The brain

This article originally appeared in BMJ USA

Every organ is a masterwork in complexity, but the brain is the most enigmatic. It is not just the maze of neural pathways and the mystery of how they integrate sensation, motor control, and balance to operate the body. Nor is it the miracle by which the fetal prosencephalon grows into an object that reasons, writes symphonies, and designs skyscrapers. The greatest enigma is the mind, assuming it is in the brain. In what sulcus resides our personality, the memory of our mothers' cooking, the instinct of which way to turn when we are lost, our sense of humor, dignity, and pride in our children?

Someday we will know the answers, but for now we concern ourselves with keeping that amazing organ alive and healthy. For years there was little to do, but ours is an era of new possibilities in protecting the brain. Stroke, the third leading cause of death, can be prevented by controlling blood pressure. A new strategy is emerging in angiotensin-converting enzyme inhibition, which seems to prevent stroke through a mechanism unrelated to blood pressure (BMJ USA p 261). Such drugs, like statins, may find their greatest use in the primary prevention of cardiovascular disease.

The care of the brain is not without controversy. Lenzer argues that the maker of alteplase and the American Heart Association allowed conflicts of interest to influence their promotion of thrombolytic therapy to prevent stroke (BMJ USA p 283). Her message suffers from its tone, which seems so bent on portraying a conspiracy that one wonders whether both sides of the story are presented. Her hyperbole touches on irreverence when she uses “disappearing,” a term used for the murder of dissidents, to describe the failure to list an individual as a guideline author. That individual comes to her defense (BMJ USA p 293), but Saver and colleagues challenge her depiction of the evidence and her premise that ties to drug companies are inherently problematic (BMJ USA p 291). Cynical readers will note that Saver et al, and two editorialists making a similar point (BMJ USA p 246), are themselves beneficiaries of drug company money.

Wiebe and Nicolle (BMJ USA p 276) turn our attention to other brain ailments, such as epilepsy, dementia, multiple sclerosis, and migraine. We can now specify the odds of benefit and harm from carotid endarterectomy and of treating atrial fibrillation. We know much less about the mind-body connection, such as how sheer determination can seemingly maintain the myocardium through a grandson's wedding (BMJ USA p 264). Maxmin (BMJ USA p 297) introduces us to a general practitioner who died from a brainstem lymphoma, suffering emotionally at the hands of doctors who treated his brain but ignored his mind. He urged his colleagues to listen better, but we know from Recordon (BMJ USA p 274) that skilled communication is the brain performing at its best, a skill that few physicians master.

Use of ramipril (Bosch), BMJ USA p 261, http://www.bmj.com/cgi/content/full/324/7339/699

Alteplase for stroke (Lenzer), BMJ USA p 283, http://www.bmj.com/cgi/content/full/324/7339/723#art

Rapid response, BMJ USA p 293, http://www.bmj.com/cgi/eletters/324/7339/723#20806

Thrombolysis in stroke: it works (Saver), BMJ USA p 291, http://www.bmj.com/cgi/content/full/324/7339/723#resp2

Brains, claims, and the pharmaceutical industry (Alberts), BMJ USA p 246, http://www.bmj.com/cgi/doi/10.1136/bmjusa.02050002

Recent developments in neurology (Wiebe), BMJ USA p 276, http://www.bmj.com/cgi/content/full/324/7338/656

His own way (Bowbrick), BMJ USA p 264, http://www.bmj.com/cgi/content/full/324/7339/718

Personal views: do we hear our patients? (Maxmin), BMJ USA p 297, http://www.bmj.com/cgi/content/full/324/7338/684

Communications in the doctor-patient relationship (Goodacre), BMJ USA p 274, http://www.bmj.com/cgi/content/full/324/7337/597