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‘Success does not consist in never making mistakes but in never making the same one a second time.’ George Bernard Shaw
Making a mistake in medicine is always troubling, but recognising your mistakes is an important and powerful way to learn. And even better if you can learn from others' mistakes and avoid making the mistake yourself at all. Marjolein Aerts and colleagues (see page 264) review several patients from their movement disorder clinic who actually had neuromuscular disorders (and visa versa). This type of error is labelled ‘triage cueing’,1 where a patient who ends up in the wrong clinic goes down the wrong pathway (‘geography is destiny’). Nihat and colleagues describe a similar type of error in a patient with rheumatoid meningitis who initially was referred into the stroke service (see page 312).
Apraxia can be a source of confusion and can be easily mislabelled clinically. Adam Cassidy (see page 317) provides a helpful overview of its clinical assessment that should help to clarify a sign that may be hard to interpret. Vitamin B12 deficiency causes a wide range of neurological syndromes but for the most part its diagnosis is straightforward and confirmed with a blood test. However, in some people with B12 deficiency the conventional measurements are normal and we need more sophisticated measures. Ruth Dobson and Debie Alvares describe such a case (see page 308) and Robin Lachmann and Anthony Briddon (see page 328) provide an overview of the subject. Those unaware of this possibility have perhaps fallen into an ‘ignorance trap’.1
Subacute combined degeneration of the cord causes loss of proprioception which is classically demonstrated by Romberg's test. Or is it? Martin Turner introduces a new series on neuromythology (see page 316)—a term made famous by William Landau's series in the journal Neurology,2 a series that we are resurrecting. In the first of these, Martin argues that the Romberg's test does not stand up to scrutiny. Interestingly erroneous over-dependence on a single sign such as Romberg's is referred to as ‘anchoring’—the very opposite of Romberg's—a cognitive error often combined with ‘premature closure’.1 However, sometimes certain findings are reliable, at least in the correct clinical context. We have descriptions of important findings in two types of autoimmune encephalitis, firstly of a very specific EEG finding (see page 324) and secondly of an unusual seizure type (see page 326) that are both useful to recognise.
Jon Walters takes a different approach (see page 258), exploring contractures in muscle diseases, an uncommon and easily missed physical sign but one that narrows the differential diagnosis significantly.
Diagnosis is a precursor to treatment and informs prognosis. Most patients with cervical dystonia respond well to treatment with botulinum toxin—but sometimes they do not, or at least not as well as might be expected. What should the neurologist do? Working this out requires a rethink and could reflect a wide range of errors. Is the diagnosis correct? Are you injecting the correct muscles? Is the preparation you are using not working for some reason? Marie-Helene Marion and colleagues from the ABN botulinum toxin Special Interest Group have developed recommendations from their experience to help (see page 288).
Patients with epilepsy often link their seizures to stress and stressful life events, leaving the neurologist often unsure if this is just coincidence, or a natural tendency to try to identify seizure triggers, or something more. Hannah Cock and colleagues review the evidence and provide a wider perspective (see page 270) that we hope neurologists will find helpful to share with patients.
There is no way to avoid making errors altogether. But sharing them and disseminating what you have learnt will help others to avoid making the same mistakes in the future. Share your mistakes: send them in to Practical Neurology.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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