The patient’s performance on memory tests and his full scale IQ were rated average

The patient bent down on his right knee and grabbed the dog with his left arm as he held himself up with his right hand, which was in the puddle. He reported a ‘‘buzzing feeling” traveling up his right arm. After bringing his dog to safety, the patient returned to the site, got down on both knees, put both hands in the puddle, felt a ‘‘humming” sensation travel up both arms and felt ‘‘stuck” in that position for 2–3 s . Immediately after the shock, the patient sustained burn marks and experienced short-term memory loss and fatigue. Three dayslater, the patient saw an internist and reported upper right quadrant pain, headaches, numbness, weakness, fatigue, insomnia, and minimal, first degree burn marks on his right underarm and on the dorsal aspect of both forearms. The surface area was 1.1% for each forearm, and an additional 1.1% for the right underarm, for a total affected area of 3.3%. One week later, the patient received MRIs of the lumbosacral spine, cervical spine and brain which all reported no abnormalities. One month later, the patient visited a psychologist regarding anxiety, insomnia, and depression, and was diagnosed with post-traumatic stress disorder and retrograde amnesia. Three months after the electrical injury, the patient saw an ophthalmologist regarding pain behind his right orbital and ‘‘drooping” of the right side of his face; he was diagnosed with Bell’s palsy. Two years after the incident, the patient had an orthopedic evaluation for right side body pain, loss of right hand motor control, right hand tremors,how to cure cannabis pain behind the right orbital and headaches with no orthopedic abnormalities found. The following day, the patient visited a neurologist and a different ophthalmologist regarding the same symptoms, with no abnormalities found.

Three years after the electrical injury, the patient visited a neurologist regarding hypesthesia in the right side of the face and to pinpricks to the right hand, severe pain in the right arm and hand, moderate pain in the left arm and hand, and was diagnosed with electrocution neuropathy. Five months later, the same neurologist noted improvement of the pain in the right arm and hand area. During the same year, the patient visited a therapist and was diagnosed with PTSD, severe anxiety, and situational depression and was prescribed psychotherapy as treatment. Six years after the injury, additional documentation of the damage sustained from the electrical injury was needed to provide objective evidence as part of a lawsuit against the electric company responsible for the exposed wires. The patient visited our laboratory for an MRI DTI and quantitative volumetric analysis, and a clinical neuropsychologist for an exam. At the time of the neuropsychological exam, the patient was taking Bupropion XL, Clobex, Hydrocodone/Acetaminophen, melatonin, Klonopin , Namenda , Neurontin , and medical marijuana. On the Diller-Weinberg Test, the patient missed 39/47 stimuli, and his visual encoding/processing speed on specific Wechsler Adult Intelligence Scale subtests was between the 1st and 5th percentile. On the dominant finger tapping test, the patient scored in the 5th percentile. His performance on a timed task of fine motor dexterity was impaired between 2 – 3 standard deviations below the mean, and his motor and processing speed index was in the 2nd percentile, which is typical residual of electrical injury. The patient scored 20 less points on his Performance intelligent quotient than his Verbal IQ , which is statistically significant and notably unusual. He scored as severely depressed on his Beck, and has had severe chronic pain and PTSD symptoms in the clinical range. The patient’s past medical history was significant for meningitis at age 10, and arthritis and hypertension as an early adolescent. The patient underwent several unrelated orthopedic surgeries from sports related injuries, with the last surgery being sixteen years before the electrical injury.

According to his ex-fiancé, the patient was very social and outgoing before the electrical shock, while he became withdrawn and isolated afterwards. The patient enjoyed activities such as surfing, swimming, hiking, basketball, and skateboarding, all of which he was unable to do, or did differently, after the injury. At the time of the incident, he was in good health and working as a physical trainer.Most electrical injuries happen in the workplace, while some occur in household settings. In dense cities that experience heavy snow during the winter, like Boston or New York City, residents are at a higher risk of electrocution through stray voltage when the snow starts to melt. Stray voltage is the unintended occurrence of an electrical potential between two objects due to a fault in an electrical system and is defined to be less than 10 volts by the U.S. Department of Agriculture. These circumstances, coupled with the increased conductance caused by high-salinity snowmelt, can charge normally non-threatening metal objects, or puddles with ample amounts of stray voltage. Electrical injury occurs when a person has at least two points of contact with two sources of different voltage, one of which may be the earth ground. The extent of electrical injury is dependent on the voltage, amperage, path of and type of the current /direct current, duration of contact, and premorbid state of the patient. In the presence of an external electric field, cell membrane permeabilization occurs as the lipids in the lipid bilayer undergo reorganization in a process known as electroporation. In turn, cell contents such as ions are able to move freely in and out of cells. Through the phenomenon of electroporation, current is able to travel through and leave the body through the second contact point to a grounding source. Clearly these aspects of EI are quite mechanistic, however, one of its enigmas include the remote neuropsychological deterioration of the patient regardless of the trajectory of the current .

EI has been known to cause a spectrum of neuropsychological and psychiatric disorders. Duff compiled a review of twenty eight studies of EI and lightning injury patients, logging 2738 victims reporting a total of 4441 signs or symptoms. These signs/ symptoms were ‘‘categorized into nine different domains of sequelae, which included disturbance of consciousness, attention/concentration deficits, speech/language deficits, sensory deficits, memory deficits, other cognitive deficits, psychiatric complaints, somatic complaints, and neurological complaints”. Another study of the long-term sequelae of low-voltage electrical injury done by Singerman reported numbness, weakness, and memory problems as the most frequent neurological problems and anxiety, nightmares, insomnia, and flashbacks of the event as the most frequent psychological problems. Since the literature suggests EI causes neuropsychological sequelae, it is worth using MRI imaging techniques to examine any structural abnormalities and cerebral lesions. Irregularities observed on MRI scans are generally unique to each EI case, however white matter hyperintensities found on fluid-attenuated inversion recovery image sequences are a common factor. The latter three of the case studies cited all report WMH specifically in the cerebral corticospinal tract. EI has also been known to cause hypoxia, which is characterized by cytotoxic edema in the cortex of the central region and the basal ganglia.The average lamppost in a densely populated city, such as New York City, works on a single-phase 120 V/240 V 60 Hz, AC received from a nearby three-phase generator . The patient received an electrical shock after submerging his hands in a puddle on a sidewalk charged with stray voltage from a nearby lamppost. Workers from the electrical company in the area testified that exposed ends of an electrical cable of a lamppost were causing 8 V of stray voltage. Using the information we know about wet skin resistance,indoor grow methods we can also assume that the patient’s hand had a resistance of 1000 X, while the patient’s internal body had a resistance of 300 X . Rearranging Eq. , we calculate the current passing through the patient’s hand to be approximately 8 mA, while the current passing through the internal body is approximately 26 mA. However since salt water is more conductive than pure water, this would have potentially lowered the resistivity of the patient’s hand, causing the current passing through his hands to be comparatively higher and thus accounting for the no-let-go phenomenon he experienced. To examine the validity of this approximation, we consider the patient’s dog that went into seizure upon stepping in the charged puddle.

A study done by Woodbury investigated the stimulus parameters needed to induce electroshock seizures on rats, and found that at 60 Hz AC, the current needed to promote seizures was 17.7 mA. This is extremely similar to the current needed, 16 mA, to induce the no-let-go phenomenon in the average male. Thus we can assume with substantial confidence that the current passing through the patient’s hand was roughly around 16 mA AC.At age 10, the patient was treated for meningitis. One week after the electrical injury, the 37-year-old patient received a brain MRI that reported no abnormalities. Six years after the injury, the patient had another brain MRI, which was sent to our laboratory. Since the cavitation of his right lateral ventricle is prominent on T1 multi-planar reconstruction and T2 FLAIR MRI sequences , it is highly probable that this particular abnormality was not derived from the patient’s childhood meningitis, otherwise it would have been observed by his former radiologist. MRI DTI analysis done on adult meningitis reports increased FA values in cortical regions, while analysis done on neonatal meningitis reports increased FA values in leptomeningeal regions and decreased FA values in periventricular white matter regions. However, to date, there are no studies that report white matter abnormalities found in adults with childhood meningitis, or studies that have assessed high diffusion anisotropy sequelae in patients with a history of meningitis.At the time of the neuropsychological exam, the patient was taking multiple medications that could have potentially affected cognitive performance. An investigation of these potential effects was conducted. Depressed patients treated with Bupropion scored similarly to normal, healthy controls on neuropsychiatric tests that assessed verbal memory, visual memory, finger tapping, and symbol digital coding. On the dominant finger-tapping test, our patient scored in 5th percentile, while on the coding subtest, he scored in the 10th percentile. The patient’s visual and verbal memory scores were average. In a study that assessed the neuropsychiatric effects of Hydrocodone, subjects that had taken hydrocodone performed 10% worse than the mean on the motor performance test, while no variance was found on simple and complex reaction time tests. Our patient scored in the 2nd percentile on the motor and processing speed index. In a study done on 38 patients taking Clonazepam, 8 patients experienced behavioral side effects while 30 patients did not . The mean absolute discrepancy between VIQ and PIQ of the 8 patients was 17.5 points, while the discrepancy between VIQ and PIQ of the 30 patients who did not experience behavioral side effects was 6.5 points. Our patient’s VIQ and PIQ difference was 20 points. No study has been done on the effects of memantine on cognitive behavior for patients without Alzheimer’s disease , but for patients with AD, memantine improved language and memory scores in comparison to a placebo group. Gonzalez measured the effects of cannabis on cognitive performance by determining overall indexes of neuropsychological performance and running individual neuropsychological tests . Habitual cannabis users performed 1/5th a standard deviation worse than controls in overall index scores, and had performed significantly worse on memory tests. No effects of melatonin on neurocognitive performance were found. No effects of gabapentin on neurocognitive performance were found.Advances in digital technologies and data analytics have created unprecedented opportunities to assess and enhance health behavior and to accelerate the ability of science to understand and contribute to improved health behavior and health outcomes. Over 5 billion people in the world have access to mobile phone services . And access to these technologies is not confined to high income populations or countries but is also increasingly evident in many low and middle income countries and traditionally underserved populations . Digital health refers to the use of digital technologies and data analytics to understand people’s health-related behavior and provide personalized health care resources . Given the widespread access to technology worldwide, digital health offers great promise to enable widespread reach and scalability of evidence-based treatments to promote health behavior and collectively lead to transformations in the delivery of science-based health care.