This is a superb book that deserves to be better known, at least on
my side of the Atlantic. In addition to Barker's outstanding depiction of
WW1 Britain, the sympathetic and revealing exploration of the physician-
patient relationship is peerless. Interested readers should know that
Regeneration is the first book in a trilogy, though neither is quite as
good as Regeneration. The second book, The Eye in the Door, is qui...
This is a superb book that deserves to be better known, at least on
my side of the Atlantic. In addition to Barker's outstanding depiction of
WW1 Britain, the sympathetic and revealing exploration of the physician-
patient relationship is peerless. Interested readers should know that
Regeneration is the first book in a trilogy, though neither is quite as
good as Regeneration. The second book, The Eye in the Door, is quite
good. The final book, The Ghost Road, is a bit uneven but the final
section of this book, describing an infantry assault in the closing stages
of the war, is an absolute tour-de-force of sympathetic description.
In a paper published last year in the New England Journal of Medicine
(NEJM), Messerli noted "a surprisingly powerful correlation between
chocolate intake per capita and the number of Nobel laureates in various
countries," which he postulated as "most likely" related to the cognitive
enhancing benefits of chocolate.1 This article in one of the premier
journals in the world received extraordinary press reports around the t...
In a paper published last year in the New England Journal of Medicine
(NEJM), Messerli noted "a surprisingly powerful correlation between
chocolate intake per capita and the number of Nobel laureates in various
countries," which he postulated as "most likely" related to the cognitive
enhancing benefits of chocolate.1 This article in one of the premier
journals in the world received extraordinary press reports around the time
of its release including in television (BBC News, CBC) and print (Time,
Reuters, Associated Press, and Forbes) media.
We found substantial methodological and conceptual errors in the Messerli
article that we brought to the attention of the editor of the NEJM shortly
after its publication. However, much to our surprise and dismay, no letter
to the editor (including ours), note or article addressing these concerns
have appeared in the NEJM since publication of the original article,
although several authors have subsequently brought several statistical
criticisms to light in other journals,2-5 including Practical Neurology.
While several authors who have criticized the Messerli article have done a
wonderful job of highlighting the limitations of association studies, no
one, to date, has addressed two issues we feel are even more important to
the scientific process: 1. Messerli's use of secondary sources (i.e.,
Wikipedia) for his data and 2. Messerli's selective use of data to support
his hypothesis.
In his article, Messerli notes, correlation does not "prove" causation and
he notes he lacks the specific chocolate intake of individual Nobel
Laureates. However, correlation between 2 variables is frequently used for
hypothesis generation and Messerli suggests several hypotheses to account
for his correlation.
First, hypotheses generated from data are, of course, no better than the
data on which they are based. Therefore, it is essential that authors use
primary sources when possible. Messerli used data on Nobel laureates from
Wikipedia6, which were based upon a BBC source, instead of data obtained
directly from the Nobel Prize website7 which is readily available. The
distinction is important and changes the resultant number of awardees
based upon whether one chooses to count a Nobel laureate who is born in a
country or where the person is located at the time of the award. For
example, there are 323 Nobel laureates (1901-2012) who were affiliated
with an organization in the USA at the time they were awarded the Nobel
prize and 247 Nobel laureates who were born in the USA.7
Second, and perhaps even more important than the sources from which data
are drawn, is the use of complete data sets and not just those that
support a hypothesis. The selective use of data from secondary sources has
no place in science to support, refute or generate hypotheses. This is a
serious methodological lapse and is called into question by the following:
1. Wikipedia lists 71 countries with per capita Nobel laureate data6, yet
only 23 were selected for Messerli's analysis; and 2. Data on chocolate
consumption used were from non-contiguous years (2002, 2004, 2010 and
2011) although data from the same sources are available for multiple
intervening years and per capita chocolate consumption for countries also
change from year to year but Messerli chose certain data while excluding
other data. Which data were selected skews the correlation substantially.
For example, if one selects the top 10 chocolate consuming countries and
using Messerli's data, the correlation is non-existent (r2= 0.04).
It is important to remember in any hypothesis generating study that bias
is easily introduced into that study through design flaws (e.g., selective
use of data or use of secondary sources) as well as known statistical
artifacts (e.g., ecological analysis2). Such bias can render the study
completely useless or, worse, damages the integrity of the scientific
process and the peer-review process of publication. As with others in the
medical and scientific community2-5 and the press, we did not see
Messerli's article as a joke intended by the author and the NEJM. However,
we assert that if an article is published in a medical journal draws
widespread publicity and is interpreted inappropriately as a valid
scientific study, it is the responsibility of the editors of that journal
to clarify the misinterpretation. Otherwise, the integrity of all
scientific journals may become suspect. This will be the subject of an
editorial in Practical Neurology.
Competing Interests: None
Contributorship statement: This article was originally conceived by BDP
and was discussed with the other two authors who helped in the analysis
and writing of the original article and its reviews. Each author
contributed to the writing and revision of this revised article and
approved the final version.
References
1. Dunstan, F. Nobel Prizes, Chocolate and Milk: The Statistical View
Pract Neurol 2013;13:206-207.
2. Messerli, F.H. Chocolate Consumption, Cognitive Function, and Nobel
Laureates N Engl J Med 2012;367:16:1562-4.
3. Maurage, P., Heeren, A., Pesenti, M. Does Chocolate Consumption Really
Boost Nobel Award Chances The Peril of Over-Interpreting Correlations in
Health Studies" J Nutr 2013;143:931-933.
4. Kayser, M. Editor's pick: Christmas is coming-time for chocolate to get
ready for your Nobel Prize Investigative Genetics 2012;3:26.
5. Linthwaite, S., Fuller, G.N., Milk, chocolate and Nobel prizes Pract
Neurol 2013;13:63.
6. List of countries by Nobel laureates per capita [Internet]. San
Francisco: Wikipedia.-[accessed 2012 October 25]. Available from:
http://en.wikipedia.org/wiki/List_of_countries_by_Nobel_laureates_per_capita
7. The Official Website of the Nobel Prize [Internet]. [accessed 2013 May
30]. Available from www.nobelprize.org.
Sir, the report on "spontaneously resolving cerebellar syndrome as a
sequelae of dengue viral infection" is very interesting [1]. In fact,
neurological complication of dengue is not common but it can be detectable
[2]. The spontaneously resolving cerebellar syndrome in this report is
questionable for the relationship to dengue. Based on the previous study
from Thailand, the spontaneously resolving pathology of cerebellum...
Sir, the report on "spontaneously resolving cerebellar syndrome as a
sequelae of dengue viral infection" is very interesting [1]. In fact,
neurological complication of dengue is not common but it can be detectable
[2]. The spontaneously resolving cerebellar syndrome in this report is
questionable for the relationship to dengue. Based on the previous study
from Thailand, the spontaneously resolving pathology of cerebellum was not
detected [3]. Although virus can be detected at cerebellum it is usually
identified in death cases [3 - 4].. The case of spontaneously resolving
cerebellar syndrome is usually identified in the patients with concurrent
infection between dengue and Epstein-Barr virus infection [5]. The
interesting topic is whether there is any interaction during co-infection
that contribute to observed cerebellar pathology.
References
1. Weeratunga PN, Caldera HP, Gooneratne IK, Gamage R, Perera WS,
Ranasinghe GV, Niraj M. Spontaneously resolving cerebellar syndrome as a
sequelae of dengue viral infection: a case series from Sri Lanka. Pract
Neurol. 2013 Jul 9. [Epub ahead of print]
2. Wiwanitkit V. Dengue fever: diagnosis and treatment. Expert Rev Anti
Infect Ther. 2010 Jul;8(7):841-5.
3. Wiwanitkit V. Magnitude and pattern of neurological pathology in fatal
dengue hemorrhagic fever: a summary of Thai cases. Neuropathology. 2005
Dec;25(4):398.
4. Ramos C, S?nchez G, Pando RH, Baquera J, Hern?ndez D, Mota J, Ramos J,
Flores A, Llaus?s E. Dengue virus in the brain of a fatal case of
hemorrhagic dengue fever. J Neurovirol. 1998 Aug;4(4):465-8.
5. Karunarathne S, Udayakumara Y, Fernando H. Epstein-Barr virus co-
infection in a patient with dengue fever presenting with post-infectious
cerebellitis: a case report. J Med Case Rep. 2012 Jan 30;6(1):43.
I really enjoyed Dr. Fuller's wonderful article on a likely emerging
public and professional fascination with neurology. The bad news, however,
is humankind's perpetual fascination with phobias; a fascination with
'death' being but one example. I'd perhaps say that neurology has joined
some rather elite company.
I would postulate that neurophobia, rather than neurophilia, drives
the impetus to produce copious ar...
I really enjoyed Dr. Fuller's wonderful article on a likely emerging
public and professional fascination with neurology. The bad news, however,
is humankind's perpetual fascination with phobias; a fascination with
'death' being but one example. I'd perhaps say that neurology has joined
some rather elite company.
I would postulate that neurophobia, rather than neurophilia, drives
the impetus to produce copious articles and books on neurology. I am still
hopeful that all the books I have purchased on neurology will miraculously
cure me of my phobia (notwithstanding the fact that reading neurology
texts convinces me that I have alexia).
Medscape's 2012 Physician Lifestyle Report by Dr. Carol Peckam has
neurologists tied for first place as the most unhappy of campers. So, no
cigar there either.
I applaud Dr. Fuller again for the propaganda piece on neurology: I
hope it works.
We enjoyed the review by our colleagues Finlayson et al 1 from the
United Kingdom, Congenital Myasthenic service, covering all aspects of the
congenital myasthenic syndromes. We would, however, suggest that the
section on neurophysiology could have been expanded and elaborated more.
To state that the neurophysiological findings in congenital myasthenic
syndromes are similar to those in autoimmune myasthenia gravis is corr...
We enjoyed the review by our colleagues Finlayson et al 1 from the
United Kingdom, Congenital Myasthenic service, covering all aspects of the
congenital myasthenic syndromes. We would, however, suggest that the
section on neurophysiology could have been expanded and elaborated more.
To state that the neurophysiological findings in congenital myasthenic
syndromes are similar to those in autoimmune myasthenia gravis is correct
perhaps with respect to repetitive nerve stimulation but when talking
about single fibre EMG (SFEMG) it should be emphasised for accuracy that
it is stimulated single fibre EMG (StimSFEMG) that should be used in
children, certainly under the age of eight years or in the intensive care
setting, and not the voluntary SFEMG technique, which requires significant
levels of patient cooperation. Furthermore, with most congenital
myasthenic syndromes (CMS) having symptoms at birth, which do not always
include ptosis, the use of StimSFEMG should be encouraged as it has
superior sensitivity in comparison to repetitive nerve stimulation, which
makes it the better screening test. The test is well tolerated and is
usually performed in the outpatient setting with the child awake. The
problem of the specificity of StimSFEMG can be addressed if the technique
is used as part of a more wide-ranging neurophysiological examination
including nerve conduction studies and EMG examination of limb and bulbar
muscles. As an example, demonstration of significant myopathic changes in
other muscles will direct the clinician more to the diagnosis of a
myopathy with associated secondary neuromuscular transmission defect
rather than a primary myasthenic syndrome.
We do not hesitate to use Stim SFEMG, which is well tolerated even by the
youngest of infants, and consequently we have seen a decrease in both the
age at referral for investigation and subsequent diagnosis over the years.
This approach has to be encouraged as in several studies it is clear that
in many children with CMS, symptoms have been present from birth, which
are often non-specific, such as feeding difficulties 2 or stridor 3. Many
of us have experienced the consequences of delayed diagnosis, regrettably
including sibling death, and we feel that the liberal use of this
excellent technique has been a major factor in preventing this by
providing an early diagnosis. In an article for a wide readership it is
perhaps an omission not to use this opportunity to advertise this
technique, available at many Neurophysiological centres (including those
of the authors). Hopefully this letter will in part address this
oversight.
Reference List
1 Finlayson S, Beeson D, Palace J. Congenital myasthenic syndromes:
an update. Pract Neurol 2013;13:80-91.
2 Kinali M, Beeson D, Pitt MC, et al. Congenital Myasthenic
Syndromes in childhood: Diagnostic and management challenges 1. J
Neuroimmunol 2008 15;201-202:6-12.
3 Jephson CG, Mills NA, Pitt MC, et al. Congenital stridor with
feeding difficulty as a presenting symptom of Dok7 congenital myasthenic
syndrome. Int J Pediatr Otorhinolaryngol 2010;74:991-994.
The borderland between functional diseases and neurological diseases
gets blurred especially when the patient presents with a myriad of
symptoms which do not localize to any one level of the neural axis.1 If in
addition the neurological examination is normal (especially the lack of
'hard' neurological signs such as upgoing plantars, cranial nerve signs,
definite asymmetry of the deep tendon reflexes, cerebellar signs and...
The borderland between functional diseases and neurological diseases
gets blurred especially when the patient presents with a myriad of
symptoms which do not localize to any one level of the neural axis.1 If in
addition the neurological examination is normal (especially the lack of
'hard' neurological signs such as upgoing plantars, cranial nerve signs,
definite asymmetry of the deep tendon reflexes, cerebellar signs and gait
disorder) the question of a functional disease certainly crosses the mind.
In my mind there are two ways to approach such patients. One way is to
order an exhaustive battery of tests including laboratory, neurophysiology
and neuroimaging studies. This "fishing" for an answer approach rarely if
ever yields the answer and risks reinforcing the sick role in the
patient's and caregiver's psyche ("I must have a horrible and terrible
illness which the doctor is trying hard to find"). The other approach is
one I have adopted in my practice. If after a thorough history,
examination and relevant investigations the answer still eludes me and I
am reasonably certain (though not 100% sure) that the patient's
presentation is unlikely on account of an organic neurological disease, I
adopt a policy of wait and watch after reassuring the patient that if new
symptoms were to appear or if the current symptoms were to change in
frequency or intensity, I would consider re approaching the diagnosis. The
patient at this point may or may not be ready to see a psychiatrist but I
do suggest that consulting one may be helpful.
References
1. Stone J, Reuber M, Carson A. Functional symptoms in neurology:
mimics and chameleons. Pract Neurol 2013; 13:104-13.
Turner and Talbot rightly emphasize that in spite of advances in EMG
techniques and emergence of novel neuroimaging and CSF biomarkers the
diagnosis of motor neuron disease (MND) still remains a clinical one.1
Find upper motor neuron (UMN) and lower motor neuron (LMN) signs in the
same limb and MND should be high up in the differential I recall was
taught to me in medical school. EMG was to be used in atypical cases wher...
Turner and Talbot rightly emphasize that in spite of advances in EMG
techniques and emergence of novel neuroimaging and CSF biomarkers the
diagnosis of motor neuron disease (MND) still remains a clinical one.1
Find upper motor neuron (UMN) and lower motor neuron (LMN) signs in the
same limb and MND should be high up in the differential I recall was
taught to me in medical school. EMG was to be used in atypical cases where
the diagnosis was in doubt. In today's world the pendulum has swung to the
other extreme. UMN and LMN signs in the same limb-->could be MND---
>order a 4 limb EMG making certain that tongue and paraspinal
musculature is examined-->then make the call-->definite MND Vs
probable Vs possible. This over reliance on neuroimaging and
neurophysiological data to make the diagnosis is not unique to MND;
multiple sclerosis (MS) is another causality. Two discreet attacks
separated by time (determined by history) and space (determined by
examination findings) and the diagnosis of MS can be made confidently. No
MRI brain, visual evoked potentials, somatosensory evoked potentials or
oligoclonal bands in CSF are needed. How many of us do that now?
References
1. Turner MR, Talbot K. Motor neurone disease is a clinical
diagnosis. Pract Neurol. 2012 Dec; 12(6):396-7.
Neurophilia can be loosely defined as the love of or fascination for
neurology. Now you may think this is a new recently described exotic
neurological syndrome but dwell into the ancient eastern Hindu and
Buddhist philosophies and you shall quickly realize that the disorder is
as ancient as these civilizations themselves 1. The workings of the brain
and of the mind fascinated these first neurophilia inflicted philosopher...
Neurophilia can be loosely defined as the love of or fascination for
neurology. Now you may think this is a new recently described exotic
neurological syndrome but dwell into the ancient eastern Hindu and
Buddhist philosophies and you shall quickly realize that the disorder is
as ancient as these civilizations themselves 1. The workings of the brain
and of the mind fascinated these first neurophilia inflicted philosophers
and they spent an inordinate amount of time trying to decipher its
secrets. Techniques to control the mind through meditation and
introspection were described and perfected over the years. One can imagine
these neurophiles wondering how this roughly 1400 gram lump of wrinkled
tissue with no moving parts, no joints or valves could function as the
motherboard for all other body systems as well as serve as the seat of the
mind, thoughts, senses; in fact the very essence of the individual. As we
slowly unlock the secrets of the living brain with the aid of
sophisticated imaging techniques, the prevalence of neurophilia has
increased exponentially. One would not be wrong to label it currently as a
pandemic. Identification of this disorder is relatively easy.
Five signs that you may have neurophilia (in no particular order of
importance)
1. You cannot wait for the next book by Oliver Sacks or V.S Ramachandran
to come out.
2. You think Dr. House should only concentrate on neurology cases
henceforth (a variation of this sign was first described by Dr. Fuller)
3. You name your first and only child "Brain"
4. You identify a Queen Square reflex hammer , a tuning fork and a
Wattenberg pin among your priciest possessions
5. You count diagnosing passers-by with Parkinson's disease by mere
observation of their gait as one of your favorite pastimes.
Once inflicted with neurophilia the "disease" course is highly
variable. In some it merely manifests with a curiosity to know more about
the workings of the brain, yet in others (like us neurologists,
neurosurgeons and neuroscientists) it becomes a lifelong obsession to know
everything about the brain both in disease as well as in health. My own
passion for neurology was kindled at a young age by my neurophilia
inflicted neurologist father. Little did I realize that exposure at a
tender age would result in such a passion for the study of the brain. Yes
it is true and I admit it proudly-I have a bad case of neurophilia. Watch
out people it is contagious!
References
1. Fuller GN. Neurophilia: a fascination for neurology--a new syndrome.
Pract Neurol. 2012; 12:276-8.
I enjoyed Fuller's description of 'neurophilia' - we can finally
label this condition afflicting neurologists, and recognise that is
widespread within medicine and the general population.(1) Neurophilia is
probably infectious (i.e. environmental); my personal experience and
informal discussions with neurology colleagues revealed that many chose
neurology as a career following positive experiences during their Senior
Ho...
I enjoyed Fuller's description of 'neurophilia' - we can finally
label this condition afflicting neurologists, and recognise that is
widespread within medicine and the general population.(1) Neurophilia is
probably infectious (i.e. environmental); my personal experience and
informal discussions with neurology colleagues revealed that many chose
neurology as a career following positive experiences during their Senior
House Officer jobs. This emphasizes the suggestion that neurophobia can
be dispelled and neurophilia encouraged through effective, inspirational
teaching, accessible textbooks and journals.
However, I would also like to highlight a potential genetic
contribution. In the UK, I am aware of at least 6 neurological families
- those families where more than one first degree relatives are
neurologists. - many more than would be expected by chance. This does
suggest that neurophilia may have genetic as well as environmental
elements.
Reference
1. Fuller GN. Neurophilia: a fascination for neurology--a new syndrome.
Practical Neurology. 2012;12(5):276-8.
I read with interest the article by Dr. Leach. As things stand at
present, it is not mandatory for physicians in the United States to
discuss about SUDEP with patients or their caregivers. In fact this was
not included in the recently released American Academy of Neurology (AAN)
performance measures for epilepsy 1. Advice about safe recreation and
driving though is included as one of the 8 performance measures. So is...
I read with interest the article by Dr. Leach. As things stand at
present, it is not mandatory for physicians in the United States to
discuss about SUDEP with patients or their caregivers. In fact this was
not included in the recently released American Academy of Neurology (AAN)
performance measures for epilepsy 1. Advice about safe recreation and
driving though is included as one of the 8 performance measures. So is
information about SUDEP useful or too much information (TMI)? Does every
patient with epilepsy warrant this information? What is the ideal time to
impart this information to the patient and the caregivers: first office
visit where this information competes with other "more relevant"
information about anticonvulsant dosing, side-effects and importance of
compliance for the patient's attention or in subsequent office visits when
the patient's seizure semiology and frequency is better characterized? No
two patient's seizure disorder is exactly alike hence the potential risk
of SUDEP varies from patient to patient. So it reasons that information
about SUDEP needs to be customized to the individual patient at hand. Both
Dr. Leach's article and my letter raise more questions than answers. In
the meantime we are all left pondering how to impart this information to
our epilepsy patients and importantly how to do that and take a detailed
history, fulfill the performance measures for epilepsy, exam the patient
and document this all in the 1 hour allocated for a new patient visit.
Reference
1. Fountain NB, Van Ness PC, Swain-Eng R, Tonn S, Bever CT Jr;
American Academy of Neurology Epilepsy Measure Development Panel and the
American Medical Association-Convened Physician Consortium for Performance
Improvement Independent Measure Development Process. Quality improvement
in neurology: AAN epilepsy quality measures: Report of the Quality
Measurement and Reporting Subcommittee of the American Academy of
Neurology. Neurology. 2011 Jan 4;76(1):94-9
This is a superb book that deserves to be better known, at least on my side of the Atlantic. In addition to Barker's outstanding depiction of WW1 Britain, the sympathetic and revealing exploration of the physician- patient relationship is peerless. Interested readers should know that Regeneration is the first book in a trilogy, though neither is quite as good as Regeneration. The second book, The Eye in the Door, is qui...
In a paper published last year in the New England Journal of Medicine (NEJM), Messerli noted "a surprisingly powerful correlation between chocolate intake per capita and the number of Nobel laureates in various countries," which he postulated as "most likely" related to the cognitive enhancing benefits of chocolate.1 This article in one of the premier journals in the world received extraordinary press reports around the t...
Sir, the report on "spontaneously resolving cerebellar syndrome as a sequelae of dengue viral infection" is very interesting [1]. In fact, neurological complication of dengue is not common but it can be detectable [2]. The spontaneously resolving cerebellar syndrome in this report is questionable for the relationship to dengue. Based on the previous study from Thailand, the spontaneously resolving pathology of cerebellum...
I really enjoyed Dr. Fuller's wonderful article on a likely emerging public and professional fascination with neurology. The bad news, however, is humankind's perpetual fascination with phobias; a fascination with 'death' being but one example. I'd perhaps say that neurology has joined some rather elite company.
I would postulate that neurophobia, rather than neurophilia, drives the impetus to produce copious ar...
We enjoyed the review by our colleagues Finlayson et al 1 from the United Kingdom, Congenital Myasthenic service, covering all aspects of the congenital myasthenic syndromes. We would, however, suggest that the section on neurophysiology could have been expanded and elaborated more. To state that the neurophysiological findings in congenital myasthenic syndromes are similar to those in autoimmune myasthenia gravis is corr...
The borderland between functional diseases and neurological diseases gets blurred especially when the patient presents with a myriad of symptoms which do not localize to any one level of the neural axis.1 If in addition the neurological examination is normal (especially the lack of 'hard' neurological signs such as upgoing plantars, cranial nerve signs, definite asymmetry of the deep tendon reflexes, cerebellar signs and...
Turner and Talbot rightly emphasize that in spite of advances in EMG techniques and emergence of novel neuroimaging and CSF biomarkers the diagnosis of motor neuron disease (MND) still remains a clinical one.1 Find upper motor neuron (UMN) and lower motor neuron (LMN) signs in the same limb and MND should be high up in the differential I recall was taught to me in medical school. EMG was to be used in atypical cases wher...
Neurophilia can be loosely defined as the love of or fascination for neurology. Now you may think this is a new recently described exotic neurological syndrome but dwell into the ancient eastern Hindu and Buddhist philosophies and you shall quickly realize that the disorder is as ancient as these civilizations themselves 1. The workings of the brain and of the mind fascinated these first neurophilia inflicted philosopher...
I enjoyed Fuller's description of 'neurophilia' - we can finally label this condition afflicting neurologists, and recognise that is widespread within medicine and the general population.(1) Neurophilia is probably infectious (i.e. environmental); my personal experience and informal discussions with neurology colleagues revealed that many chose neurology as a career following positive experiences during their Senior Ho...
I read with interest the article by Dr. Leach. As things stand at present, it is not mandatory for physicians in the United States to discuss about SUDEP with patients or their caregivers. In fact this was not included in the recently released American Academy of Neurology (AAN) performance measures for epilepsy 1. Advice about safe recreation and driving though is included as one of the 8 performance measures. So is...
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