Monday) was compared to the average of accidents on the matching day of the weeks before and after the shift. This was repeated for each daylights saving time shift.

The results of the study showed that there was a significant increase in accidents for the Monday immediately following the spring shift to daylights savings time. There was also a significant increase in number of accidents on the Sunday of the fall shift from daylights savings time. No significant changes were observed for the other days.

The authors concluded that sleep deprivation on the Monday following a shift to spring daylights savings time results in a small increase in fatal accidents. For fall daylights savings time, the authors concluded that the behavioral changes associated with anticipating the longer day on Sunday led to an increased number of accidents. This suggested an increase in late night (early Sunday morning) driving when traffic related fatalities are high possibly related to alcohol consumption and driving while sleepy.

The authors recommended that public health educators should probably consider issuing warnings both about the effects of sleep loss in the spring shift and possible behaviors such as staying out later, particularly when consuming alcohol in the fall shift. The authors concluded that physical and behavioral responses of the body to forced circadian rhythm changes (the body’s biological clock) due to daylights savings changes are important factors for sleep clinicians to be aware of.

Suggested reading: Daylight Savings Time Change May Increase Heart Attack Risk.

Reference: Varughese,J., Allen, R. (2001). Fatal accidents following changes in daylight savings time: the American experience. Sleep Med., 2(1):31-36.

Pink Slime in Your Children's Hamburgers

One of my favorite shows on TV is “Good Eats” with Alton Brown. If you have not seen the show, he focuses a half hour episode on a particular food product and he teaches you how to prepare certain meals from it along with interesting historical and scientific tidbits. Last weekend, I tuned into a show he did on hamburgers. He showed a very easy way to make your own burgers by purchasing fresh cuts of beef and grinding it yourself. If that sounds too time consuming, it isn't because you can easily do it with 10 pulses in the food processor. If you grind the beef yourself, you can feel much more comfortable about what is in your burger as opposed to purchasing the beef in an already ground up form.

The reason the above is important is because I have recently become revolted by the revelation that most ground beef products humans are eating (primarily from fast food restaurants) contain something known as “pink slime.” Pink slime (see above) is a nick name for a filler substance made from previously inedible cuts of beef that are made edible through a spinning separation process that involves treatment with water and ammonia. I used to add ammonia to a mop bucket and hot water when I mopped floors as a kid. It is not something that should ever be added to food. I used to think that I could trust the ingredients label on the package to know what was in my food, but as it turns out when pink slime is used, it is not listed and neither is the ammonia present. This is because the FDA does not view ammonia as an ingredient but part of a “process.” This makes no sense whatsoever because all cooking is a process and if a substance is being added to my food, especially if it is a chemical, I want to know about it. This is why I have dramatically changed my eating habits and that of my children after writing the blog entry called: Does Your Kids Cereal Contain BHT or BHA? – Mine Did.

Fortunately, many fast food chains now say that they are pulling “pink slime” from their food products. Unfortunately, many school cafeterias are still serving it to children and they use it as a filler as opposed to using originally edible meat. The FDA says pink slime is safe, but even if you believe that, why would anyone want to feed this to your children. Don’t get me wrong, enjoy a hamburger, but do it right and make sure the meat is actually real and do it yourself for the best results. The video below is really a must see for those who want to be educated more about this issue.

Why I Don't Go to the Doctor on My Birthday

Today is my birthday and I am NOT going to the doctor. You may be wondering why I am mentioning this, but there are a subset of people who go to the doctor on their birthday, despite the fact that most people try to avoid doing so. This applies not only to regular doctor visits but also to surgeries – most people try to avoid doing this on their birthday. Dr. Stuart Handysides (terrific name by the way) decided to study why some people decide to go to the doctor on their birthday and published his findings last year in the British Journal of General Practice (full reference below). He looked back at his files for 10 years (2001 to 2010) to identify such individuals and tabulate the reasons.

Dr. Handysides identified 30 people who did this, ranging in age from 1-90 (16 males, 14 females), with a modal age of 50 to 59 years. As it turns out, most of the people (10 of the 30) went in for an acute medical problem. As the author points out, if you have an acute medical problem you usually seek help when you need it, regardless of the day. However, such patients often express disappointment that their birthday has been taken up by a medical appointment. That being said, not every person seeks medical care the same day of acute symptom onset so Dr. Handysides speculated that a presentation to a doctor on a birthday signifies a more serious problem. Alternatively, he suggested that it may reflect a desire for reassurance that everything is ok on their special day. Another possibility, however, is that some people don’t care too much about their birthday and may not care about going to the doctor on a birthday.

It is interesting to note that in the study, that birthday consulters visited their general practitioner about 6.5 times a year which is almost double the normal average. Three people died on the year they consulted on their birthday, one of whom was the only patient in the study who consulted on two birthdays. The death rate of the birthday consulters was twice as high as non-birthday consulters. Interesting stuff and it may all be coincidence but I am happy that on my birthday, I am not going to the doctor. Special thanks to Dr. Handysides for sending me a copy of his article.

Reference: Br J Gen Pract. 2011 Sep;61(590):575-6.Characteristics of patients who consult their GP on their birthdays. Handysides S.

Move over Lite Brite...Child Swallows 37 Buckyballs

I remember when I was younger and I accidentally swallowed a Lite Brite peg, which was a small peg-shaped piece made of hard plastic. Fortunately, it was only one and there were no serious problems or complications that resulted. No one really uses Lite Brite anymore unless you have one of these relics in your attic. Instead, kids these days play with virtual Lite Brite, one of the iPad app. None of those kids will swallow any plastic pegs. But instead of Lite Brite pegs, parents now have something new to be careful about --Buckyballs.

If you have not heard of Buckyballs (or Buckeycubes), they are high powered colored magnets (pictured above) that can be connected to make all sorts of artistic designs and objects. Although they are not children’s toys, their color and shape makes them look appealing and fun to play with for children. Children have been known to put these objects in their mouth, perhaps because they look like some types of colored candies. Older children put them in their mouth to simulate a tongue piercing. Overall, 22 children are reported by the Consumer Product Safety Commission to have ingested small magnets.

In Oregon, a 3-year-old girl recently swallowed 37 Buckyballs, which then connected together in the child’s intestines. Because the magnets were so strong, when they connected they tore three holes in her intestines and one in the stomach. This required surgery to remove the Buckyballs and fix the tears. She is fortunately expected to make a full recovery. Signs and symptoms of magnet ingestion includes pain, nausea, vomiting and diarrhea. Of the 22 children who ingested magnets, 11 needed surgery. Don’t let the next one be your child. Keep these small objects away from the little ones if you have them.

My First Book Available for Pre-Order on Amazon.com

I am happy to announce that my first book (Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering) is now available here for pre-order at Amazon.com and will be released on 7/1/12. The entry lists a brief description of the book, which was co-edited by my colleague, Dr. Shane Bush. Amazon does not yet list the Table of Contents, but a sneak preview is presented below. A final version of the cover should be ready soon, with the picture to the top left showing a prior version.


Preface

1. Introduction: Historical Perspectives on Mild Traumatic Brain Injury, Symptom Validity Assessment, and Malingering

2. The Role of Clinical Judgment in Symptom Validity Assessment

3. Ethical Considerations in Mild Traumatic Brain Injury Cases and Symptom Validity Assessment

4. Differential Diagnosis of Malingering

5. Noncredible Explanations of Noncredible Performance on Symptom Validity Tests

6. Providing Feedback on Symptom Validity, Mental Health, and Treatment in Mild Traumatic Brain Injury

7. Research and Symptom Validity Assessment in Mild Traumatic Brain Injury Cases

8. Free-standing Cognitive Symptom Validity Tests: Use and Selection in Mild Traumatic Brain Injury

9. Use of Embedded Cognitive Symptom Validity Measures in Mild Traumatic Brain Injury Cases

10. Psychological Assessment of Symptom Magnification in Mild Traumatic Brain Injury Cases

11. Strategies for Non-neuropsychology Clinicians to Detect Non-Credible Presentations after Mild Traumatic Brain Injury

12. Assessing Non-credible Attention, Processing Speed, Language and Visuospatial/Perceptual Function in Mild Traumatic Brain Injury Cases

13. Assessing Non-credible Sensory-motor Function, Executive Function, and Test Batteries in Mild Traumatic Brain Injury Cases

14. Functional Neuroanatomical Bases of Deceptive Behavior and Malingering

15. Cognitive Performance Validity Assessment in Mild Traumatic Brain Injury, Physical Pain, and Posttraumatic Stress

16. Symptom Validity Assessment of Mild Traumatic Brain Injury Cases in Disability and Civil Litigation Contexts

17. Symptom Validity Assessment and Sports Concussion

18. Symptom Validity Assessment of Military and Veteran Populations Following Mild Traumatic Brain Injury

19. Symptom Validity Assessment with Special Populations

Walt Disney World and the Obesity Controversy

I have always loved Walt Disney World ever since I was a little kid. I recently went back for a trip with my family. I am not sure if I am just old enough to realize something I missed when I was a kid but as an adult it is easy to see that the Disney Corporation is trying to take on social causes that they believe will appeal to the majority of their customer base, even if the message is contradictory. For example, on a rainy day, my family and I were stuck in Epcot’s The Land exhibit and to pass some time, we watched a movie called Circle of Life: An Environmental Fable -- obviously designed for those who are passionate about the environment. In the film, the cartoon characters lament how terrible mankind is for knocking down trees and entire forests for development, which would include business expansion. At this point, I could not help thinking, “How do you think Walt Disney World was built?!”

More recently, Walt Disney World found themselves under attack from The National Association to Advance Fat Acceptance for allegedly being insensitive in another cartoon by reinforcing stereotypes that obese people eat junk food and watch TV too much television. Regardless of the merits of that argument, I object to Disney’s argument on other grounds. The fact is, people do not become obese from eating junk food or watching too much TV. You can become obese from eating excessive amounts of any type of food, regardless of whether it is junky or not. Also, you can watch all of the TV you want, but watching TV does not cause obesity. If Disney wants to promote any type of message about obesity, it should simply be this: if you take in more calories than you burn, you gain weight. Not too hard to understand. Even Dumbo can understand that. If you want to add something to it, you can say that eating too much, often combined with too much inactivity can cause obesity. People should not feel vilified for eating candy bars, drinking soda, or being a coach potato once in awhile. It’s all a matter of balance and doing things in moderation.

My Medical Remake of Dr. Seuss's ABC Book

Theodor Seuss Geisel (affectionately known as Dr. Seuss) was born today in 1904. His books have delighted children and parents for generations, include my own. Thus, I pay tribute to Dr. Seuss with a medical version of his famous ABC book. I hope you enjoy it. If so, please share with others.


Big A
little a
What begins with A?
Aunt Aunnie’s angiography.
A..a..A

Big B
little b
What begins with b?
Basophil
baby
bone scan
and a
biopsy.

Big C
little c
What begins with C?
Cancer on the colon
C..c..C

Big D
little d
Dr. Dominic Doo
dreamed
a dozen discharges
and
a dentist too.

ABCDE..e..e
e. coli
edema
eosinophil
e
e
E

Big F
little f
F..f..F
Four fetid feces
on a
Fiber-feffer-feff

ABCD
EFG
Gram
Girl
Gynecologist
G…g…G

Big H
little h
Headache head
HEY!
Halloween is here
Hooray! Hooray!

Big I
little i
i..i..i
Intestines
are
irritable.
So am I.

Big J
littlej
What begins with j?
Jimmy Jolly’s
jaundice
and janiceps
begin that way

Big K
little k
kilogram-aroo
Kick a Kaposi's
sarcoma
and
Korsakoff’s too.

Big L
little l
Little Liter Lopp
Left loin.
Lower neuron
lacrimal drops.

Big M
little m
Many MRIs
are making
multiple sclerosis
and the myelin
mighty bright

Big N
little n
What begins with those?
nine neuropsychologists
and a neutrophil
and a nose.

O is very useful
You use it when you say
“Ophelia’s ophthalmologist
owns
an orange optometer today.”

ABCDEFGHIJKLMNO…P

Pregnant Preeclampsia
Plasma in a pail
Peter’s poisoned poulty
And now
Protein’s in the pail.

Big Q
Little q
What begins with Q?
The quad
Queen of Quadriceps
and her
quadriplegia too.

Big R
Little r
Rosy Rehab Ridth
Rosy’s going running
With a low red cell distribution width.

Big S
Little s
Silly Shelley Smith
Saw a squamous lesion
And got
sick sick sick.

T…..T
t…..t
What begins with T?
Ten tired tapeworms
On the trunk of a tree.

Big U
little u
What begins with u?
Unmyelinated axons
and an
ultrasound too.

Big V
little v
Vera Vermis Vinn
is
very
very
very awful
taking vitamins.

W..w..W
wrinkle Wally Woo
washes Wendell Wiggins
who’s on the
Wall of Fame too.

The X chromosome is useful
if you want
to be a girl
X-rays comes in handy
All throughout the world.

Big Y
little y
Young yellow skin.
Yvonne did yoga
With the yang
But not the yin.

ABCDEFGHIJKLMNOPQRSTUVWXY..and…
Z
Big Z
little z
What begins with Z?
I do.
I'm a
Zinc Zafirlukast
as you can
plainly see.

A Follow-Up to The Psychological Profile of TJ Lane

Yesterday, I posted a psychological profile of Chardon school shooter, T.J. Lane (pictured to the left). As always happens, the day after such incidents, more detailed information emerges about the shooter. So far, everything I have read confirms the information I posted yesterday. Lane has already confessed to prosecutors that he shot his victims at random and did not know them (although he apparently knew one in middle school). 

This is consistent with the pattern of many school shooters, and the theory that he was lashing out against a “system,” be it society, government, the educational system, or all three. This type of behavior actually transcends school shooters and fits into a broader category of mass murderers who commit terrorist acts. For example, I remember walking through the Oklahoma City Memorial and seeing the tiny shoes of the babies who lost their lives after Timothy McVeigh bombed the federal building. McVeigh did not view the babies as innocent individuals who he had a personal problem with but saw them as necessary casualties of war in his fight against the government. In this sense, the victims are actually symbolic representations of a much larger system that the aggressor is upset about.

Although violence prediction is difficult, for Lane’s lawyer to say that this could never have been predicted is simply not true. Lane clearly was in a high risk category for this type of behavior based on what was noted yesterday. Part of this high risk comes from a troubled family life. More specifics regarding this have emerged that fits yesterday’s profile. Specifically, Lane's father has been arrested several times for violent crimes against female acquaintances, including his mother. For the first two years of Lane's life, his parents (who divorced in 2002) were both arrested for domestic violence against each other. His father also served prison time for assaulting a police officer and was charged with holding another woman under running water and bashing her head into a wall. He has been charged with kidnapping, felonious assault, attempted murder (eventually dropped), and disrupting public service. His father had been warned by law enforcement officials to stay away from him on multiple occasions. Thus, Lane clearly had a role model in life for violent behavior as a means to solve problems and lacked proper parental role models.  

It was noted yesterday that Lane attended an alternative H.S. and that this made it likely that he had academic and behavioral problems. Information disclosed today revealed that his alternative H.S. was a place for "at risk" students who are "reluctant learners" with problems such as "substance abuse /chemical dependency, anger issues, mental health issues, truancy, delinquency, difficulties with attention/organization, and academic deficiencies." Thus, there clearly were concerns that people had about him but it is unclear yet if any mental health professionals evaluated him and if anyone made any connections between his family background, belief systems, and tendencies for aggressive behavior.

On the 911 tape, Lane was described as a quiet kid who did not really talk to anyone, which, according to one friend, was associated with a Goth phase he became involved in as a freshman. Neighbors described him as very sullen, rarely showing his face and always wearing a hoodie, the latter being yet another symbol of alienation from society (when interpreted in the context of everything else that is known about him) as the hood can serve as a shell for him to hide in. It is noted that he wore a gray hoodie (again note the absence of bright colors) on the day of the school shooting based on 911 witness accounts. Another student noted that he would sit in the lunch room and no one knew he was there. That is interesting considering that the shooting occurred in the lunchroom. The school lunchroom is one of the most stigmatizing locations in school because this is where the student body becomes segregated into cliques. Students sitting by themselves in the lunch room (either by choice or through not being accepted) can be another sign of social alienation. Thus, he may have chosen an area that symbolized his social alienation as an area for the school shooting. The large availability of students to chose from in the lunchroom setting may have also played a roll.

Suggested Reading: Without Conscience: The Disturbing World of the Psychopaths Among Us