Jackie Birnbaum

English 3307
Tom Akbari
Unit 1 Final Draft
May 13, 2017

Updating the Medical Field on How to Diagnose Chronic Traumatic Encephalopathy

The review titled, Clinical appraisal of chronic traumatic encephalopathy: current

perspectives and future directions, outlines the current [as of 2011] information and knowledge

that the medical field has regarding chronic traumatic encephalopathy (CTE). This article has

several authors from various institutions, all of whom have a Ph.D. or M.D.: Brandon E. Gavett,

Robert C. Cantu, Martha Shenton, Alexander P. Lin, Christopher J. Nowinski, Ann C. McKee

and Robert A. Stern. It was published in Current Opinion in Neurology in 2011 with the purpose

of providing an overview of existing and upcoming methods for diagnosing CTE. CTE is a

disease characterized by degeneration of neuronal tissue in the patients brain and it is commonly

thought that multiple concussive or subconcussive injuries can lead to the development of the

disease. CTE cannot be confirmed in a living person as there is not an established set of clinical

criteria that allow it to be diagnosed or treated. Based on this notion, I feel that this article is

significant because doctors or researchers who deal with neurodegenerative diseases, traumatic

brain injuries, or CTE specifically can learn about new techniques in their field which may allow

them to evaluate and potentially treat a patient more effectively.

Although researchers and other people may read this review, doctors in particular would

benefit from the information; it is imperative that doctors know the most recent diagnostic tools

available to them so that they can alter, if necessary, how they assess a patient. Doctors, as the
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only ones qualified to examine patients, can use the proposed clinical tests and look for the

symptoms discussed throughout the article:. For instance, whole brain atrophy has been

reported as a common feature of CTE at autopsy in addition to cavum septum pellucidum...each

of these features may be detected with MRI1(p.527). Since these neuropathological phenomena

are often seen in the post-mortem examination of confirmed CTE patients, the authors are

suggesting that doctors utilize MRI as a tool to check for these changes within the brains of

living people. The language and terms used within the quoted sentence show, again, that doctors

are meant to read and glean information from this review. Through the use of specific

neuroanatomical terms the authors were able to narrow down the group of people who would be

able to effectively understand and use the information that they present; this lends itself to the

concept of a discourse community as described by Swales. Had this review been intended for

coaches of football players, the authors would not have used such technical language such as

cavum septum pellucidum; but rather everyday language, prevention tips, and signs of a

concussion would have been discussed. Instead, the authors discuss specific pathologies of the

brain and how these can be detected by tools accessible to physicians in order to potentially

diagnose patients with CTE.

There are various means by which diseases and disorders can be diagnosed; the review is

organized into sections based on different detectable effects that CTE is thought to have on a

patients body. The four headings (Neurologic effects, Neuropsychological and neuropsychiatric

effects, Radiologic effects, and Blood and cerebrospinal fluid biomarkers)1(p.526, 527, 529) function

to outline which category a potential diagnostic criterion falls into. Each heading visually stands

out to the reader as a result of the enlarged text; this signals to the reader that the paper will be

moving on from the previous section and onto a new topic of research. The large text also
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allows the reader to glean the main topics and points of the paper with only a quick glance. By

grouping symptoms together based on the level at which a patient is affected (mood or behavior

would be a more broad level where as changes in brain metabolism would be more specific), the

authors came up with the terms that are used in the headings. The Neurologic effects and

Blood and cerebrospinal fluid biomarkers sections are substantially shorter than the other two

and also lack subheadings. Despite having less information, these sections were not omitted

because the aforementioned areas can be a potential topic of future research regarding CTE

diagnosis. While the authors reference specific quantitative data in the Neurologic Effects

section, they do not pull data from the sources that they cited in the Blood and cerebrospinal

fluid biomarkers section. The language in the latter section is not particularly effective in

convincing the reader that biomarkers show promise in the field of CTE diagnosis; the following

quote demonstrates this notion: For instance, CSF tau and phosphorylated tau, and isoprostanes

in plasma and CSF may have the potential to contribute to the prediction and diagnosis of CTE

[5861],1(p.529). Instead of stating definitively that these molecules are promising avenues for

research, the authors say that the molecules may have potential. The word may conveys

uncertainty in this context and thus implies that the authors themselves are not convinced that

biomarkers will be useful in diagnosing CTE. Alzheimers and CTE share some

neuropathological changes which is why the authors chose to mention that biomarkers may be a

diagnostic tool for CTE in the future. The inclusion of these sections implies that doctors and

researchers should expect more upcoming findings about biomarkers and neurological

dysfunction in the context of CTE.

In neuropathologically confirmed CTE, executive dysfunction may be common prior to

death [16]. Poor insight, judgment, and disinhibition have been reported very commonly in
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individuals with CTE,1(p.527). The cognitive deficits described in this quote fall under the

subheading of Executive function which is under the umbrella of Neuropsychological and

neuropsychatric effects. Organization of this sort allows the reader to more easily see which of

these CTE pathologies present in a manner that can be tested for and subsequently confirmed.

The quote states specifically how executive function is thought to be impeded in cases of CTE;

the neuropsychological tests that a doctor should administer to patients are not detailed in this

section (or at all in the review). Explanations of neuropsychological exams would be

unnecessary in this case because, as the authors assume, a doctor should already know how

he/she can test for deficits in executive function. This lends itself to a point made earlier: the

review is meant to be read by doctors or researchers with prior knowledge in the field. By only

including which cognitive deficits to test for and how they are related to CTE, the authors made

the paper more focused on the goal of summarizing new and future information for the readers.

A known expectation of physicians is that they do not stop learning about conditions that

they encounter and treat after medical school or residency. In this sense, reviews similar to this

one are what I would expect to encounter in the field of medicine. Particularly when dealing

with a disease such as CTE that is gaining attention from the media, athletes, and the research

community, I would want to ensure that I am administering the proper neuropsychological tests,

neuroimaging tests, and (hopefully in the near future) blood tests to patients. In order to be able

to write a medical document such as this review, one must have extensively studied patients or

cases of the specific disease. This necessitates either going through medical school or graduate

school with a focus on neurodegenerative disease. My educational path should prepare me to

become a member of this specific discourse community; during medical school it is vital that one

learns the medical lexicon used in hospitals and other clinical settings. I have shadowed a
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neurologist and can attest to the fact that there are acronyms, abbreviations, and terms specific

not only to medicine, but to the narrower field of neurology. At this point in my education, I feel

that I can read and potentially write a review on the research of a particular neurodegenerative

disease. As a behavioral neuroscience major I am comfortable with the neural mechanisms

discussed in a review such as this one; for example, diffuse axonal injury and excitotoxicity as a

result of too much glutamate are two concepts discussed by the authors because they are

implicated in CTE. Based on my co-op and the information I have learned in class, I understood

these concepts thoroughly but only in terms of how neurons are affected in those scenarios. I do

not know, however, how these concepts impact a patient in a clinical setting. If I needed to

write a more medicine-oriented review I would need to learn much more about and have

administered medical evaluations and treatment for the disease as opposed to just understanding

the neuroscience-based concepts. Direct patient experience in the medical field would allow me

to have enough knowledge to organize concepts and main points into specific categories, as is

done in this paper. Additionally, I still have a lot of medical terminology to learn in order to be

able to write more influentially in the field of medicine. The term cavum septum pellucidum

is contained within a quote that I presented earlier; while I know vaguely in the brain where this

structure is, I dont understand the role that it plays in normal human function. Thoroughly

understanding neuroanatomy and the function of different brain regions is important if one wants

to be able to read medical literature, write said literature, and ultimately be a good neurologist.

Reference

1. Gavett BE, Cantu RC, Shenton M, Lin AP, Nowinski CJ, McKee AC, Stern RA. 2011.

Clinical appraisal of chronic traumatic encephalopathy: current perspectives and future

directions. Current Opinion in Neurology. 24:525-531