We thank Dr Weydt and colleagues for their interest in our review. We are aware of the subjective benefit of cannabinoids reported by some living with multiple sclerosis, and a trial of THC:CDB spray is also approved by the UK’s National Institute for Health & Care Excellence (NICE). The CANALS study mentioned, in which PLS patients were well represented (28% of treatment arm and 20% of placebo arm), was a Phase 2 study powered to consider safety and tolerability. Adverse events were reported in 76% of the treatment group versus 27% in the placebo group. A reduction in the clinician’s Modified Ashworth Spasticity scale score was noted, and in the patient’s numeric rating scale score for pain, but not their scores for spasm or spasticity. In the discussion, the authors note that muscle cramping was not alleviated in a prior randomised trial of THC in ALS (1). We agree with their call for further evaluation, through a Phase 3 study of the benefit of cannabinoids over the licensed therapies for spasticity outlined in our review.
Reference:
1. Weber M, Goldman B, Truniger S. Tetrahydrocannabinol (THC) for cramps in amyotrophic lateral sclerosis: a randomised, double-blind crossover trial. J Neurol Neurosurg Psychiatry. 2010 Oct;81(10):1135-40. doi: 10.1136/jnnp.2009.200642. PMID: 20498181.
It gives more discomfort than pleasure to comment on DaT scanning again but your editorial [1] prompted me to find out that the number of DaTscans carried out in England is increasing yearly, from 4550 in 2012/3 to 8840 in 2018/9. A trip to the dentist might have been wiser, my long-expressed opinion (based on the fundamental principles that let down 18FDopa PET) being that the DaTscan is a waste of time, radiation and money [2]. In brief it is a low resolution, inadequately sensitive, inadequately reproducible test with too many false negatives and little knowledge of confounding influences. The acronym SWEDD has, mercifully, been consigned to the dustbin[3] but we don’t have the neuropathological studies or large and long-term blinded follow-up studies, in patients and healthy individuals, despite the many tests and years since its commercial introduction, that would tell the true false positive and negative rate of the test. We can’t then confidently say how strongly a normal result argues against a clinical diagnosis of PD. Neurology is not the only specialty that uses DaTscan and indication-creep (good for the shareholder, bad for the taxpayer) means that it is also being used to distinguish Lewy Body Dementia from Alzheimer’s Dementia despite limited supportive data (4). It must also be remembered that the test measures biochemistry, not pathology; the statement in the case presentation [5] “a DaTscan was normal, with no evidence of degenerative Parkinsonism” is...
It gives more discomfort than pleasure to comment on DaT scanning again but your editorial [1] prompted me to find out that the number of DaTscans carried out in England is increasing yearly, from 4550 in 2012/3 to 8840 in 2018/9. A trip to the dentist might have been wiser, my long-expressed opinion (based on the fundamental principles that let down 18FDopa PET) being that the DaTscan is a waste of time, radiation and money [2]. In brief it is a low resolution, inadequately sensitive, inadequately reproducible test with too many false negatives and little knowledge of confounding influences. The acronym SWEDD has, mercifully, been consigned to the dustbin[3] but we don’t have the neuropathological studies or large and long-term blinded follow-up studies, in patients and healthy individuals, despite the many tests and years since its commercial introduction, that would tell the true false positive and negative rate of the test. We can’t then confidently say how strongly a normal result argues against a clinical diagnosis of PD. Neurology is not the only specialty that uses DaTscan and indication-creep (good for the shareholder, bad for the taxpayer) means that it is also being used to distinguish Lewy Body Dementia from Alzheimer’s Dementia despite limited supportive data (4). It must also be remembered that the test measures biochemistry, not pathology; the statement in the case presentation [5] “a DaTscan was normal, with no evidence of degenerative Parkinsonism” is a common but incorrect oversimplification. For drug-induced parkinsonism, is it my own oversimplification to ask why a drug that is biochemically producing parkinsonism doesn’t change the result of a biochemical test that is used to detect parkinsonism? Small studies with an unreliable test and heavy sales pitch encourage more indication-creep.
A practical neurologist’s approach is to ask if the outcome of a test will change what one does or advises and if a test can’t be trusted it shouldn’t be requested. I wonder if the £12M or more spent on the test in England in 2018 might have been more usefully used and whether the Scottish, known for their financial prudence, have a neologism for colleagues that request DaTscans?
References:
1. Araujo R, van Rumund A, Bloem BR. To scan or not to scan your Parkinson patient: that is the question! Pract Neurol 2019;19:462-4. doi: 10.1136/practneurol-2019-002225
2. Morrish PK. Controversies in Neuroimaging. in Factor SA and Weiner WJ eds. Parkinson’s disease; Diagnosis and Clinical Management. Demos Publishing (New York). 2008: 317-326
3. Erro R, Schneider SA, Stamelou M, et al. What do patients with scans without evidence of dopaminergic deficit (SWEDD) have? New evidence and continuing controversies. J Neurol Neurosurg Psychiatry 2016; 87: 319-323. doi: 10.1136/jnnp-2014-310256
4. McCleery J, Morgan S, Bradley KM et al. Dopamine transporter imaging for the diagnosis of dementia with Lewy bodies. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD010633. doi: 10.1002/14651858.CD010633.pub2
5. Wiblin I, Mitra D, Naomi W. An unusual cause of treatable parkinsonism. Pract Neurol 2019; 19; 518-20. doi: 10.1136/practneurol-2019-002339
Acknowledgement: Figures for 2018 DaTscan use kindly provided by Sheila M Dixon, Senior Analytical Manager, Performance Analysis Team, NHS England & NHS Improvement
With great interest, we read the review by Markus on personalising the secondary prevention approach to patients with stroke ¹, published in the most recent issue of Practical Neurology. Where we are presented with clinically useful and evidence-based advice for the etiological assessment of patients with acute ischemic stroke (AIS), focusing on lacunar stroke syndromes of a non-lacunar cause, and its appropriate therapeutic management. We consider the article of great importance: a must-read for all physicians who care for patients with AIS since etiological assessment is paramount to dictate the appropriate secondary prevention measures.
The author proposes using the TOAST classification (Trial of Organon 10172 in Acute Stroke Treatment), arguing that classification systems that prime clinical syndromes over pathophysiological mechanisms are less useful. Nevertheless, the author omitted one classification which–partially–resolves the issue: the ASCOD (Atherosclerosis, Small-vessel, Cardiac embolism, Other, Dissection) system ². A comprehensive classification, which allows for more than one aetiology, while giving a degree of a causal relationship to the presence of each category of disease (1 potential, 2 uncertain, 3 unlikely, 0 disease not detected) including incomplete assessment (9 insufficient work-up), while considering some clinical features.
The ASCOD approach permits the identification of patients with diseases that would have been left as indeterm...
With great interest, we read the review by Markus on personalising the secondary prevention approach to patients with stroke ¹, published in the most recent issue of Practical Neurology. Where we are presented with clinically useful and evidence-based advice for the etiological assessment of patients with acute ischemic stroke (AIS), focusing on lacunar stroke syndromes of a non-lacunar cause, and its appropriate therapeutic management. We consider the article of great importance: a must-read for all physicians who care for patients with AIS since etiological assessment is paramount to dictate the appropriate secondary prevention measures.
The author proposes using the TOAST classification (Trial of Organon 10172 in Acute Stroke Treatment), arguing that classification systems that prime clinical syndromes over pathophysiological mechanisms are less useful. Nevertheless, the author omitted one classification which–partially–resolves the issue: the ASCOD (Atherosclerosis, Small-vessel, Cardiac embolism, Other, Dissection) system ². A comprehensive classification, which allows for more than one aetiology, while giving a degree of a causal relationship to the presence of each category of disease (1 potential, 2 uncertain, 3 unlikely, 0 disease not detected) including incomplete assessment (9 insufficient work-up), while considering some clinical features.
The ASCOD approach permits the identification of patients with diseases that would have been left as indeterminate with other classification systems, thus increasing the risk of stroke because of inadequate secondary prevention. Comparisons with other classification systems have shown that ASCO (the predecessor of ASCOD) allows for more than one cause of stroke, with a larger proportion of atherosclerosis and lower of indeterminate and small vessel disease with the potential to magnify cardiac embolism thus leading to overtreatment ³, but with a recurrence risk strongly tied to aetiology regardless of the classification system used ⁴.
However, both of the above mentioned-comparisons have a flaw: they used ASCO as a dichotomic variable, which is not, and is precisely the advantage of ASCOD, that allows individualizing secondary prevention approaches for the most likely aetiology without discarding other possible etiologies, thus decreasing the proportion of indeterminate strokes facilitating inclusion for clinical trials ⁵. The relevance of considering multiple etiologies this has been demonstrated by studies like AMISTAD in which concurrent intra- and extracranial atherosclerosis increased the risk of major adverse cardiovascular events ⁶, and the secondary analysis of SOCRATES, which demonstrated ticagrelor to be superior to aspirin in patients with atherosclerosis regardless of causal link ⁷.
Bottom line, the critical issue is to assess patients with AIS to detect the most likely aetiology responsible for the stroke, without losing sight of possible comorbidities and regardless of the classification system used. In our Hospital, we use ASCOD since it allows neurology residents to consider all potential etiologies, but each centre should individualize to its specific needs.
References
1. Markus H. Personalising secondary prevention: different treatments for different strokes. Practical Neurology Published Online First: 04 September 2019 doi: 10.1136/practneurol-2018-002006
2. Amarenco P, Bogousslavsky J, Caplan LR, et al. The ASCOD phenotyping of ischemic stroke (Updated ASCO Phenotyping). Cerebrovasc Dis 2013;36(1):1-5. doi: 10.1159/000352050
3. Shang W, Liu J. Stroke subtype classification: a comparative study of ASCO and modified TOAST. J Neurol Sci 2012;314(1-2):66-70. doi: 10.1016/j.jns.2011.10.029
4. Arsava EM, Helenius J, Avery R, et al. Assessment of the Predictive Validity of Etiologic Stroke Classification. JAMA Neurol 2017;74(4):419-26. doi: 10.1001/jamaneurol.2016.5815
5. Sirimarco G, Lavallee PC, Labreuche J, et al. Overlap of diseases underlying ischemic stroke: the ASCOD phenotyping. Stroke 2013;44(9):2427-33. doi: 10.1161/STROKEAHA.113.001363
6. Hoshino T, Sissani L, Labreuche J, et al. Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease. JAMA Neurol 2018;75(2):203-11. doi: 10.1001/jamaneurol.2017.3960
7. Amarenco P, Albers GW, Denison H, et al. Efficacy and safety of ticagrelor versus aspirin in acute stroke or transient ischaemic attack of atherosclerotic origin: a subgroup analysis of SOCRATES, a randomised, double-blind, controlled trial. Lancet Neurol 2017;16(4):301-10. doi: 10.1016/S1474-4422(17)30038-8
Following the publication of the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” in January 2019, new data has become available and an update is required. Whilst these updates do not change the overall recommendations in the guidelines, they add information, which we feel all neurologists should be aware of in order to provide the highest quality of information to all women with MS considering pregnancy.
(1) Interferon beta preparations in pregnancy
In September 2019, the EMA Committee for Medicinal Products for Human Use (CHMP) recommended a label change for interferon beta-1a, peginterferon beta-1a and interferon beta-1b, i.e. Avonex, Betaferon, Extavia, Plegridy and Rebif, stating that they may be considered during pregnancy if clinically indicated, and can be used during breastfeeding [1]. This decision was based on data from interferon beta registries, national registries and post-marketing experience. However, data from exposure during second and third trimesters remains limited. The duration of exposure during the first trimester is uncertain, because data were collected when interferon beta use was contraindicated during pregnancy, and it is likely that treatment was interrupted in many women when the pregnancy was detected and/or confirmed.
This supports the recommendation in the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” that these products are safe to be continued at least until...
Following the publication of the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” in January 2019, new data has become available and an update is required. Whilst these updates do not change the overall recommendations in the guidelines, they add information, which we feel all neurologists should be aware of in order to provide the highest quality of information to all women with MS considering pregnancy.
(1) Interferon beta preparations in pregnancy
In September 2019, the EMA Committee for Medicinal Products for Human Use (CHMP) recommended a label change for interferon beta-1a, peginterferon beta-1a and interferon beta-1b, i.e. Avonex, Betaferon, Extavia, Plegridy and Rebif, stating that they may be considered during pregnancy if clinically indicated, and can be used during breastfeeding [1]. This decision was based on data from interferon beta registries, national registries and post-marketing experience. However, data from exposure during second and third trimesters remains limited. The duration of exposure during the first trimester is uncertain, because data were collected when interferon beta use was contraindicated during pregnancy, and it is likely that treatment was interrupted in many women when the pregnancy was detected and/or confirmed.
This supports the recommendation in the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” that these products are safe to be continued at least until conception, in addition to extending this advice such that women should be offered the choice of continuation during pregnancy.
(2) Fingolimod (Gilenya)
In September 2019, the MHRA issued an alert on the safety of fingolimod (Gilenya) in pregnancy [2] after data from international pregnancy registers demonstrated that exposure in pregnancy leads to an estimated additional two to three major congenital malformations per 100 livebirths compared with the general population (a two-fold increase). Reported malformations include congenital heart disease, such as tetralogy of Fallot, atrial and ventricular septal defects, and renal and musculoskeletal abnormalities [2].
If a woman of childbearing potential is started on fingolimod, the advice in the summary of product characteristics is that she must be informed of the risk of teratogenicity and provided with a patient reminder card. She must have a negative pregnancy test before receiving the first dose and at suitable intervals during treatment as appropriate. She should be regularly advised to use effective contraception during treatment and for at least two months after stopping it. Women should be advised that recurrence of disease activity, which can be substantial, has been reported in around a quarter of women after stopping fingolimod to get pregnant [4-6].
In November 2018, the license for fingolimod was extended to include its use in for children and young adults (10-17 years) with MS [3]. Due to limited treatment options in this group, fingolimod use in young women is anticipated to increase.
In our opinion, fingolimod is best avoided in women of childbearing age unless there is no other suitable treatment. Serious consideration should be given to proactively switching women of childbearing age who are taking fingolimod to an alternative DMD of at least similar efficacy well in advance of trying to conceive, and the possibility of unplanned pregnancy should be considered in all women of childbearing potential.
Work is ongoing to develop a UK MS Pregnancy Register; the above new information highlights the need for an independent register to inform practice.
Dr Ruth Dobson1,2* and Dr Peter Brex3; on behalf of all authors and the UK MS Pregnancy Register Steering Group
Acknowledgements
The following individuals and groups provided input into this update:
UK MS Pregnancy Register steering group (Dr David Rog, Dr Owen Pearson, Dr Katy Murray, Dr Stella Hughes, Dr Helen Ford, Dr Peter Brex and Dr Ruth Dobson)
UK consensus on pregnancy in multiple sclerosis: ABN guideline authors (Dr Catherine Nelson-Piercy, Dr Pooja Dassan, Megan Roberts, Prof Gavin GIovannoni)
Aoife Shields, Neuroscience Specialist Pharmacist
References
1. https://www.acnr.co.uk/2019/09/interferon-beta-treatments-receive-positi...
2. https://www.gov.uk/drug-safety-update/fingolimod-gilenya-increased-risk-...
3. https://www.ema.europa.eu/en/documents/product-information/gilenya-epar-...
4. Hemat S, Houtschens M, Vidal-Jordana A, et al. Disease activity during pregnancy after Fingolimod withdrawal due to planning a pregnancy in women with multiple sclerosis. Poster presented at: 70th American Academy of Neurology Annual Meeting; April 21–27, 2018; Los Angeles, CA.
5. Meinl I, Havla J, Hohlfeld R, Kümpfel T. Recurrence of disease activity during pregnancy after cessation of fingolimod in multiple sclerosis. Mult Scler 2018;24(7):991–914. doi:10.1177/ 1352458517731913.
6. Novi G, Ghezzi A, Pizzorno M, et al. Dramatic rebounds of MS during pregnancy following fingolimod withdrawal. Neurol Neuroimmunol Neuroinflamm 2017;4(5):e377. doi:10.1212/ NXI.0000000000000377.
We read the article “neuromythololgy” by Martin Turner and Phillip Smith ,” clinic letters revisited”1. We completely agree that the 2002 Department of Health directive that patients should be sent a copy of their clinic letters was ,” a major force in improving clinic letters”.
The article however makes no mention of the 2018 advice2 from the Academy of Medical Royal Colleges entitled ,” please write to me”. It strongly recommends that most letters be addressed directly to the patient with a copy to the GP and that English fully comprehensible to patients is used and any technical language is explained. This approach avoids much of the discussion in the article of terms like ,”this pleasant gentleman”.
We have both adopted this recommended approach since 2018. One of us starts letters,” thank you for coming this morning and explaining that you are a 43 year old garage mechanic and that you have suffered tingling in the right hand for 6 months”. The other starts,” your GP wrote to me that you have had tingling in your right hand for 6 months”.
We have carried out a preliminary audit of patients, GPs, and hospital consultants attitude to this suggested change by showing them 2 similar letters one addressed to the GP and the other to the patient. GPs quite strongly favoured letters addressed to the patient saying they received far fewer requests to clarify what the hospital doctor meant. Patients were roughly evenly divided, whilst hospital consultants st...
We read the article “neuromythololgy” by Martin Turner and Phillip Smith ,” clinic letters revisited”1. We completely agree that the 2002 Department of Health directive that patients should be sent a copy of their clinic letters was ,” a major force in improving clinic letters”.
The article however makes no mention of the 2018 advice2 from the Academy of Medical Royal Colleges entitled ,” please write to me”. It strongly recommends that most letters be addressed directly to the patient with a copy to the GP and that English fully comprehensible to patients is used and any technical language is explained. This approach avoids much of the discussion in the article of terms like ,”this pleasant gentleman”.
We have both adopted this recommended approach since 2018. One of us starts letters,” thank you for coming this morning and explaining that you are a 43 year old garage mechanic and that you have suffered tingling in the right hand for 6 months”. The other starts,” your GP wrote to me that you have had tingling in your right hand for 6 months”.
We have carried out a preliminary audit of patients, GPs, and hospital consultants attitude to this suggested change by showing them 2 similar letters one addressed to the GP and the other to the patient. GPs quite strongly favoured letters addressed to the patient saying they received far fewer requests to clarify what the hospital doctor meant. Patients were roughly evenly divided, whilst hospital consultants strongly favoured the traditional letter to the GP.
Our impression is that very few hospital doctors have actually tried the new format. We recommend colleagues give it a try.
References.
1. Turner MR, Smith PEM, Practical Neurology 2019;19:457.
2. Working group on copying letters to patients. Department of health 2002
3. Please, write to me. Writing outpatient clinic letters to patients.
Academy of Medical Royal Colleges. 2018
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...
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 Neurology(1), where they elaborate on the importance of beginning the neurological examination before the patient enters the doctor's office. An excellent chronicle on many signs that we might have seen but not acknowledged, in a clear and concise manner. However, while reading the article some concerns (unrelated to the quality and value of the article) were brought to our attention. How about outside the clinic or the Hospital?
Should we approach the gentleman or the lady portrayed in the first two paragraphs by author SACT? For neurologists, particularly for movement disorders specialists, patients can be found everywhere. Should neurologists be observant of the Goldwater rule (2), that prohibits psychiatrists to diagnose a subject they have not personally examined, and to communicate that diagnosis without the subjects consent? Are we then only to observe and describe just like James Parkinson did(3)? We observe as a clinical exercise, to describe phenomenology but we would never approach a person in public to invite them to our clinic, or to give an unsolicited diagnosis; that would be preposterous, we have no right to do so. In ‘Do no harm’, Henry Marsh states that neurologists are like kids looking for “strange and obscure diseases, sometimes untreatable, (...) deeply fascinating, and which they collect like rare butterflies and report in their journals(4)”. Yet we feel this description to be quite unfair because phenomenology might seize our attention, but we must strive to be like the great physician that Sir William Osler envisioned, the one who cares about “the patient who has the disease.”.
As a general neurology resident, the movement disorders field seems more and more appealing. The fact that even outside the doctor’s office we can start the diagnostic process, prompted one of the authors (SACT) to write the opening paragraphs, based on real-life experiences, in order to ask for the author’s advice on how to approach this situation; and to encourage more residents into neurology and movement disorders, because of the growing pandemic of neurodegenerative disorders like Parkinson’s disease that is calling us into action(5).
Acknowledgments: SACT would like to thank Mariana Castillo-Torres (Bachelor in Languages for Interpreting and Translation), for her kind assistance on English-language, editing and style.
Contributorship Statement: SACT contributed to the conceptual design of the article with the opening paragraphs and drafting of the manuscript. FFA contributed with the drafting of the manuscript, and a review of intellectually relevant content. IEB contributed to article conception and design, drawing from personal experiences, as well as a review for intellectually relevant content. All authors agreed on the final version of the manuscript.
References
1. Araujo R, van de Warrenburg B, Lang A, et al. The Waiting Room: neurological observations made outside the movement disorder specialist's consulting office. Pract Neurol 2019 doi: 10.1136/practneurol-2018-002110
2. Lilienfeld SO, Miller JD, Lynam DR. The Goldwater Rule: Perspectives From, and Implications for, Psychological Science. Perspect Psychol Sci 2018;13(1):3-27. doi: 10.1177/1745691617727864
3. Kempster PA, Hurwitz B, Lees AJ. A new look at James Parkinson's Essay on the Shaking Palsy. Neurology 2007;69(5):482-5. doi: 10.1212/01.wnl.0000266639.50620.d1
4. Marsh H. Do no harm: stories of life, death and brain surgery: Hachette UK 2014.
5. Dorsey ER, Bloem BR. The Parkinson Pandemic-A Call to Action. JAMA Neurol 2018;75(1):9-10. doi: 10.1001/jamaneurol.2017.3299
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...
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 video materials of these individuals. An exception could be made for patients who are already part of one’s own clinic, and where a fortunate observation of e.g. this person’s gait outside the hospital may offer additional value to what can be noted within the hospital itself. For example, cobbled stones on the street can elicit occasional stumbles that might be missed on the perfectly even hospital floors. We also find it illustrative to see how difficult it can be for patients to step outside of their car (seats are usually very low, causing great problems for patients with Parkinson’s disease or proximal leg weakness). Finally, we have seen patients manifesting freezing of gait only when they approached the revolving doors of the hospital – these can be a great challenge for people with Parkinson's.
Bastiaan R. Bloem, MD, PhD. (corresponding author)
Radboud university medical centre
Donders Institute for Brain, Cognition and Behaviour
Department of Neurology
Nijmegen, the Netherlands
bas.bloem@radboudumc.nl
Rui Araújo, MD.
Neurology Department, Centro Hospitalar e Universitário de Coimbra
Coimbra, Portugal
rmma22@gmail.com
Bart P. van de Warrenburg, MD, PhD.
Radboud university medical centre
Donders Institute for Brain, Cognition and Behaviour
Department of Neurology;
Nijmegen, the Netherlands
bart.vandewarrenburg@radboudumc.nl
Anthony E. Lang, MD, FRCPC.
Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J Safra Program in Parkinson’s Disease, Toronto Western Hospital
399 Bathurst Street, Toronto, Ontario
lang@uhnresearch.ca
Andrew J. Lees, MD, FRCP, FMedSci.
National Hospital, Queen Square
Reta Lila Weston Institute, University College London
Reference
1. Araujo R, Ferreira JJ, Antonini A, Bloem BR. "Gunslinger's gait": a new cause of unilaterally reduced arm swing. BMJ 2015;351:h6141.
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...
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 clinical management in this clinical setting. Notably, LP may be performed immediately, which may be clinically relevant, if the drug levels are under the cut-off chosen to rule out any anticoagulant effect. However, consensus is still lacking and different advisory bodies (French expert opinion, [2] Swiss operating procedures [3]) set the lower threshold limit for the anticoagulant effect of DOACs at a range between 20-50 ng/mL for other urgent procedures, like intravenous thrombolysis.
Therefore, if there were an international, or at least European consensus on the recommended DOAC drug level cut-off to rule out any anticoagulant effect, the management of patients requiring urgent or emergent procedure, like LP or surgery, would be facilitated. Obviously, if the DOACs levels are within the therapeutical range, a delay before the LP is required, according to the recommendations.
However, a remarkably different management may be prospected if an LP is indicated in patients is on dabigatran, where emergency reversal may be achieved by idarucizumab, as Dodd et al. [1] report, recommending previous consultation with a hematologist. This is another crucial point and a clinical novelty, where an urgent/emergent LP may be allowed in dabigatran-treated patients in only a few minutes after idarucizumab administration. Although literature evidence is still scarce and only a few cases (three, considering ours) have been reported to date, in our experience an LP after dabigatran emergency reversal by idarucizumab is a safe procedure, as was demonstrated by our two personal cases, one published, [4] one in press. Therefore, we are of the opinion that idarucizumab could be safely administered to patients requiring LP, also in the absence of a haematologist, to save the time inevitably required by the consultation.
Another reversal agent, andexanet-alpha, was recently approved by the FDA and seems to be appealing for patients on direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), as Dodd et al. [1] report. However, the time required to reverse the DOAC effect and the putative pro-thrombotic effect of andexanet-alpha make it an unlikely candidate for an emergency reversal of direct factor Xa inhibitors before an LP.
Lastly, Dodd et al. [1] recommend the DOAC first dose 6 hours after an atraumatic LP. We suggest the following algorhythm: in the presence of a CHADSVADSC score of >=3 administer the DOAC after 6 hours and after 12 hours with a CHADSVASC score of <3.
It is, however, encouraging that a novel clinical scenario is emerging for the management of patients on DOACs, where outstanding opportunities are provided by the availability of specific DOAC levels dosages, even if international consensus would be welcome to set a clear cut-offs for the anticoagulant effect and, above all, by the reversal agent idarucizumab, which seems to be a safe and effective tool for urgent/emergent LP in dabigatran-treated patients.
References
1. Dodd KC, Emsley HCA, Desborough MJR, Chhetri SK. Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline. Pract Neurol. 2018 Aug 28. pii: practneurol-2017-001820. doi: 10.1136/practneurol-2017-001820. [Epub ahead of print]
2. Touzé E, Gruel Y, Gouin-Thibault I, De Maistre E, et al. Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants. Expert opinion of the SocieteFrancaise de NeurologieVasculaire (SFNV) and the GroupeFrancaisd'etudes sur l'Hemostase et la Thrombose (GFHT). Eur J Neurol 2018 Jan 23. doi: 10.1111/ene.13582.
3. Seiffge DJ, Traenka C, Polymeris AA, et al. Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice. J Stroke 2017; 19(3): 347-355.
4. Agosti S, Casalino L, Daffonchio A, Arena L, Celli L and Rota E. Emergency Lumbar Puncture for Suspected Meningitis after Dabigatran Reversal with Idarucizumab: A Case Report. J Clin Case Rep 2018, 8:4.
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.
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.
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 Yabsley MJ, Parsons NJ, Horne EC, et al. Novel relapsing fever Borrelia detected in African penguins (Spheniscus demersus) admitted to two rehabilitation centers in South Africa. Parasitol Res 2012;110:1125–30. doi:10.1007/s00436-011-2602-2
2 Global distribution of natural plague foci. WHO. 2016.http://www.who.int/csr/disease/plague/Plague-map-2016.pdf?ua=1
3 Carpio A, Fleury A, Romo ML, et al. Neurocysticercosis: the good, the bad, and the missing. Expert Rev Neurother 2018;18:289–301. doi:10.1080/14737175.2018.1451328
4 Singh G, Sharma R. Controversies in the treatment of seizures associated with neurocysticercosis. Epilepsy Behav 2017;76:163–7. doi:10.1016/j.yebeh.2017.05.033
We thank Dr Weydt and colleagues for their interest in our review. We are aware of the subjective benefit of cannabinoids reported by some living with multiple sclerosis, and a trial of THC:CDB spray is also approved by the UK’s National Institute for Health & Care Excellence (NICE). The CANALS study mentioned, in which PLS patients were well represented (28% of treatment arm and 20% of placebo arm), was a Phase 2 study powered to consider safety and tolerability. Adverse events were reported in 76% of the treatment group versus 27% in the placebo group. A reduction in the clinician’s Modified Ashworth Spasticity scale score was noted, and in the patient’s numeric rating scale score for pain, but not their scores for spasm or spasticity. In the discussion, the authors note that muscle cramping was not alleviated in a prior randomised trial of THC in ALS (1). We agree with their call for further evaluation, through a Phase 3 study of the benefit of cannabinoids over the licensed therapies for spasticity outlined in our review.
Reference:
1. Weber M, Goldman B, Truniger S. Tetrahydrocannabinol (THC) for cramps in amyotrophic lateral sclerosis: a randomised, double-blind crossover trial. J Neurol Neurosurg Psychiatry. 2010 Oct;81(10):1135-40. doi: 10.1136/jnnp.2009.200642. PMID: 20498181.
It gives more discomfort than pleasure to comment on DaT scanning again but your editorial [1] prompted me to find out that the number of DaTscans carried out in England is increasing yearly, from 4550 in 2012/3 to 8840 in 2018/9. A trip to the dentist might have been wiser, my long-expressed opinion (based on the fundamental principles that let down 18FDopa PET) being that the DaTscan is a waste of time, radiation and money [2]. In brief it is a low resolution, inadequately sensitive, inadequately reproducible test with too many false negatives and little knowledge of confounding influences. The acronym SWEDD has, mercifully, been consigned to the dustbin[3] but we don’t have the neuropathological studies or large and long-term blinded follow-up studies, in patients and healthy individuals, despite the many tests and years since its commercial introduction, that would tell the true false positive and negative rate of the test. We can’t then confidently say how strongly a normal result argues against a clinical diagnosis of PD. Neurology is not the only specialty that uses DaTscan and indication-creep (good for the shareholder, bad for the taxpayer) means that it is also being used to distinguish Lewy Body Dementia from Alzheimer’s Dementia despite limited supportive data (4). It must also be remembered that the test measures biochemistry, not pathology; the statement in the case presentation [5] “a DaTscan was normal, with no evidence of degenerative Parkinsonism” is...
Show MoreWith great interest, we read the review by Markus on personalising the secondary prevention approach to patients with stroke ¹, published in the most recent issue of Practical Neurology. Where we are presented with clinically useful and evidence-based advice for the etiological assessment of patients with acute ischemic stroke (AIS), focusing on lacunar stroke syndromes of a non-lacunar cause, and its appropriate therapeutic management. We consider the article of great importance: a must-read for all physicians who care for patients with AIS since etiological assessment is paramount to dictate the appropriate secondary prevention measures.
The author proposes using the TOAST classification (Trial of Organon 10172 in Acute Stroke Treatment), arguing that classification systems that prime clinical syndromes over pathophysiological mechanisms are less useful. Nevertheless, the author omitted one classification which–partially–resolves the issue: the ASCOD (Atherosclerosis, Small-vessel, Cardiac embolism, Other, Dissection) system ². A comprehensive classification, which allows for more than one aetiology, while giving a degree of a causal relationship to the presence of each category of disease (1 potential, 2 uncertain, 3 unlikely, 0 disease not detected) including incomplete assessment (9 insufficient work-up), while considering some clinical features.
The ASCOD approach permits the identification of patients with diseases that would have been left as indeterm...
Show MoreDear Editors,
Following the publication of the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” in January 2019, new data has become available and an update is required. Whilst these updates do not change the overall recommendations in the guidelines, they add information, which we feel all neurologists should be aware of in order to provide the highest quality of information to all women with MS considering pregnancy.
(1) Interferon beta preparations in pregnancy
In September 2019, the EMA Committee for Medicinal Products for Human Use (CHMP) recommended a label change for interferon beta-1a, peginterferon beta-1a and interferon beta-1b, i.e. Avonex, Betaferon, Extavia, Plegridy and Rebif, stating that they may be considered during pregnancy if clinically indicated, and can be used during breastfeeding [1]. This decision was based on data from interferon beta registries, national registries and post-marketing experience. However, data from exposure during second and third trimesters remains limited. The duration of exposure during the first trimester is uncertain, because data were collected when interferon beta use was contraindicated during pregnancy, and it is likely that treatment was interrupted in many women when the pregnancy was detected and/or confirmed.
This supports the recommendation in the “UK consensus on pregnancy in multiple sclerosis: ABN guidelines” that these products are safe to be continued at least until...
Show MoreWe read the article “neuromythololgy” by Martin Turner and Phillip Smith ,” clinic letters revisited”1. We completely agree that the 2002 Department of Health directive that patients should be sent a copy of their clinic letters was ,” a major force in improving clinic letters”.
The article however makes no mention of the 2018 advice2 from the Academy of Medical Royal Colleges entitled ,” please write to me”. It strongly recommends that most letters be addressed directly to the patient with a copy to the GP and that English fully comprehensible to patients is used and any technical language is explained. This approach avoids much of the discussion in the article of terms like ,”this pleasant gentleman”.
We have both adopted this recommended approach since 2018. One of us starts letters,” thank you for coming this morning and explaining that you are a 43 year old garage mechanic and that you have suffered tingling in the right hand for 6 months”. The other starts,” your GP wrote to me that you have had tingling in your right hand for 6 months”.
We have carried out a preliminary audit of patients, GPs, and hospital consultants attitude to this suggested change by showing them 2 similar letters one addressed to the GP and the other to the patient. GPs quite strongly favoured letters addressed to the patient saying they received far fewer requests to clarify what the hospital doctor meant. Patients were roughly evenly divided, whilst hospital consultants st...
Show MoreAs 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...
Show MoreWe 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...
Show MoreDear Editor,
Show MoreWe 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...
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.
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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