We read with interest Dr. Hawkes point of view titled "get rid of your stethoscope"1. In his indomitable style of writing (which we have grown to appreciate!) he makes a rather outlandish plea to neurologists around the world to sell their stethoscopes and move on to new more fancy gizmos. I trust Dr. Hawkes takes this polarized viewpoint with the intention to spur debate among the readers. Old technology is not synonymous...
We read with interest Dr. Hawkes point of view titled "get rid of your stethoscope"1. In his indomitable style of writing (which we have grown to appreciate!) he makes a rather outlandish plea to neurologists around the world to sell their stethoscopes and move on to new more fancy gizmos. I trust Dr. Hawkes takes this polarized viewpoint with the intention to spur debate among the readers. Old technology is not synonymous with outdated technology. Our beloved and trusted stethoscope has and continues to serve us well. In the hands of a trained neurologist or cardiologist it can help identify a potentially symptomatic carotid stenosis or differentiate between the different systolic and diastolic murmurs. Rather than finding faults with the humble stethoscope we should take a critical look at the deteriorating clinical acumen of physicians of today. Our ability to realize its full potential pales when compared to our senior and past colleagues. Finally, the stethoscope is a symbol of our profession since time immemorial. We shall certainly embrace some of the new technology but give up the stethoscope - No sir we won't!
Reference
1. Hawkes CH. Get rid of your stethoscope!. Pract Neurol 2010;10:344
-346
I read with interest the article by Dr. Stern and the accompanying
comments by Dr. Warlow in which they lament about the deteriorating
standards of grand rounds in the academic neurology institutions of
today. Here across the Atlantic we too are confronting some of the same
issues. The standard of grand rounds varies from institution to
institution. In certain institutions the job of organizing the grand
rounds is wholly en...
I read with interest the article by Dr. Stern and the accompanying
comments by Dr. Warlow in which they lament about the deteriorating
standards of grand rounds in the academic neurology institutions of
today. Here across the Atlantic we too are confronting some of the same
issues. The standard of grand rounds varies from institution to
institution. In certain institutions the job of organizing the grand
rounds is wholly entrusted to the neurology chief residents who then
decide which topic should be covered and by whom. Usually respected
outside faculty members are invited to present on topics of their
expertise. This is usually a didactic hour long lecture with no patient or
caregiver present. For an epileptologist like me, an hour long talk on
new biomarkers for Parkinson's disease may hold little interest.
Consultants frequently attend the grand rounds with the sole intention of
satisfying their continuing medical education (CME) requirements. The
resident staff and the medical students sit in the very back of the room
and gain precious little in this one way exchange of thoughts. On rare
occasion comes along a speaker who is dynamic, witty and engaging and one
walks away from the grand round with the feeling of having learnt
something new. I agree with both Dr. Stern and Dr. Warlow that neurology's
hallowed tradition of grand rounds needs a thorough overall. Having the
patient physically present during the grand round, a healthy sprinkling of
subspecialty neurologists in the audience and eager to learn house staff
are essential ingredients of this concoction.
Reference
1. Stern G. Whither grand rounds? Pract Neurol.2010 Oct; 10(5):284-
9.
Given the fact that the advent of medical admissions units(MAUs) and
their ethos of "physician of the week" has coincided with increasing
subspecialisation(1), physicians with a special interest who participate
in the MAU on call rota are now the ones in greatest need of the
educational benefit conferred by grand rounds. In this context the grand
round has the potential to refresh those "generalist" diagnostic skills
which...
Given the fact that the advent of medical admissions units(MAUs) and
their ethos of "physician of the week" has coincided with increasing
subspecialisation(1), physicians with a special interest who participate
in the MAU on call rota are now the ones in greatest need of the
educational benefit conferred by grand rounds. In this context the grand
round has the potential to refresh those "generalist" diagnostic skills
which are in danger of atrophy when encroached upon by the ever increasing
demands of the special interest. Furthermore, the grand round is sometimes
the arena where the definitive diagnosis turns up when it has previously
proved elusive in the MAU. For the junior doctor(and also for the
enterprising medical student), my advice is the one I used to give to my
own juniors(and one which I still follow in my retirement as a
regular attender of grand rounds), and that advice is to do a literature
search after each grand round, covering the topics and contentious issues
raised in the grand round, and to do so while the grand round is still in
recent memory. What I used to say was that, with the benefit of those
iterature searches, if they then decided to take higher exams, they would
have the opportunity to amaze, if not intimidate, the examiners with the
extent and depth of their knowledge. For those juniors who simply enjoy
the pursuit of knowledge for its own sake the grand round is also an
opportunity to challenge received wisdom by identifying gaps and
contradictions in evidence-based medicine. This is sometimes the first
step to formulating hypotheses or to offer new insights through the medium
of, for example, a "Letter to the Editor" which, in the event of its
publication gives a tremendous boost to career propspects.
References
(1) Stern G
Whither grand rounds(and commentary by the Editor in chief)
Practical Neurology 2010;10:284-289
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...
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.
Dr. Al-Shahi Salman in his editorial writes about the dangers of
acting on incidental findings on brain MRI. He says primary prevention by
avoiding MRI in the first place is the best approach. Unfortunately today
in the United States avoiding imaging is easier said than done. The
pressure to do a quick MRI is omnipresent. Thus almost every patient who
walks into the emergency room with a headache, a new onset seizure or even...
Dr. Al-Shahi Salman in his editorial writes about the dangers of
acting on incidental findings on brain MRI. He says primary prevention by
avoiding MRI in the first place is the best approach. Unfortunately today
in the United States avoiding imaging is easier said than done. The
pressure to do a quick MRI is omnipresent. Thus almost every patient who
walks into the emergency room with a headache, a new onset seizure or even
vague non-localizing subjective complaints like dizziness and light
headedness invariably gets scanned. Residents in training and even
experienced physicians request neuroimaging because they do not want to
miss anything. The thought of an expensive medico legal litigation case
looms large in the physician mind. What if the patient has a malignant
brain tumor and I dismiss it as a primary headache? Years of medical
training in rational decision making are thrown to the wind and good
doctors end up requesting unnecessary scans. The patients too are at fault
and frequently equate a good doctor with one who scans for every
complaint. Such doctors are perceived to be thorough and unlikely to miss
anything. In our current world a doctor who images a patient with headache
only in the presence of red flags such as focal neurological findings on
examination or an atypical history is perceived to be a bad doctor. That I
am afraid is the reality.
Over and above the recommendation that clinicians should have a low
threshold for lying and standing blood pressure measurements in the
elderly, even when the history is not typical(1), mention must also be
made of the role of cardiac investigations such as telemetry, so as to
identify conduction defects as an underlying cause in patients who
present with vertigo(2), even though this issue was not raised by the
authors. Th...
Over and above the recommendation that clinicians should have a low
threshold for lying and standing blood pressure measurements in the
elderly, even when the history is not typical(1), mention must also be
made of the role of cardiac investigations such as telemetry, so as to
identify conduction defects as an underlying cause in patients who
present with vertigo(2), even though this issue was not raised by the
authors. The occurence of so-called "cardiogenic vertigo" as a presenting
symptom of sinus node disease was exemplified by a 90 year old woman who
had a history of "spells" with mixed vertiginous and non-vertiginous
dizziness spanning more than a decade. Seven years after the onset of
these spells she began to have syncopal attacks as well, and the eventual
underlying diagnosis was elucidated by cardiac telemetry which documented
transient asystole during a syncopal episode. When asked afterwards what
symptoms she had experienced in association with that particular syncopal
episode, she said she had experienced a spinning sensation shortly before
her faint. On follow up one year after implantation of a single chamber
ventricular pacemaker, she had had no more recurrent
symptoms(3). Vertigo may be a symptom even in patients with confirmed
orthostatic hypotension on tilt table testing. This was the case in 37%
of 90 patients who experienced symptoms in association with either a
decrease of 30 mm Hg or more in systolic blood pressure(BP)or a decrease
of 15 mm Hg or more in diastolic BP, or a decrease of 20 mm Hg or more in
mean BP after a 5 minute duration tilt of 80 degrees or more(3). A more
acute presentation of cardiogenic vertigo is the one associated with
myocardial infarction, exemplified by the fact that, in one study, 8% of
1546 patients with myocardial infarction described vertigo as one of their
presenting symptoms(4). Accordingly, although "common vestibular
diagnoses can be found if specifically looked for in the elderly who
complain of vague disequilibrium"(1), vestibular symptomatology does not
necessarily rule out significant underlying cardiac pathology.
(2)Newman-Toker DE., Camargo CA
"Cardiogenic vertigo"-true vertigo as the presenting manifestation of
primary cardiac disease
Nature Clinical Practice Neurology 2006;2:167-172
(3)Low PA., Opfer-Gehrking TL., McPhee BR et al
Prospective evaluation of clinical characteristics of orthostatic
hypotension
Mayo Clinic Proceedings 1995;70:617-622
(4)Culic V., Miric D., Eterovic D
Correlation between symptomatology and site of acute myocardial infarction
International Journal of Cardiology 2001;77:163-168
The article "Why I became a neurologist" passed through my brain into my
heart because I am in the same place as you were so many years ago.
The world has changed a lot, but in different countries at different paces -
we in Nepal are many years behind you in Australia. You were inspired by
your father and grandfather by virtue of their intelligence, but for me I
became interested in neurology, and in stroke...
The article "Why I became a neurologist" passed through my brain into my
heart because I am in the same place as you were so many years ago.
The world has changed a lot, but in different countries at different paces -
we in Nepal are many years behind you in Australia. You were inspired by
your father and grandfather by virtue of their intelligence, but for me I
became interested in neurology, and in stroke because my father had one. I
still remember I was a very young when I took my father to hospital. The
doctor said "This is the end..nothing can be done".
My father died because of his stroke but I feel that people who have strokes
in my country should not die, at least not because of the lack of
neurologists. Then I went to medical school, did my internal
medicine, and I have just joined the first neurology training scheme
in our country started by Prof. PVS Rana. Times have changed but neurology
has been changing at the pace of a tortoise in here because of a lack of
interest in the subject by doctors and the myth that neurology is only
diagnosis and prognosis. But neurology is more than this. It gives us the
pleasure of treating people who others neglect.This is why I want to be a
neurologist.
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...
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
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....
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.
Although no mention of subdural haematoma was made by the
authors(1), the occurence of reversible urinary retention, even in a
patient who is awake and ambulatory, can be a feature of bilateral chronic
subdural haematoma, as was the case in an 87 year old woman reported
by Lang et al(2). On the basis of the fact that she regained full bladder
control after evacuation of the haematoma, the authors proposed that there
might be...
Although no mention of subdural haematoma was made by the
authors(1), the occurence of reversible urinary retention, even in a
patient who is awake and ambulatory, can be a feature of bilateral chronic
subdural haematoma, as was the case in an 87 year old woman reported
by Lang et al(2). On the basis of the fact that she regained full bladder
control after evacuation of the haematoma, the authors proposed that there
might be a supratentorial micturition centre located in the region of the
frontal convexity cortex and anterior portion of the interhemispheric
fissure(2). Instead of urinary retention, some patients with bilateral
chronic subdural haematomas have urinary incontinence, and this, too,
is not necessarily associated with obtundation(3)(4). In one report
somnolence and stupor was a feature in only three of the six patients
with
the association of bilateral chronic subdural haematoma and urinary
incontinence. All six patients had "excellent recovery" after
evacuation of the haematomas(3). In another report, a 71 year old
woman with bilateral chronic subdural haematomas presented with
ataxia, paraparesis(although he could still walk), and incontinence of
the bladderand bowel. Although his level of consciousness was not
specifically documented, his speech was reported as being "slow and
superficial, but clear, distinct, and without aphasia". After
evacuation of the haematoma "he was discharged from the hospital
asymptomatic on the 9th postoperativeday"(4). Accordingly, "clinicians
should be aware that urinary incontinence may be a symptom of subdural
haematoma....and that its
occurence in patients who are reasonably alert should prompt a
detailed documentation of its onset in relation to head injury and its
resolution in relation to evacuation of subdural haematoma so as to
advance our understanding of this phenomenon"(5)
References:
(1) Panicker JN., Fowler CJ
Uro-neurology
Practical Neurology 2010;10:178-185
(2)Lang EW., Chesnut RM., Hennerici M
Urinary retention and space-occupying lesions of the frontal cortex
European Neurology 1996;36:43-47
(3)Goto I., Kuroiwa Y., Kitamura K
The triad of neurological manifestations in bilateral chronic subdural
hematoma and normal pressure hydrocephalus
J Neurosurg Sci 1986;30:123-128
(4)Bortnick RJ., Murphy JP
Paraparesis with incontinence of bowel and bladder
A syndrome of bilateral subdural hematoma
J Neurosurgery 1963;20:352-353
(5) Jolobe OMP
Urinary incontinence may be a feature of bilateral subdural haemorrhage in
patients who have no lateralizing signs(letter)
Journal of the American Geriatrics Society 2010;58:403
We read with interest Dr. Hawkes point of view titled "get rid of your stethoscope"1. In his indomitable style of writing (which we have grown to appreciate!) he makes a rather outlandish plea to neurologists around the world to sell their stethoscopes and move on to new more fancy gizmos. I trust Dr. Hawkes takes this polarized viewpoint with the intention to spur debate among the readers. Old technology is not synonymous...
I read with interest the article by Dr. Stern and the accompanying comments by Dr. Warlow in which they lament about the deteriorating standards of grand rounds in the academic neurology institutions of today. Here across the Atlantic we too are confronting some of the same issues. The standard of grand rounds varies from institution to institution. In certain institutions the job of organizing the grand rounds is wholly en...
Given the fact that the advent of medical admissions units(MAUs) and their ethos of "physician of the week" has coincided with increasing subspecialisation(1), physicians with a special interest who participate in the MAU on call rota are now the ones in greatest need of the educational benefit conferred by grand rounds. In this context the grand round has the potential to refresh those "generalist" diagnostic skills which...
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...
Dr. Al-Shahi Salman in his editorial writes about the dangers of acting on incidental findings on brain MRI. He says primary prevention by avoiding MRI in the first place is the best approach. Unfortunately today in the United States avoiding imaging is easier said than done. The pressure to do a quick MRI is omnipresent. Thus almost every patient who walks into the emergency room with a headache, a new onset seizure or even...
Over and above the recommendation that clinicians should have a low threshold for lying and standing blood pressure measurements in the elderly, even when the history is not typical(1), mention must also be made of the role of cardiac investigations such as telemetry, so as to identify conduction defects as an underlying cause in patients who present with vertigo(2), even though this issue was not raised by the authors. Th...
Dear Sir,
The article "Why I became a neurologist" passed through my brain into my heart because I am in the same place as you were so many years ago. The world has changed a lot, but in different countries at different paces - we in Nepal are many years behind you in Australia. You were inspired by your father and grandfather by virtue of their intelligence, but for me I became interested in neurology, and in stroke...
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...
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....
Although no mention of subdural haematoma was made by the authors(1), the occurence of reversible urinary retention, even in a patient who is awake and ambulatory, can be a feature of bilateral chronic subdural haematoma, as was the case in an 87 year old woman reported by Lang et al(2). On the basis of the fact that she regained full bladder control after evacuation of the haematoma, the authors proposed that there might be...
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