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• Re:Why I shall never stop examining patients
  Jan M. Keppel Hesselink
  Published on: 14 April 2016
• a restatement of core values
  oscar,m jolobe
  Published on: 14 April 2016
• Why I shall never stop examining patients
  Nitin K. Sethi
  Published on: 14 April 2016

• Published on: 14 April 2016

  Re:Why I shall never stop examining patients

  • Jan M. Keppel Hesselink, Director R&D, professor of pharmacology

  Dear Editor,

  With great interest I savoured the editorial by Dr. Warlow (1). Apart from learning the meaning of the word shibboleth, his analysis is most crisp and brings us back to the most important factor in medicine: the interaction between patient and physician.As a pain specialist I see many patients suffering from neuropathic pain, and I always examine thesm, especially their painful feet.Although I can...

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  Dear Editor,

  With great interest I savoured the editorial by Dr. Warlow (1). Apart from learning the meaning of the word shibboleth, his analysis is most crisp and brings us back to the most important factor in medicine: the interaction between patient and physician.As a pain specialist I see many patients suffering from neuropathic pain, and I always examine thesm, especially their painful feet.Although I can predict mostly what I will find, the act of examining the feet also helps the patient to bring his attention to his feet. Examining not only gives a signal that I take the experienced pain as seriously as possible, it is a start for the patient to re-incorporate his painful feet into his body-image. The concept of body-image was developed by the famous neurologist Henry Head and refers to the mental representation of one's own physical appearance.The examination of gnostic and vital sensibility reveals, besides diminished sensibility, most often a disturbed body-image. The bodyimage, which is a fundamental aspect of self-awareness and self-identity, is frequently severely disrupted in chonic neuropathic pain conditions. From modern imaging research we have learned that distortions of the bodyimage modulate painful sensations themselves. To bring back the patient's attention to body parts in chronic pains tates is a first step towards a more healthy incorporation of the feet into the body image. Directly after our physical examination we use the findings to iscuss and point out how patients have mostly 'cut off' their feet from their own body image. Prescibing topical amitriptyline cream and teaeching patients to apply the cream to their own feet twice a day, helps diminish the pain via pharmacology and also repaires the pathological relation the patients have created with their own feet. Taking the physical examination of neuropathic feet seriously is therfore the first step of our treatment. Therefore I am most greatful to have read Dr. Warlow's masterpiece and I too will never stop examining my neuropathic pain patients.

  References:

  1. Warlow C. Why I have not stopped examining patients. Pract Neurol. 2010 Jun; 10(3):126-8.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 14 April 2016

  a restatement of core values

  • oscar,m jolobe, retired geriatrician

  Professor Warlow is to be congratulated on his masterly restatement of the core values of clinical medicine, in general, and neurology, in particular(1). As a corollary to his observation regarding "whether what you find on imaging is relevant to the problem or is merely incidental"(1), recognition should be made that the scan, itself, may generate images which are either falsely normal(2), or too nonspecifically abnormal...

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  Professor Warlow is to be congratulated on his masterly restatement of the core values of clinical medicine, in general, and neurology, in particular(1). As a corollary to his observation regarding "whether what you find on imaging is relevant to the problem or is merely incidental"(1), recognition should be made that the scan, itself, may generate images which are either falsely normal(2), or too nonspecifically abnormal to form the basis of an unequivocal diagnosis(2)(3)(4). At the other extreme there may be a "surfeit" of potentially significant images, generating the possibility of dual pathology as the underlying cause of a single neurological disorder(4)(5). All these scenarios are encountered during evaluation of the underlying causes of temporal lobe epilepsy and partial complex seizures. In one series, where 19 patients were identified as having gangioglioma as the underlying cause of partial complex seizures, there were two instances where "the MRfindings were normal", leading the investigators to conclude that CT should also be performed to recognise calcifications that may be missed on MR imaging(2). Even where MR is abnormal stigmata of ganglioglioma may be nonspecific, ranging from signal hypointensity or even isointensity, to hyperintensity relative to gray matter(3)(4). Diagnostic uncertainty is compounded by the fact that ganglioma-related MR images may sometimes fail to enhance after administration of contrast(6), and that, even in the event of contrast enhancement, the pattern of enhancement may be non specific(4), an observation which resonates with the view that, in this disorder, "CT and MR findings [are] not specific"(2). At the other extreme there is the problem of dual pathology as the potential underlying cause of either temporal lobe or partial complex epilepsy. This was exemplified by a study where two of the twenty four patients with partial complex epilepsy and ganglioglioma were identified as having coexisting ipsilateral hippocampal sclerosis(4),and also by a study where other potential causes coexisted with hippocampal sclerosis(5). The final twist is where two lesions are present, either or both of which could be an underlying cause of temporal lobe epilepsy but only one of the lesions is epileptogenic. This was the case in a 25 year old man in whom CT scan showed a calcified left temporal lobe lesion which was characterised, on MR, by heterogenous signal intensity suggestive of ganglioglioma. Concurrently, also on MR, he had a right temporal lobe lesion characterised by loss of gray-white matter demarcation, and by increased signal intensity on the STIR(short tau inversion recovery) image suggestive of a right-sided seizure focus. On intracranial EEG and on intraoperative electrocorticography, however, only the right-sided lesion was shown to be epiliptogenic. Pathological examination of the excised right-sided lesion revealed stigmata of cerebral microdysgenesis(7), a "pathological entity with clinical relevance[in the context of drug- resistant epilepsy"(8).

  References:

  (1) Warlow C Why I have not stopped examining patients Practical Neurology 2010;10:126-128

  (2) Tampieri D., Moumdjian R., Melanson D et al Intracerebral gangliogliomas in patients with partial complex seizures: CT and MR imaging findings Am J Neuroradiol 1991;12:749-755

  (3) Castello M., Davis PC., Takei Y., Hoffman JC Intracranial ganglioglioma:MR.CT,and clinical findings in 18 patients Am J Neuroradiol 1990;11:109-114

  (4) Adachi Y., Yagishita A Gangliogliomas: characteristic imaging findings and role in tempopral lobe epilepsy Diagnostic Neuroradiology 2008;50:829-834

  (5) Salanova V., Markand O., Worth R Temporal lobe epilpsy: analysis of patients with dual pathology Acta Neurol Scand 2004;109:126-131

  (6) Zentner J., Wolf HK., Ostertun B et al Gangliogliomas: clinical, radiological, and histopathological findings in 51 patients J Neurol Neurosurg Psychiatry 1994;57:1497-1502

  (7) Adachi Y., Yagishita A., Arai N White matter abnormalities in the anterior temporal lobe suggests the side of the seizure foci in temporal lobe epilepsy Neuroradiology 2006;48:460-464

  (8) Pasquier B., Peoc'h M., Fabre-Bocquentin B et al Surgical pathology of drug-resisteant partial epilepsy. A 10 year experience with a series of 327 consecutive resections Epileptic Disorders 2002;4:99-119

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 14 April 2016

  Why I shall never stop examining patients

  • Nitin K. Sethi, Assistant Professor of Neurology

  Dear Editor,

  I read with interest the editorial by Dr. Warlow (1). It follows the earlier editorial by Dr. Hawkes titled "I have stopped examining patients" (2). That editorial evoked a fury of concerned responses from both neurologists and neurologists to be. The editorial by Dr.Warlow will be far less controversial and I feel aptly balances the debate between examining and not examining neurologists. Dr....

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  Dear Editor,

  I read with interest the editorial by Dr. Warlow (1). It follows the earlier editorial by Dr. Hawkes titled "I have stopped examining patients" (2). That editorial evoked a fury of concerned responses from both neurologists and neurologists to be. The editorial by Dr.Warlow will be far less controversial and I feel aptly balances the debate between examining and not examining neurologists. Dr. Warlow lays forth the argument for examining at least some aspects of the neurological system in selected patients guided by their history. This if I remember rightly is what is called a focussed examination. Dr. Warlow lists 10 reasons in no particular order of importance to defend the value of a neurological examination. To his comprehensive 10, I should like to add a couple of my own, again in no particular order of importance:

  1.It makes me feel like a doctor: neurologists at least here in the United States have already surrendered the stethoscope to the internists. If I surrender my neurological examination skills too, I risk losing my very identity as a neurologist.

  2.It makes my office day less monotonous and gives me a reason to get away from the electronic medical chart on the computer and get some much needed exercise. A well performed motor examination is actually quite a decent workout! For the above reasons and the many others so eloquently listed by Dr. Warlow, I shall never stop examining patients.

  References:

  1. Warlow C. Why I have not stopped examining patients. Pract Neurol. 2010 Jun; 10(3):126-8.

  2. Hawkes CH. I have stopped examining patients!. Pract Neurol. 2009 Aug;9(4):192-4.

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

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