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Wijdicks EFM, Burkle C. The Language of the UDDA is Sufficiently Precise and Pragmatic. Neurocrit Care 2024:10.1007/s12028-024-02004-3. [PMID: 38862708 DOI: 10.1007/s12028-024-02004-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/24/2024] [Indexed: 06/13/2024]
Abstract
We have a reason to value the Uniform Determination of Death Act (UDDA). Since enactment, the UDDA has been of paramount importance to US citizens, families of comatose patients, and the health care professionals who care for them. The UDDA sets forth two standards for determining death and leaves to the medical community to elaborate criteria by which physicians can determine when those standards have been met. Neurologists and neurocritical care experts always have been center stage in this effort. Perfectly established, why change it? What ignited the recent review of the UDDA were lawsuits questioning medical (neurological) authority leading to the wording and accuracy of the UDDA being revisited. The major objections to the language of the UDDA by several groups led a committee appointed by the Uniform Law Commission to consider several substantial changes in the Act. After several years of discussion without reaching a consensus, the committee's chair suspended the effort. Upending the UDDA will lead to a legal crisis and confusion across the states. We present our main arguments against revising this statute and argue that the committee's failure to revise the UDDA should actually be seen as a necessary success.
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Affiliation(s)
- Eelco F M Wijdicks
- Neurosciences Intensive Care Unit and Department of Neurology and Anesthesiology, Mayo Clinic Hospital, Saint Marys Campus, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Christopher Burkle
- Neurosciences Intensive Care Unit and Department of Neurology and Anesthesiology, Mayo Clinic Hospital, Saint Marys Campus, 200 First Street SW, Rochester, MN, 55905, USA
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Wang J, Zhao W, Wang H, Leng H, Xue Q, Peng M, Min B, Jin X, Tan L, Gao K, Wang H. Brain-wide activation involved in 15 mA transcranial alternating current stimulation in patients with first-episode major depressive disorder. Gen Psychiatr 2024; 37:e101338. [PMID: 38476648 PMCID: PMC10928782 DOI: 10.1136/gpsych-2023-101338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/31/2024] [Indexed: 03/14/2024] Open
Abstract
Background Although 15 mA transcranial alternating current stimulation (tACS) has a therapeutic effect on depression, the activations of brain structures in humans accounting for this tACS configuration remain largely unknown. Aims To investigate which intracranial brain structures are engaged in the tACS at 77.5 Hz and 15 mA, delivered via the forehead and the mastoid electrodes in the human brain. Methods Actual human head models were built using the magnetic resonance imagings of eight outpatient volunteers with drug-naïve, first-episode major depressive disorder and then used to perform the electric field distributions with SimNIBS software. Results The electric field distributions of the sagittal, coronal and axial planes showed that the bilateral frontal lobes, bilateral temporal lobes, hippocampus, cingulate, hypothalamus, thalamus, amygdala, cerebellum and brainstem were visibly stimulated by the 15 mA tACS procedure. Conclusions Brain-wide activation, including the cortex, subcortical structures, cerebellum and brainstem, is involved in the 15 mA tACS intervention for first-episode major depressive disorder. Our results indicate that the simultaneous involvement of multiple brain regions is a possible mechanism for its effectiveness in reducing depressive symptoms.
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Affiliation(s)
- Jie Wang
- Songjiang Hospital and Songjiang Research Institute, Shanghai Key Laboratory of Emotions and Affective Disorders, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Neuroscience and Brain Diseases, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Wenfeng Zhao
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Huang Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haixia Leng
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qing Xue
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Mao Peng
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Baoquan Min
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xiukun Jin
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Liucen Tan
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Keming Gao
- Electroconvulsive Therapy, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Hongxing Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
- Institute of Sleep and Consciousness Disorders, Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
- Institute of Special Medical Sciences, School of Forensic Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
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Taran S, Gros P, Gofton T, Boyd G, Briard JN, Chassé M, Singh JM. The reticular activating system: a narrative review of discovery, evolving understanding, and relevance to current formulations of brain death. Can J Anaesth 2023; 70:788-795. [PMID: 37155119 PMCID: PMC10203024 DOI: 10.1007/s12630-023-02421-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 05/10/2023] Open
Abstract
A series of landmark experiments conducted throughout the 20th century progressively localized the regions involved in consciousness to the reticular activating system (RAS) and its ascending projections. The first description of the RAS emerged in 1949 through seminal experiments performed by Moruzzi and Magoun in feline brainstems; additional experiments in the 1950s revealed connections between the RAS and the thalamus and neocortical structures. This knowledge has allowed for the explanation of disorders of consciousness with exquisite anatomic precision. The clinical relevance of the RAS is further apparent in modern definitions of brain death/death by neurologic criteria (BD/DNC), which require demonstration of the complete and permanent loss of capacity for consciousness as one of their core criteria. BD/DNC is currently understood across jurisdictions in terms of "whole brain" and "brainstem" formulations. Although their clinical examination between formulations is indistinguishable, policies for BD/DNC declaration may differ in the rare scenario of patients with isolated infratentorial brain injuries, in which ancillary testing is advised in the whole brain formulation but not the brainstem formulation. Canadian guidelines acknowledge that the distinction between whole brain and brainstem formulations is unclear with respect to clinical implications for patients with isolated infratentorial injuries. This has led to variability in Canadian clinicians' use of ancillary testing when the mechanism of BD/DNC is suspected to be an isolated infratentorial injury. The present narrative review highlights these concepts and explores implications for determination of BD/DNC in Canada, with specific emphasis on the RAS and its relevance to both formulations.
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Affiliation(s)
- Shaurya Taran
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Western Hospital, Office 411-L, 2nd Floor McLaughlin, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Priti Gros
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Division of Neurology, University Health Network, Toronto, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Gordon Boyd
- Department of Medicine (Neurology) and Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Joel Neves Briard
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
- Université de Montréal Hospital Research Centre, Montreal, QC, Canada
| | - Jeffrey M Singh
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Ontario Health - Trillium Gift of Life Network, Toronto, ON, Canada
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ctDNA-Based Liquid Biopsy of Cerebrospinal Fluid in Brain Cancer. Cancers (Basel) 2021; 13:cancers13091989. [PMID: 33919036 PMCID: PMC8122255 DOI: 10.3390/cancers13091989] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 12/18/2022] Open
Abstract
The correct characterisation of central nervous system (CNS) malignancies is crucial for accurate diagnosis and prognosis and also the identification of actionable genomic alterations that can guide the therapeutic strategy. Surgical biopsies are performed to characterise the tumour; however, these procedures are invasive and are not always feasible for all patients. Moreover, they only provide a static snapshot and can miss tumour heterogeneity. Currently, monitoring of CNS cancer is performed by conventional imaging techniques and, in some cases, cytology analysis of the cerebrospinal fluid (CSF); however, these techniques have limited sensitivity. To overcome these limitations, a liquid biopsy of the CSF can be used to obtain information about the tumour in a less invasive manner. The CSF is a source of cell-free circulating tumour DNA (ctDNA), and the analysis of this biomarker can characterise and monitor brain cancer. Recent studies have shown that ctDNA is more abundant in the CSF than plasma for CNS malignancies and that it can be sequenced to reveal tumour heterogeneity and provide diagnostic and prognostic information. Furthermore, analysis of longitudinal samples can aid patient monitoring by detecting residual disease or even tracking tumour evolution at relapse and, therefore, tailoring the therapeutic strategy. In this review, we provide an overview of the potential clinical applications of the analysis of CSF ctDNA and the challenges that need to be overcome in order to translate research findings into a tool for clinical practice.
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