Arie Perry | Neuropathology Songs

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Neuropathology Songs

by Arie Perry

An educational and fun album for medical professionals wishing to learn about common neurologicl disorders. The high caliber music and wide range of genres will keep you thoroughly entertained.
Genre: Classical: Vocal Music
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1. Neuropathology Introduction (Oh Holy Night)
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2. Multiple Sclerosis
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3. Leukodystrophies (Greensleeves)
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4. Astrocytic Tumors
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5. Oligodendroglioma
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6. Primitive Neuroectodermal Tumor (Danny Boy)
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7. Meningiomas
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8. Schwannoma
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9. Craniopharyngioma (Una Furtiva Lagrima)
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10. Cerebrovascular Disorders (Aura Lee)
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11. Parkinson's Disease (Torna Surriento)
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12. Alzheimer's Disease (Silent Night)
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13. Creutzfeldt-Jakob Disease
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14. Acute Meningitis (Amazing Grace)
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15. Encephalitis
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16. Toxoplasmosis (O' Sole Mio)
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ABOUT THIS ALBUM


Album Notes
BACKGROUND
Years ago, during Dr. Arie Perry's pathology training, one of his attendings challenged the residents to make their conference presentations more “entertaining”. Taking this to heart, he presented a schwannoma (benign tumor of nerve) the following week. Following the traditional viewing of the case around a multi-headed teaching microscope, he pulled out a guitar and sang a brand new composition: the “schwannoma song”. Several years later, it occurred to him that music might provide students with a highly enjoyable and more efficient way to learn some key facts about common disorders of the nervous system. In fact, science tells us that musical memory is often superior to pure rote memory. Once laid down, these musical memories also tend to be retained longer; learning your ABCs with the alphabet song as a child is a good example.

Recalling his own experiences as a medical student with literally thousands of hours of dry lectures presented in rapid succession, Arie felt that Neuropathology songs could provide a novel and refreshing way to learn, when used as a supplement to more conventional approaches. This technique of teaching Neuropathology has since been covered in media reports by the St. Louis Post Dispatch, Washington University Record, KWMU radio station, National Public Radio's (NPR) Marketplace, and the Singer Network, a service of Chorus America.

The current collection of Neuropathology songs is specifically targeted to medical trainees and professionals. The songs cover a wide array of topics, although Dr. Perry has lectured most often on brain tumors and infections, so these topics are more heavily represented. They have been employed primarily for teaching medical students, with whom they've been enthusiastically embraced. As word of this practice spread however, Arie was increasingly asked to include his songs in invited lectures nationally and internationally to well-established medical specialists and even to the lay public in a "Mini Medical School Course", both associated with glowingly positive feedback. Increasingly, Dr. Perry also received requests to share his songs with educators and students from other medical centers, in part prompting him to create the current CD.

In extremely rare cases, a student has misinterpreted these songs as trivializing patient suffering. However, nothing could be further from the truth! Being factual in nature, these songs were created specifically to help medical professionals remember the salient features of common diseases. Where the prognosis is favorable or recent progress has been made, the positive aspects are heavily emphasized. Nonetheless, where we still have a long way to go towards effective therapy, these limitations are highlighted in the hope that some trainees will be inspired to enter the field and find ways to further improve the standard of care for these patients. Short of that goal, the hope is simply that the student of Neuropathology lays down some medically useful, long term musical memories and if they have fun in the process despite the seriousness of the topic, all the better!

ABOUT THE MUSIC
When Arie first started using Neuropathology songs, he wrote both the music and the lyrics. However, it quickly became evident that students had a hard time remembering new melodies after hearing them only once in class (prior to the time when recordings were made available to them). Therefore, for most, he ultimately switched to pre-existing public domain music and simply replaced the lyrics. With either approach, the biggest challenge was fitting often long and complex medical jargon into simpler, more structured rhythmical formulas. In fact, audiences are often not used to hearing such "choppy" medical terminology expressed in a fluid lyrical fashion, so this often elicits a few chuckles at first.

Nevertheless, in the end it actually worked well, as the music was carefully selected to fit the lyrics for each individual disease. Originally, all the songs were performed by Dr. Perry purely on acoustic guitar and voice. Recognizing that this could get monotonous when applied to 16 songs in a row and also that students, like everyone else, have exceptionally wide ranges of musical tastes and cultural backgrounds, a major goal in creating the CD was to provide ample musical variety, both in terms of instrumentation and styles. For that, Arie recruited the talented St. Louis musician and recording engineer, Chris Bergmann to help expand the musical arrangements. Genres included to lesser or greater extents include: American folk, Neapolitan/Italian, Blues, Holiday, Country/Blue grass, English Renaissance, Classical/Opera, Irish tenor, Jamaican Reggae, 60's Rock Musical, Gospel, Brazilian Bossa nova, and Spanish Flamenco. Perhaps some is best described simply as Perry/Bergmann style.

ABOUT THE ARTIST
In terms of medical training, Dr. Perry went to medical school and stayed on for residency at the University of Texas Southwestern Medical Center in Dallas, TX, subsequently receiving fellowship training at the Mayo Clinic in Rochester, MN. He spent the next 12 years as a staff neuropathologist at Washington University School of Medicine in St. Louis, MO. In July of 2010, he will assume duties as a Professor in the departments of Pathology and Neurological Surgery at UCSF in San Francisco, CA, serving as the chief of the Neuropathology Division and maintaining a busy consult service for brain biopsy interpretation. Additionally, he is the chief editor of Brain Pathology, the official journal of the International Society of Neuropathology. He is best known for his clinical and research work on classifying, grading, and genetically characterizing brain tumors, authoring over 220 scientific articles, reviews, and book chapters. He is also co-editor of the new textbook, Practical Surgical Neuropathology, published by Elsevier.

In terms of musical training, Arie started with folk guitar lessons during childhood. Like Luke Skywalker from Star Wars, he unfortunately left this discipline before his training was complete. Nonetheless, he picked up just enough of it to be dangerous and he hopes the force is with him every time he plays guitar in public. He later discovered his tenor voice in high school, when he decided that classical training would assist him in his new role as the lead singer in a rock band. Once bitten by the classical bug, he continued his vocal training at the University of Texas at Austin and has carried on as an active choral singer and tenor soloist for over 25 years. Although music is not his main profession, he feels extremely fortunate to have had the opportunity to work with many highly talented conductors, singers, and orchestral musicians over the years. His tenor solo performances have most often featured compositions by Bach, Berlioz, Britten, Donizetti, Handel, Mendelssohn, Mozart, Puccini, Rachmaninoff, Schubert, and Vaughn Williams.

LYRICS TO SONGS

ACUTE MENINGITIS
Music to “Amazing Grace” by John Newton, Lyrics by Arie Perry, M.D.

Acute meningitis is a dangerous disease, bacteremia spreads into the brain
Through cerebrospinal fluid of the subarachnoid space, patients at risk vary with bacterial strain

It starts with plexitis and moves on down the spine, with meningismus from irritation by the pus
Vasculitis and neuropathy congealed within the mire, infarcts and deafness are the threats to each of us

Organization over time yields complications that are prime, such as seizures, IQ loss, learning deficits
Mycotic aneurysms bleed, as the organisms breed, as well as hydrocephalus if drainage is on the fritz

Acute meningitis requires urgent care, a spinal tap should be done emergently
Check the gram stain with due haste, quickly treat, no time to waste, early antibiotics is the key
Early antibiotics is the key

ALHEIMER'S DISEASE
Music of “Silent Night” by Franz Gruber, Lyrics by Arie Perry, M.D.

Alzheimer’s disease, a dementing disease, with progressive loss of memories
Cognitive deficits predominate, a several year course is the typical rate
With increased disease as we age, with increased disease as we age

Generalized atrophy, marked tauopathy, hydrocephalus ex vacuo secondarily
Hippocampal disease is especially severe, basal cholinergic output all but disappears
Neuron loss and gliosis are key, neuron loss and gliosis are key

Tangles abound, even ghost forms are found, tau paired helical filaments sure stick around
ABeta-amyloid’s important in neuritic plaques, angiopathy makes vessels look somewhat like wax
Lobar hemorrhage is a perilous snag, lobar hemorrhage is a perilous snag

Familial disease, needs genetic expertise, early onset is often the first clue for these
Down’s syndrome has chromosome 21 APP, while others are linked to type 4 apoE
Presenilin mutations as well, presinilin mutations as well

ASTROCYTIC TUMORS
Music and Lyrics by Arie Perry, M.D.

Astrocytic tumors of the CNS, are the most common primaries, more frequent than all the rest
In adults, differentiation is one of the following three, low grade, anaplastic, glioblastoma multiforme

Ch: Four criteria are important histologically, atypia, necrosis, endothelial hyperplasia, mitotic activity
Low grade tumors can have one of these but no more, while glioblastomas must have three or four

They present most commonly, in middle age or elderly, age is directly proportional to the anaplastic degree
Survival time depends on the grade, although in most there's no effective blockade
Transformation to a higher grade, is quite common I’m afraid (chorus)

In adults, astrocytomas are most often fibrillary, they infiltrate diffusely through the centrum semiovale
Grossly or on CT, there’s midline shifts and asymmetry
Ring enhancement is indicative of glioblastoma multiforme (chorus)

In children, they behave differently, there’s not uniform malignancy, pilocytic morphology may confer survivability
They present infratentorially, well defined and cystic commonly
In a surgically resectable site, they can escape the adult’s plight (chorus)

CEREBROVASCULAR DISORDERS
Music to Aura Lee by W.W. Fosdick and George R. Poulton, Lyrics by Arie Perry, M.D.

Cerebral infarct, or a stroke, due to hypoxic/ischemic disease
From thromboembolic or atherosclerotic disease of large head and neck arteries
Red dead neurons, neutrophils, give way to sheets of histiocytes
Over time necrotic tissue liquefies, collapsing down to a cystic site

Intracerebral hemorrhage, from hypertension most commonly
Charcot-Bouchard aneurysms rupturing, from small vessel pathology
Basal ganglia, thalamus, and the pons, are the sites at greatest risk
Herniations and Duret hemorrhage, occur if mass effect is brisk

Selective vulnerability, due to global ischemic disease
Causes watershed infarcts, Purkinje cell death, and hippocampal neurons die with ease
The classic clinical history is a patient with cardiac arrest
Revived after several minutes down, but brain function remains suppressed

Subarachnoid hemorrhage usually, results from ruptured Berry aneurysm
Surgical clipping or vascular embolism, hopes to avoid potential cataclysm
In the U.S., strokes kill 200,000 annually, and there’s also much morbidity
Early treatment can be oh so critical, when there is some reversibility
Early treatment can be oh so critical, when there is some reversibility

CREUTZFELDT-JACOB DISEASE
Music and Lyrics by Arie Perry, M.D.

Intro: Creutzfeldt-Jakob disease, classic prion disorder

Ch: Oh CJD, it’s plain to see, your spongiform encephalopathy, marked neuronal loss, it comes across
Gray matter is gliotic with cerebral atrophy, please keep mutant prion proteins far away from me
Last chorus repeat: Please keep mutant prion proteins far away from me

Rapid dementia is the first clue, periodic sharp waves, and myoclonus too
Most are sporadic, one in a million rate, beta-pleated PrP amyloid leads to poor fate, histology shows (chorus)

Sporadic form is the common type, infectious spread is rare, despite the media hype
Familial cases in five to ten percent, PrP germline mutations is what this represents, histology shows (chorus)

Mad cow disease was linked within the U. K., with new variant CJD, many bovines did they slay
Psychiatric symptoms and ataxia at young age, homozygous Met at codon 129 will set the stage, histology shows (chorus)


CRANIOPHARYNGIOMA
Music to ‘Una Furtiva Lagrima’ from Elixir of Love by G. Donizetti, Lyrics by Arie Perry, M.D.

Craniopharyngioma, epithelial tumor of the brain; benign and yet aggressive, it permeates all around the stalk
Making it hard to resect en bloc, making it hard to resect en bloc, leading to complications such as hypopit

Cyst fluid rich in cholesterol, grossly resembles motor oil; squamoid with basal palisades resembling ribbons and arcades
Wet keratin and stellate reticulum, wet keratin and stellate reticulum
Filling the suprasellar space, with finger-like extensions into the brain
Ah, filling the suprasellar space, with finger-like extensions, into the brain (a cappella ornamentation) …the brain

ENCEPHALITIS
Music and Lyrics by Arie Perry, M.D.

Microglial activation and nodule formation, along with neuronophagia and perivascular lymphocytes
Meningoencephalitis or encephalomyelitis, depending on extent of disease, there’s a range of liabilities

Ch: Viral encephalitis, there are two major kinds, in the arthropod associated, no inclusions you’ll find
But in herpes encephalitis, Cowdry A is the sign, red inclusion with a clear halo, is how it’s defined

With herpes encephalitis, temporal lobe is the nidus, imaginary senses of smell is a common type of spell
It’s often necrotizing, the damage is agonizing, as you wait for CSF PCR, acyclovir will make you a star (chorus)

In AIDS dementia complex, with mental and motor deficits, multinucleated giant cells, a diagnostic feature that compels
CMV is a TORCH infection that inspires your recollection, of AIDS and perinatal disease
Ependymitis brings them to their knees (chorus)


LEUKODYSTROPHIES
Music to Greensleeves by Unknown Composer, Lyrics by Arie Perry, M.D.

The group of familial leukodystrophies, cause genetic demyelinating disease
An inborn error of metabolism, mostly triggered by enzyme deficiencies
Toxic products accumulate, as the oligodendrocytes suffocate
U-fibers are spared, it’s a mystery that this region remains unaffected

Metachromatic leukodystrophy, a recessive arylsulfatase A deficiency
Sulfatide harms oligos and Schwann cells, macrophages pick up their debris
Cresyl violet dye turns it brown, and prismatic inclusions on EM wins hands down
Sural nerve biopsy in MLD, may show onion bulbs and metachromatic Schwann cells

Krabbe’s disease strikes in infancy, galactocerebrosidase deficiency
Autosomal recessive inheritance, and galactocerebroside toxicity
Central and peripheral disease, multinucleated globoid cells diagnose with ease
These distinct histiocytic cells try to clear up the toxic byproducts

Adrenoleukodystrophy or ALD is an X-linked recessive myelinopathy
Very long chain fatty acids accumulate from peroxisomal transporter defects
Perivascular lymphocytes, along with numerous histiocytes
Resembles active MS disease, but young boys are the ones under siege

MENINGIOMAS
Music and Lyrics by Arie Perry, M.D.

From the surface of the brain and the arachnoidal membrane, grows a dural neoplasm, meningioma is its name
As a tumor of adults, with sharp margins and slow growth, it may require the gamma knife, or surgery alone

Ch: Though most are low-grade, with a bland histology, there’s an aggressive subset, with significant morbidity
Atypical meningiomas, recur quite frequently, anaplastic cases have a high mortality

On neuroimaging exams, they’re extra-axial in locale, with a classic dural tail, where the enhancement leaves a trail
Hyperostosis of adjacent bone, implies invasion where the tumor’s grown
It’s seen commonly in NF2, and there’s often a female skew (chorus)

With a wide morphologic range, the differential may seem strange, but with the histologic grade, predictions may be made
The cases graded as atypical have a distinct proclivity, to display brain invasion or mitotic activity (chorus)

Aggressive variants, include grades II and III, with atypical, clear cell, and chordoid in the grade II category
High-grade malignancy corresponds to grade III, they include anaplastic, rhabdoid, and papillary (chorus)

A common tumor from the surface of the brain, meningioma is its name


MULTIPLE SCLEROSIS
Music and Lyrics by Arie Perry, M.D.

MS is thought to be an autoimmune, demyelinating disease
Forming plaques in the brain and the spine, stripping myelin with ease
Relapsing and remitting most of the time, progressive deficits are clues to the crime
Sites of involvement seem random to me, but they determine signs and symptoms we see, oh MS!

Optic neuritis, spinal pathology, periventricular plaques, Dawson's fingers fan out radially, surrounding vascular tracks
They're sharply demarcated, I don't know why; looks gray and sunken to the naked eye
Cortex may be involved, this we know now, cognitive loss occurs, perhaps this is how, oh MS!...oh MS!

Foamy macrophages predominate, in plaques with activity, perivascular lymphocyte cuffs, increase the cellularity
Marked myelin loss is seen on Luxol fast blue, PAS positive material too
Axons are spared on neurofilament stains, although affected, most axons are retained in MS!…oh MS!

Tumefactive MS is challenging, diagnostically, a ring enhancing mass often provokes, a tissue biopsy
Mitotic figures shouldn't be misconstrued, don't call it GBM or you might get sued
Foamy macrophages provide the clue, to let you know that tumor's probably not true, oh MS

A chronic debilitating disease, we need new therapies, new therapies

NEUROPATHOLOGY INTRODUCTION
Music to Oh Holy Night by Adolphe Adam, Lyrics by Arie Perry, M.D.

The brain is unique, from other organ systems; it has a functional neuroanatomy
Lesions at various sites, result in different symptoms, with patterns of selective vulnerability
The limited space, in the craniospinal axis, means tribulations, when there are mass effects
The brain herniates, against the dural reflections, cingulate gyrus under the falx, and the uncus transtentorially
The tonsils through foramen magnum, Duret hemorrhage secondarily

Astrocyte foot processes and tight endothelial junctions, ensure the blood brain barrier remains intact
Keeping bad things out, is one of its major functions, although this can backfire for a negative impact
Once in the brain, enjoying a safe haven, from the immune system, and therapeutic drugs
Increasing risk, from CNS infections, as well as malignancies, such as systemic metastases
With few possibilities, around for treating just such a disease

Response to injuries, appears in several fashions, with astrocyte gliosis seen most commonly
For neurons, red is dead, it’s an association, with hypoxic or ischemic injury
Rod cells are activated microglia, nodules are formed in encephalitides
Chromatolysis, results from disrupted axons, in massive injury, gitter cells clean up debris
In massive injury, gitter cells clean up the debris


OLIGODENDROGLIOMA
Music to Ave Maria by F. Schubert, Lyrics by Arie Perry, MD

Oligodendroglioma, diffuse cerebral tumor of adults
Invading cortex, causing epilepsy; on imaging, often you are calcified
And although, you tend to progress over time, for long periods you're fine

You're famous for your rounded nuclei, clear haloes look like honeycombs or fried eggs
With branching chicken wire capillaries, and perineuronal satellitosis

Oligodendroglioma, genetically, you are quite unique
With 1p a-and 19q deletions, from translocation with loss of one derivative
Represents a genetically favorable set, when FISH criteria are met

Anaplastic cases grow more rapidly, assigned a W.H.O. grade III
With microvascular proliferation, or increased mitotic activity. Oligodendroglioma

PARKINSON'S DISEASE
Music to Torna a Surriento by Ernesto De Curtis, Lyrics by Arie Perry

Ch: Parkinson’s Disease, a common movement disorder, with synuclein positive Lewy bodies

Shuffling gait and resting tremor, with substantia nigra pallor
And loss of neurons in the locus, in pigmented brainstem nuclei
Bradykinesia and rigidity, along with postural instability, responsive to L-dopa commonly, in early stages of disease
Increasingly it’s more refractory, requiring other forms of therapy, such as deep brain stimulation, or pallidotomy (chorus)

If there are psychiatric symptoms, it may involve the limbic system, dementia may become a feature, in cortical disease
Lewy bodies in the hippocampus, and many in the cingulate gyrus, as well as entorhinal cortex, defining DLBD
Though at least one other explanation, for dementia in a PD patient
There’s more than just a chance relation, for Alzheimer’s disease (chorus)

PRIMITIVE NEUROECTODERMAL TUMOR
Music to “Danny Boy”, Lyrics by Arie Perry

Oh primitive neuroectodermal tumor; ye be a harsh embryonal neoplasm
Hypercellular with apoptotic nuclei; a small blue cell tumor with little cytoplasm
You grow so fast, mitoses are a plenty; afflicting lads, as young as young may be
And you can spread, through CSF like icing; we’ll break your stride with rads and chemotherapy

You show divergent differentiation, along neuronal lines most commonly
Homer Wright rosettes is one manifestation, with synaptophysin positivity
The cerebellum is the site you favor; medulloblastoma’s the name we grant to thee
And your prognosis may be somewhat better; than the supratentorial PNET

On MRI, you’re solid and enhancing, with brain invasion microscopically
The differential that we are examining, ependymoma and pilocytic naturally
Our therapies have been somewhat successful, with survivals up to eighty percent
But infants’ side effects are still disgraceful, superior chemo’s needed before we’ll feel content
Superior chemo’s needed before we’ll feel content



SCWHANNOMA
Music and Lyrics by Arie Perry, MD

Schwannomas present in adult patients in their forties or their fifties
They’re peripheral nerve tumors, often solitary, and they grow next to the nerve eccentrically
Because of this feature, they can be excised, and still the nerve can be spared
It’s mainly the compression of adjacent nerve, which makes the patient impaired (chorus)

Ch: Schwannomas are no mystery; you look for Antoni A and Antoni B
And Verocay bodies will clinch the diagnosis for me
Hyalinized vessels is another clue, and good encapsulation is a key feature too
To make the diagnosis when the surgeon’s leaning over you

Acoustic neuromas are in the CP angle, and involve cranial nerve VIII
In the spinal canal, nerve roots are involved, and can alter the patient’s gait
Grossly, they’re firm, grey-white masses, on cut surface, they’re gelatinous
Ancient neuromas have degenerative changes, cystic spaces and hemorrhage (chorus)

Multiple tumors, and young age of onset, suggests hereditary disease
Vestibular schwannomas, and meningiomas, meet NF2 criteria with ease
The term schwannomatosis may be utilized, when multiple tumors are seen
Non-vestibular involvement is a defining feature, so the head MRI should be clean (chorus)

TOXOPLASMOSIS
Music to ‘O Sole Mio by E. di Capua, Lyrics by Arie Perry, M.D.

Toxoplasma gondii, an opportunistic parasite, afflicting patients who are immunocompromised
In the central nervous system, lesions are necrotizing, in neonates and HIV, that is where you’re gonna see, a problem

Ch: Toxoplasmosis, a feline pest, keep it in your differential, so you don’t fail the test
Remember, it’s treatable, with the right antibiotics, lesions regress

On brain biopsy, of an enhancing lesion, there’s vasculitis and encephalitis
Abscess formation and rod cell activation, there are bradyzoite cysts and tachyzoites exist as free forms (chorus)


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Prof. Lajos László

Sensatianal impression at PRION 2010, Salzburg
As a fiend of prion research, I realised in Salzburg that Professor Arie Perry knows much more about Creutzfeldt-Jakob Disease than anybody else.