eLetters

104 e-Letters

  • Response to Torres et al

    We thank Dr Torres and colleagues for drawing the readers’ attention to the additional value of observing patients with parkinsonian syndromes even before they enter the hospital premises. They focus specifically on the question how neurologists should act when one incidentally spots clear signs of a neurological disease among total strangers in social situations, and they emphasize just how exceptionally difficult this may be for experts in movement disorders, as these conditions can be very visible even to bystanders. Many readers will recognize how compelled one can feel to make a heartfelt recommendation to strangers to seek a neurological consultation, for example when they demonstrate clear-cut signs of Parkinson’s disease or some other neurological condition. However, we have neither acted on the impulse as this would be a serious breach of this person’s privacy. In addition, we need to realize that we are fully ignorant of the person’s context, barriers and motives that have prevented this person – who might already be aware of the signs - from seeking medical attention. We agree that one can only observe, but interfering would be out of line. Indeed, we previously observed a remarkable Parkinson-like gait disorder in Russian president Vladimir Putin and several other highly ranked Russian officials,1 just because we could not suppress our almost innate tendency to analyze movements, in this case when observing the publicly available v...

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  • Outside The Waiting Room

    As I make my way to the outpatient clinic, late as usual after the morning rounds to start another busy day, an unusual walk in front of me seizes my attention: an elderly lady, with a narrow-based and short-stepped gait, decreased left-arm swing and stooped posture; unable to see her face, I assume she’s heading for the neurology outpatient clinic. Yet she passes by and I lose sight of her on the ophthalmology service. Not a patient of ours, I think to myself. That same night, while having supper at a restaurant with my soon-to-be-wife, I notice a few tables away a man on his seventies celebrating his birthday, surrounded by family. In front of the candle-sparkling birthday cake, I get a glimpse of an unusual face: elevated eyebrows, like on a permanent surprise, unable to direct his gaze to the cake—Procerus sign and vertical gaze paresis—I think to myself, while I notice the stooped posture and global slowness of movements while everyone on the table compliments him—parkinsonism also, definitely progressive supranucl…—“You’re doing that again, leave the man alone.” My train of thought gets wrecked by my fiancee, not being the first time, she knows I tend to distinguish and observe people with abnormal movements. I leave the man alone and finish my supper. -SACT.

    It was with exceptional interest that we read “The Waiting Room”, by Araújo et al. recently published online on Practical Neurolo...

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  • Insult to injured Montezuma...

    To the Editor

    With respect to the article entitled ‘Montezuma’s revenge’: neurological disorders in the returning traveller, the authors make an important point about the treatment of malaria: hopefully GPs and potential travellers in the UK are always extra-ordinarily careful about malaria prophylaxis.
    However, I believe it worth pointing out that the list of illnesses which may be acquired in certain countries is, unfortunately, simply wrong (Figure 1). The following infectious diseases are not found in South Africa:
    1. Relapsing fever (except described in penguins![1]).
    2. Plague.
    3. African sleeping sickness.
    Following successful treatment of the outbreak in Madagascar perhaps one should also note that the Western half of the United States is historically a region where plague is found (not mentioned by the authors)[2]. I appreciate that the list provided in the article is derived from another source, but I am sure the authors will agree on the importance of avoiding the promulgation of inaccurate information.
    Finally, despite what the authors may maintain, the correct treatment, if any, of cerebral neurocysticercosis does indeed continue to remain controversial, and adequate RCTs have not been performed[3][4]. Decisions on treatment may well need to be made on a case by case basis, and it is important that neurologists should be aware of the dearth of hard evidence concerning the treatment of neurocysticercosis.

    1 Yab...

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  • Re: Lumbar puncture on Direct Oral Anticoagulants (DOACs): a novel, emerging perspective

    We are very grateful to Dr Rota and colleagues for their interest in our guideline.

    In essence, we agree that international consensus on DOAC level measurement and cut-off levels would be welcome.

    The experience reported by Dr Rota and colleagues of their use of idarucizumab for emergency reversal of dabigatran prior to lumbar puncture is reassuring. Our guideline refers to the need to consult a haematologist prior to administration; however, a guideline is for guidance and we recognise that locally agreed protocols may vary. Likewise, the timings mentioned in the guideline relating to the safe reinitiation of DOACs are by necessity pragmatic. Further evidence in this area will of course be very welcome to further inform practice.

  • Lumbar puncture on Direct Oral Anticoagulants (DOACs): a novel, emerging perspective

    Dear Editor,
    We read the article by Dodd et al. (2018) [1] with great interest. The authors provide evidence-based recommendations for the periprocedural management of antithrombotic and anticoagulant treatment in patients who require a lumbar puncture (LP). Indeed, this is a very relevant practical point for neurologists, above all when an urgent diagnostic LP is mandatory to rule out an infectious disease of the central nervous system, or a subarachnoid hemorrhage. The recommendations on adjustment/reversal of warfarin for patients on oral anticoagulants, who require LP, are well known, i.e. long-term LP allowed if INR is < 1.4. Whilst the question of how to manage patients on Direct Oral Anticoagulants (DOACS), a relatively novel pharmacological class, is also to be answered. Dodd et al’s article [1] reports that if a non-urgent LP has to be carried out he these patients, current recommendations vary among different advisory bodies about the time lapse necessary for DOAC withdrawal before the LP, depending on the renal function. The interesting possibility of measuring the drug-specific levels, so as to estimate the anticoagulant effect of a DOAC, is also mentioned, although the authors are of the opinion that routine testing before the LP is not necessary. [1]
    We believe that this is a crucial point, above all in the case of an urgent or emergent LP. Indeed, in our experience, when available, drug-specific levels can be obtained quickly and guide the cl...

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  • Ankle jerks

    Sir,
    I thoroughly enjoyed reading Dr. Allen’s excellent paper on the right way to do the ankle jerk. He is quite right in saying that ‘tendon reflexes’ are not tendon reflexes. Tapping a tendon leads to stimulation of the Golgi tendon organs, which are actually inhibitory to the alpha neurones, so no response should occur. The muscle contraction probably results from the vibrations transmitted to the intrafusal muscle fibres, leading to activation of the anterior horn cells and thus causing muscle contraction in response to the stimulus. The term “deep tendon reflex” is completely inappropriate; which deep tendons can one access? Levator palpebrae superioris? Piriformis? Gluteus medius? The tendons percussed have to be superficial so that we can get at them.

    Although Dr. Allen’s method is absolutely appropriate in patients who are confined to bed, those patients who are mobile can, I suggest, be better examined if you ask them first to kneel on the seat of the chair on which they were sitting, grasping its back with their hands. They are thus unconsciously performing a Jendrassik manoeuvre, augmenting any response that their bodies might make. Their ankles, projected out behind the seat, can be tapped easily, and the response noted with equal facility.

    Now in my 80s, I cannot remember whether it was Erb or Westphal or Romberg or somebody else who first suggested this method; but after 55 years in Neurology, I still find it the best way to asse...

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  • Reply to Graham Warner’s e-letter
    It is interesting that Graham Warner mentions the sound of absent ankle reflexes. I remember discussing the thud of an absent ankle with Michael Harrison, who was my greatest clinical guru, when I was his registrar at the Middlesex Hospital in London. I have also mentioned it to my students but tended to get the l look back that tells me politely that I might not come from the same planet as them. I suspect this is because learning to examine patients involves learning novel complex perceptions. Much of this is honed over many years and like all complex perceptions involves more than one sensory modality. As neurologists, we all know that appreciating a subtle flavour involves lot more than the sensory information from the tongue; it is mostly olfactory but also involves texture and temperature as well as context and expectation. This is why to many of us the discussions of wine buffs about the subtle flavours of different vintages sound like the ramblings of someone from an alien world. Thus when teaching students one has to realise that they are learning complex perceptions in unfamiliar contexts and may not be able to appreciate subtleties such as the sound of reflexes. So their “what planet is he from?” look is appropriate because perceptually they are in a different world to that of an experienced clinician. As teachers, we need to guide them to our world of complex perceptions and not all can follow, just as I would never succeed as a wine-taster (not that I don’t like...Show More
  • Reflection on reflexes

    Chris Allen’s series on neurological examination offers huge relief to fellow experts who execute it incorrectly, such as the “ankle jerks”. I too use the plantar method although caution Juniors/Students to do it the right way (tendon method) when non-neurologists assess in osce’s/finals. But in teaching them how to tick the boxes I have questioned why I do what I do (self-questioning being one of the reasons I seize the opportunity to train others). I then recall as an SHO Simon Nurick (one of the people who inspired me) tellinging me to listen to the reflexes, in that when absent one hears a dull thud (rather like that of a pleural effusion, so it is interesting to learn that neurological hammers evolved from those used for respiratory examination). And it sounds more resonant when present, all akin to how taught a violin string might be, I tell them. In fact not only do I listen, as well as observe (visual observation is all that generalists teach Medical Students), but also feel. I believe this most useful when the tension in the “strings” are greatest in hypertonic such that there may be no apparent movement nor sound, but one gets tactile feed back. Hence where possible I always strike the hammer against my own hand placed carefully to achieve best transmission of the force. I suspect all “experts” draw the greater data without knowing and can so better analyse the clinical situation.
    I’m confident too that they like me may even apply varying non-standard force...

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  • Pure Autonomic Failure: the importance of waiting to confirm the diagnosis

    Dear Editor,
    Thomas Brown provided a helpful recent review of pure autonomic failure (PAF) in this journal1. However, there is one very important point which I would wish to add. The diagnosis of this rare condition should be made with extreme caution in the early years of presentation. The first case in the review had a diagnosis of PAF made just two years after symptoms began. In fact, other commoner causes of primary autonomic failure may declare themselves many years after the symptoms first begin, and I have seen a number of such cases during my time at the autonomic unit in Queen Square. A rough rule of thumb used to be that at least five years should pass before making a definitive diagnosis of PAF2. More recent evidence suggests that even longer may be required. A third of cases already with symptoms suggestive of PAF for an average of 5 years were found to have an alternative diagnosis with subsequent follow up for a further four years3. Alternative diagnoses included other synucleinopathies such as Parkinson’s disease, dementia with Lewy bodies or multiple system atrophy.
    For many years attempts have been made to find reliable ways to distinguish PAF from other causes of primary autonomic failure. PAF is seen classically as a post-ganglionic disorder whilst multiple system atrophy is seen as a pre-ganglionic form of primary autonomic failure. Utilising this pathophysiological difference, a variety of differentiating tests have been attempted....

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  • SUDEP: The thing we fear more than death

    We came across the pages of the article of Nashef and Leach recently released to the scientific community through the Practice Neurology with a great enthusiasm.1 The authors have not only had courage, but have had special ability in touching on such an important matter in a scientific and subtle manner simultaneously. As we know, along the past twenty years there has been exponential growth in the number of articles published on SUDEP with a triple increase in this scientific production in the last ten years.2 Therefore a great scientific breakthrough in SUDEP has been established with regard to epidemiological aspects, specific risk factors, mechanisms involved and possible preventive measures (if they really exist) 3. And yet, it is very well defined that the main risk factor for SUDEP is the presence and number of generalized tonic-clonic seizures (GTCS)3 and the best way to avoid a tragic event is to control these GTCS. In parallel, there is also an imperative issue in relation to all these aspects: how, when, where, why and what patients should we address on SUDEP? Despite the great effort of epileptologists and elegant studies already published, the discussion on SUDEP with patients is still a matter of debate among experts.4 In order to enable this debate, we will have to somehow let the conservative side and consider the current numbers that demonstrate that 1 in every 1000 young adults and 1 in every 4500 children with epilepsy may suddenly die. 5 And more, accor...

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