Phorest & Trees 11/2021 Thanksgiving edition

 

Phorest & Trees: Gobble Gobble it up

It was nice to see family at Thanksgiving again. Hope you enjoy these.

AANEM & NEUROMUSCULAR STUFF 

• Below is the most prolonged CMAP I’ve seen in the context of carpal tunnel. Has anyone seen longer?

• Attached is the Gold Coast criteria which may serve as a welcome alternative to the El Escorial Criteria for diagnosing ALS. This was brought up at the AANEM conference as well.
• Because someone asked for it, I dug up the AANEM’s position paper on ethics in the EMG lab. If you have not read it already, please take a look at the very practical content within.
• The AAN put out a position statement on Social Media: "We created this new position statement to build a framework of how to apply commonly accepted ethical principles -- beneficence, nonmaleficence, autonomy, and justice -- to a form of communication that is rapidly developing and ever-changing, but at the same time separate that very strictly from giving explicit advice on how to utilize certain forms or platforms of social media, because that is something very different,"
• COVID bad. Rehab good.
• Benefits of steroids without the side effects?
• Transcranial current to treat peripheral neve pain? Ultrasound FDA approved for Parkinson’s?
• A lot of so-called CIDP is actually CMT

Musculoskeletal/PAIN/Rheum

• “Intraarticular corticosteroid injections are not associated with increased risk of progression compared to hyaluronic acid.” This study is in contrast to other recent data and would definitely affect my practice if true.
• I had to read about Relapsing Polychondritis. Amazing that I’m still learning about conditions that I’ve never heard of. “Realizing the depths of your own ignorance” as per Shenoy.
• Fascinating that virtual reality incorporating CBT principles to engage pain patients, self management, deep relaxation, attention shifting, healthy movement visualization and other skills (EaseVRx) offered >50% reduction in chronic back pain patients Supercool images in the attached article about DECT 3D reformats to look at glenoids for signs of instability. (just look at the yummy pictures).
• With regard to corticosteroid injections and rapidly destructive hip disease(RDHD), several of the Bradford-Hill criteria (evaluating observed causal relationship between an exposure and a disease)  are met, including strength of association, biological gradient, experiment, and biologic plausibility. Specifically, the association between hip corticosteroid injection and RDHD was strong, with an adjusted odds ratio of 8.56. There is evidence of a biological gradient (also termed dose-response curve) as the risk of RDHD increased with the number of injections as well as the dose. Removal of the exposure was also shown to alter the frequency of the outcome (experiment) as the rate of RDHD (regardless of cause) was found to decrease in our region as the number of corticosteroid injections (specifically high-dose injections) was reduced.
• Important for the residents: MRI of the lumbar spine performed early after onset of LBP symptoms was associated with a higher probability of surgery, greater prescription opioid use, increased costs of care, and higher pain scores. Similarly, in patients with LBP who did not have red flag symptoms, routine imaging did not provide health benefits and suggested medical imaging was often performed because of a clinician’s need for a diagnosis, to identify an anatomical defect, to meet the expectations of patients, or for financial incentives.
• My initial Vitamin D level was 9. Maybe I should be exercising…
• Rheumatoid arthritis is preventable
• See attached high powered oral steroids for acute radic. “Whether the observed improvement in function (without concomitant improvement in pain) merits use of oral steroids for patients with an acute radiculopathy is a difficult decision and, ultimately, becomes a personal one that must be weighed by individual patients and their physicians. In addition, pain may limit function, so as pain decreases, function (ODI) may increase until pain again limits functional capacity. This may explain the improved function without measurable improvement in pain.”
• Exercise decreases urinary toxicity in radiation treated prostate cancer patients
• Surgical treatment for AC joint dislocation of the shoulder does not appear to be superior to conservative management in adults resulting in similar quality of life, function, and return to previous activities after one year. Surgical therapy increases the risk of hardware complications, infection, and continued discomfort. 1 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)
• A measured and broad perspective of stem cells in the regenerative landscape.
• Don’t have a colonoscopy before your total knee replacement
• Keeping risk factors in check helped people with diabetes stave off dementia. Compared with controls, Type 2 diabetics had no significant excess dementia risk with 5-7 risk factors on target (nonsmoking; guideline-recommended levels of glycated hemoglobin, blood pressure, BMI, albuminuria, physical activity, and diet). Similarly, differences in processing speed, executive function, and brain volumes were progressively smaller for a higher number of risk factors on target.
• The burden of chronic low back pain on society
• Perioperative acetaminophen in patients undergoing rotator cuff repair in this prospective randomized study improved overall satisfaction and reduced pills taken compared to oxycodone only.
• On DOXIMITY: footwear effects on arch stiffness during running, exercise increases anti-inflammatory gut microbes and endocannabinoids, Oxy aint no better than APAP + codeine post-op  fracture;
• Housework physical activity is positively associated with functional health among community-dwelling older adults, independent of recreation and other non-recreational PAs.
• Current research indicates that torus fractures should be managed with a removable splint supplied in A&E and worn for 3 weeks. There is no need for fracture clinic follow-up or repeat radiological imaging once patients are given adequate information at the time of diagnosis.
• THA can lead to spatially different remodeling of the sacrum, possibly affecting the development of contralateral Sacral Insufficiency Fractures.
• JAMA  RESTORE trial  found no difference between PRP & saline for knee OA. FWIW, since I have no experience with it, a friend opined “The PRP was only 1.4 x concentration, it is basically like taking your plasma and injecting it directly back in. Worthless study IMO”

TREES

• I have LONG awaited a study showing the financial and productivity drain of insurance companies. Here it is!
• Space flight seems to cause the same biomarker changes as brain injury.
• Teaching COVID & PMR
• Although it’s awesome that doctors are held to one of the highest standards, maybe we are starting to be treated unfairly with ageism. This was a very well written discussion of the evolving issue. 
• If not already a member, i encourage you consider joining this facebook physician group who have come together and actually addressed congress to represent us. 
• Market data shows that more people are listening and they are listening locally so that there are fewer and fewer megastars. The trends are in favor of the little guy.
• AMA, Other Physician Groups Strongly Oppose New VA Standards of Practice - U.S. Medicine (usmedicine.com)
• Specific pain conditions are associated with increased odds of suicide attempts even after including key covariates.
• When it comes to the booster decision, the federal government has committed three cardinal sins. The White House disrupted the process by making boosters seem a fait accompli when they were not. The White House, the FDA, and the CDC focused the discussion on the question of a broad approval of boosters for everyone over the age of 16, when that was unlikely to begin with. And the CDC’s Walensky chose not only to overrule an expert panel, but to insist that she was doing no such thing. By not recognizing the gravity of the action, she likely made it easier for future CDC directors to erode ACIP’s authority. Following these steps wouldn’t just result in better decision-making, it would have made the process more transparent.
• First Residency Program in Connecticut for Rehabilitation Physicians Announced  - UConn Today
• Learned the word: Monopsony in this article which does a great job of outlining the shifting healthcare ownership landscapes. Required reading to the end for business savvy residents.  For deeper dives, look at the corrupting influence of private equity groups and alternate ways to maintain autonomy.
• A nice description about Academic mentoring
• FDA is cracking down on fraudulent e-stim
• Gene-editing to protect 99% against Alzheimer’s or at least just drink a lot of coffee

 

 

Phorest & Trees 09-2021

 

PHOREST & TREES

Like the new look? always available here.

AANEM & NEUROMUSCULAR STUFF

• I may already have expressed my profound admiration for Ileana Howard MD in this space, but here it is again. “The Advocacy Award honors members or nonmembers who have made extraordinary contributions in advocating to government entities or insurance companies in regard to the diagnosis/treatment of NM or EDX medicine.” You go Supergirl!
• Here is a nice review of head drop differential. I’ve already had about 5 patients with this over the years (thanks to Ileana for the link).
• These authors propose that injected steroids (triamcinolone) in carpal tunnel work by an antifibrotic effect, suppressing collagen expression in subsynovial connective tissue fibroblasts. None of the proinflammatory IL-6, COX-2, and NF-B generes were significantly downregulated by it. Clinical eval revealed increased grip strength, EDx revealed improved SNAPs, and MRI did not reveal an antiedematous effect on synovial tissue. I thought this was a really good study.
• Very very rare GBS after vaccine and Turns out sural sparing is still a good indicator of GBS
• Don’t take too much laughing gas or you’ll get a neuropathy
• Great Job Opp

 

MUSCULOSKELETAL / PAIN / RHEUM

• “Doc, seeing what you see on my MRI, do I have to worry about future back pain?” Attached is the first large population-based study investigating longitudinal relationships between lumbar MRI findings and LBP, where analyses were conducted for the whole cohort and separately for those with and without baseline pain. Residents are encouraged to read the intro and discussion.
• How long should a sling be worn after proximal humeral fracture? Not long.
• I’m no tailbone doctor but this seems like something to consider at the tail end of treatment (heh).
• Yet another meta-analysis of injectates into knees. I just wish PRP formulations were standardized for comparison. “further investigations minimizing PRP formulation heterogeneity by standardizing PRP preparation and classification are warranted to better understand the true efficacy of PRP on clinical outcomes.”
• Treatment of RA has resulted in decreased TKA/THA
• Metformin is associated with reduced risk of needing a joint replacement in diabetes.
• I didn't know what TOLF was. It's thoracic ossification of ligamentum flavum. It can cause myelopathy but it's rare.
• Multi-day hospitalizations for E-Scooter orthopedic trauma
• Radiofrequency Echographic Multi-Spectrometry technology by analysis of native raw unfiltered ultrasound signals appears to be able to recognise and overcome the most common artifacts, such as osteoarthritis, which may underestimate BMD by DEXA
• A prospective RCT revealed oral perioperative acetaminophen reduced opioid use and showed better pain control  in patients undergoing rotator cuff repair.

TREES

• My reply when a friend sent this image to me: Conceptually not surprising but astonishingly dramatic when visually represented this way.  Many would argue this to be a major contributing cause to the frustrating impediments to progress and even daily operations. The response was “Amen! 2019 before Covid we spent $3.7 trillion for health care, total fed budget was $4 trillion, and 25% for "administrative costs" which was more than any other country paid per capita for their health care except France and they are rated #1 by the WHO, not 37th like us.”

• Just disgusting
• How much of published scientific data is fraudulent?
• This article on how to discourage doctors is probably a sham but so well-written.
• A discussion with Dan Pierce about the “many issues with the way the scientific process has evolved when using statistics... there is a real danger with p-hacking when there is such a strong bias to publish positive results. One way to combat this is to publish the protocol prior to performing the actual experiment. I remember talking about this salmon experiment in my statistics class – a humorous example of misapplying the p-value.”  Attached is the very funny article he’s referring to.
• A trauma surgeon talks about night call. “I had some subconscious awareness that I wasn't using my cortical functions until I knew the relief of staying at home or the acceptance of going in. In fact, the longer the conversation would go on without knowing whether I had to go in, the tenser I got, because of the uncertainty. “Although we can all relate to this, I wonder if this is also how our patients feel when they hear a lab result or diagnosis.
• Interesting thoughts on speaking your mind which I can understand. I wonder if this person knew how to speak his mind. The comments sections are fascinating as well.
• 41% of americans lost confidence in their doctors during covid because of less communication. Those who had more faith attributed it to virtual care.
• Unbelievable the administrative burdens that continue to be poured on physicians when it's the insurance companies that are the ones setting the billing rates Doc Groups Hail Decision to Delay 'Advanced EOB' Rule
• CMS proposed changes for payment, here's AANEM's summary.
• An interesting proposal to pay primary care
• Using AI to prevent variation in care.
• How medical notes will change if patients get to see them (kevinmd.com)
• Trans women are dying faster
• Old folks prefer texting too!

BRAIN STUFF (“abstracts only” for me)

• Geeks only. This is MEG visualization of arithmetic and simple sentence cortical processing .
• Yet another reason to exercise.
• The search for biomarkers continues with amyloid precursor protein in alzheimer’s and Neurofilament light chain in ALS.
• Vagus stim for Stroke Rehab FDA approved.
• 6-9 for bedtime. (get your mind out of the gutter!)
• The nose knows.

Phorest & Trees August 2021

 

 

 

Phorest & Trees It’s me birthday week…And of course the old ones here.  Hope you enjoy!

Physician Finance, Workplace Attire, Overlearning, & lotsa Jobs out there

I’m married to a guju JD/MBA daughter of an accountant, so lazy me didn’t bother until now. You need to understand personal finance better than I did. I found this site to be useful and I’ve vetted it for you. Here’s the most recent evidence on how attire affects whether patients believe you know what you’re doing. I think this is required reading for the residents. Many trainees want to do “just enough” to get it right. But there may be some benefit to overlearning My friend Dr. John Norbury has joined Texas Tech University as new PMR Division Chief under Dept of Neurology. He tells of 3 positions: One is “for junior faculty, one who will be a consult/outpatient MSK physician and one will be inpatient...neurorehab would be a plus.   Both physicians would include a part time VA appointment and would have an medical education component and the ability to tailor to clinical interests or research, if desired.  They would also include public service loan forgiveness. Also, the VA here is looking for a CMO (outpatient clinic).  Great senior leadership team and beautiful brand new facility.  Having a more seasoned PM&R doc with some administrative talents in that role would be super helpful, but I'm sure any specialty which cares for veterans in the outpatient world would work.  And taxes are way less than New Jersey.“ Seattle VA / U Wash opportunity: “recruiting for a PM&R physician with clinical, education and also ideally research expertise in Amputee care. The position will be 100% based at VA Puget Sound in Seattle with clinical care focused on Amputee care with resident and fellow teaching responsibilities. VA Puget Sound has a large rehab focused research program and a candidate with a history of research funding and scholarly publications will find ample opportunity here for independent research and collaborations with current researchers.” TBI opening in Portland Oregon VA Not sure if Minneapolis VA is still looking but they wanted an amputee physiatrist too.

AANEM & EDx

Quantitative electromyography: Normative data in paraspinal muscles : talks about the “abnormal” findings seen in asymptomatic patients. Very similar to how we approach at the VA. There was a fascinating discussion thread recently posing the question as to how much of the distal onset latency prolongation can really be attributed to axon loss in the setting of low amplitudes. (Residents should have access through the training portal. The rest of you can feel the FOMO) Attached is a case of EDB pseudohypertrophy in the setting of peripheral polyneuropathy Prognostic indicators for Lumbar decompression for foot drop…Duh The AAN supports banning choke holds. Intro and Discussion of this study on MRI findings in Statin induced myopathy are helpful for the residents. “MRI features of statin-associated anti-HMGCR myopathy can be differentiated from other types of myopathies, such as sporadic inclusion-body myositis and dermatomyositis, in terms of distribution of tissue edema and fatty infiltration. In dermatomyositis, edema is often found within the fascia and subcutaneous tissue,13 which is uncommon in anti-HMGCR myopathy. In sporadic inclusion-body myositis, fatty replacement is most prominent in the anterior thigh, with relative sparing of rectus femoris,14-16 whereas anti-HMGCR myopathy demonstrates preferential posterior compartmental fatty infiltration. On the other hand, MRI features of statin-associated anti-HMGCR myopathy may share similarities with anti–signal recognition particle (SRP) myopathy, another subclass of immune-mediated necrotizing myopathy with shared histopathological hallmarks and proposed pathogenesis.17 In anti-SRP myopathy, an anterolateral pattern of muscle edema in the anterior compartment and fatty replacement of hamstring muscle has been reported,18 but with less symmetry and more severe fatty replacement than anti-HMGCR myopathy.”

MSK & PAIN

Semantics are important and the spine pain community is taking a step in the right direction by reassessing the word “Failed Back Surgery Syndrome.” See attached for the letter from IASP. It’s still woefully oversimplifying if you ask me. (more on semantics in the TREES section of this email) Residents may appreciate the attached brief review of Genicular nerve blocks/RFA for knee OA. Bottom line is that the literature is conflicting (esp the anatomy) but it’s an option I refer for in non-op endstage or post TKA patients. I somehow still get the RIC journal club emails and two were shareworthy (hoping to discuss with Dr. Ma) This 2018 ACORN study’s Intro section is excellent for R1s. The study was excellent too. I’ve included my “GMNR” on AC joint for R1s as well. The attached 2021 Multicenter GRASP RCT from Lancet found a course of PT no better than a single PT best practice advice session + corticosteroid injection. If you want the details of the interventions like I did, they are found here. Opioid Tapering Carries Significant Risks according to this JAMA study. There could be inherent bias as these are patients likely chosen for their risks pre-taper. I guess the take-home is to offer support while tapering. Ate JAMA saying statins may not be any more likely than placebo to cause muscle aches. This was the first time I had heard of “N-of-1 clinical trials.”  See this if you are confused as well.  Predictors for TFCC outcomes: above elbow splinting better than short-arm; worse with complete foveal TFCC tear and a dorsally subluxated DRUJ. My father used to pay 1 dollar for each pound his obese patients lost each visit and it worked (they had to pay him a dollar for each pound they gained). Financial incentives work but should CMS pay for them? Despite the possibility of responder bias, rheumatologic flare has not really been associated with COVID vaccine. I only read the abstract but this may open up options for RA patients that previously had cancer.

Trees

A great description of restrictive covenants (non-compete clauses) ZDOGGMD breaks down the complexity of the Delta variant and offers the possibility of hope. (Here’s a complete zdoggmd non sequitur sent to me by a fellow attending but do NOT click this link if you are easily offended by poop jokes.) More and more of my outpatients ask me about COVID Vaccine. This is a helpful description of base rate bias, an issue that contributes to confusing them. Previously infected may only need one dose of vaccine and unvaccinated are twice as likely to be reinfected than vaccinated. Scientific ways to motivate change Nanotech for potentially treating cancer. Where does the joy and meaning in medicine dwell? I tried this Harvard implicit bias test. Is it wrong for me to say that the test is biased? What the rest of us can learn from gay pride… A great narrative about our field’s role in advocacy and the AMA’s new policy opposing “excited delirium.” “If you want people in your practice to contribute toward its greater success, try making them feel valued and involved as a group. That may seem like common sense, but a new study in Health Affairs finds that when medical practices have collaborative management styles that incorporate better communication, burnout is lower and that's ultimately good for everyone." A quick video on gender bias in medicine and what we can do about it some of this was surprising. As a diabetic, I can’t wait to get one of these new monitors that were discovered by accident! Semantic clarification from this paper.

 

 

Phorest & Trees July 2021

 

Phorest & Trees Every month I share stuff I’ve been reading. This month I’ve added the new R1s and a number of alumni to the list. Those of you receiving this for the first time can access the old ones here.  Hope you enjoy!
A Bit of (Personal) Good News
	Thanks to all of you for your kind words about my recent promotion to Clinical Professor. Copious gratitude to Drs. Kirshblum and Foye for their persistent tenacity, encouragement, and filling out the copious paperwork, without whom this wouldn’t have happened.  Thanks to Chae for supporting me formally and behind closed doors in ways I probably don’t even know about. Some have asked why I bothered with this considering there are no accompanying financial benefits whatsoever attached to a non-tenure clinical promotion. I am happy to share my motivation. I did this for my dad. He was so proud of me when i got the "assistant professor" designation 15 years ago. When he passed in 2016, I decided to work toward this in his honor. So hopefully he's smiling with pride somewhere in the universe...
AANEM and EDx
Holy Shish-kabob and Shut the front door!!! A review found There is scientific evidence of the benefit of BTX-A treatment for post-paretic synkinesis, but there is lack of standardized treatment protocols. The origin of allowing >50% drop on tibials.
On ReachMD, DOXIMITY & MedPage
NSAIDs over Codeine for Post-op adult pain meta analysis. Interesting that pairing with APAP was always better. Vagus Nerve Stimulation Improves Arm Function After Stroke - Clinical Pain Advisor Do We Really Need a Fourth Year of Med School?  I concur A few real-life warnings echoing my advice to residents: physicians and other healthcare workers don’t stop being seen as an upstanding member of society when they leave work.  Your affiliation is a two way street. Multimodal approach to arthroplasty pain is standard of care How much of science is fraud? Who needs doctors when you can hire APPs? Kessler residents may have it tough but at least they’re not getting stabbed in the face!
Pain, Sports, MSK & Rheum
Fascinating study on how trunk flexion angle may contribute to running injuries. Attached for sports biomechanics geeks. Multi-society and Multispecialty Advisory warns that even small doses of gadolinium-based contrast can cause encephalopathy and fibrosis warning in its use for interventional pain procedures as an alterintive to iodinated contrast media. I would be interested to know what my interventional colleagues’ experience with DRG implants of this type have been. After reading this study on PRP for adhesive capsulitis, I realized that many of us will interpret the findings differently.,  Perhaps this is true for arthroscopic infection rates after injection, but at the VA we usually advise 6 months prior to THA. Doesn’t seem to be an increased risk for nonvertebral fracture in RA on DMARDs Back Pain Treatment: Is Spinal Fusion Surgery Being Overused? (practicalpainmanagement.com) ….duh Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis ….is anyone still prescribing these?! BMAC for knee OA review…let me know when it costs less and does better than other treatments. MRI may be warranted to detect subclinical inflammation in juvenile rheum Obvious benefits with an accelerometer after THA don’t show long term benefit
Ableism – an inherently physiatric topic to consider
Being physiatrists, we pride ourselves on being knowledgeable advocates for patients with disabilities.  This editorial tells one pediatric neurologist’s perspective and is full of clickable references to support her assertions. After diving into small but growing literature into it (only 312 references since 2006), I have some developing and conflicting thoughts on the topic which we can discuss in person. Some stuff worth sharing:   “ “[i]mmediately, and from early life and thereafter, people perceive individuals with disability as ‘vulnerable’ and of low competence, and, accordingly, treat members of this group differently.”1 Consequently, people with disabilities often continue to experience social devaluation on account of their disabilities (i.e., ableism), despite the fact that the last few decades have seen an increased awareness and a decreased social acceptability of discrimination based on other characteristics such as race (i.e., racism) and gender (i.e., sexism). People with disabilities thus remain subjected to ableist attitudes in many sectors, including — often especially — the health care system.”    Another says “Disability scholar Fiona Kumari Campbell defines ableism as “a network of beliefs, processes and practices that produces a particular kind of self and body (the corporeal standard) that is projected as the perfect, species-typical and therefore essential and fully human. Disability then, is cast as a diminished state of being human.”3 Campbell delineates an inherent link between this deficit-based construction of disability and a “biomedicalist stance,” which, since the Age of Reason, has “played a critical intervening role in the lives of people with disability and people with anomalous bodies or mentalities. Medicine has operated as the primary paradigm not only for the treatment of disabled bodies but has also shaped the way decision makers, legislators, families and society in general think about and sense disability.”   If you’ve done any research, you’ve probably looked at quality of life as an outcome measure. The very notion of QOL is scrutinized in this context “At the heart of such decisions is what disability scholar Joel Reynolds has termed the “ableist conflation” of disability, suffering and death: “wherever operative, the ableist conflation flattens communication about disability to communication about pain, suffering, hardship, disadvantage, morbidity, and mortality.”   “Medicine is, at bottom, a discipline that thinks pathologically. According to a velocity of knowledge that has exponentially increased since the 18th century via scientific experimentation and technological advance, medicine functions according to the basic idea that “healthy” is “normal” and “unhealthy” is “abnormal.” The information medicine vends as truth is predicated on this distinction. In a recent piece in CMAJ, Heidi L. Janz writes that disabled people “remain subjected to ableist attitudes in many sectors, including — often especially — the health care system.”7 The reason, as Janz correctly identifies, is based in medicine’s presumption that “not normal” is the same as “unhealthy.” I wish to include ill physicians in Janz’s formulation, for the same oppressive forces medicine wields against its subjects, it also wields against itself.”   “In science, technology, engineering, and mathematics (STEM) fields, disabled people remain a significantly underrepresented part of the workforce. Recent data suggests that about 20% of undergraduates in the United States have disabilities, but representation in STEM fields is consistently lower than in the general population. Of those earning STEM degrees, only about 10% of undergraduates, 6% of graduate students, and 2% of doctoral students identify as disabled. This suggests that STEM fields have difficulty recruiting and retaining disabled students, which ultimately hurts the field, because disabled scientists bring unique problem-solving perspectives and input.”    Even though the topic is relatively new to me to consider, there is a curriculum for medical students
Trees
A lecture on “Improving Interdisciplinary Gait Deviation Assessment and Treatment Plan Among Lower Limb Prosthetic Users” Direct TRAIN Link (Non-VA) A lecture on Lower extremity Residual limb care: Challenges and solutions We have used the iFIT socket for BKAs at the VA; they are adjustable and relatively less expensive. It was developed by Dr. Timothy Dillingham. There is now an AK version as well and I have attached the brochure. A heartwarming reminder for many of us to decenter once in a while by looking for beauty. Comics intersects PMR: The PUNISHER didn’t accurately represent TBI severity? No….