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.
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.
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
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.
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
Imagine my surprise on reading your recent editorial regarding head
injury. Perhaps the editor could have looked a little closer to home
before concluding that neurologists in the UK are not involved in the
management of patients with head injuries per se.
I am a neurosciences pharmacist who is working very closely with a
consultant neurologist who has recently developed a fully comprehens...
Imagine my surprise on reading your recent editorial regarding head
injury. Perhaps the editor could have looked a little closer to home
before concluding that neurologists in the UK are not involved in the
management of patients with head injuries per se.
I am a neurosciences pharmacist who is working very closely with a
consultant neurologist who has recently developed a fully comprehensive
traumatic brain injury (TBI) service at St George's Hospital, London. The
service is seamless from the moment the patient arrives into our major
trauma centre, through neuro intensive care (NITU), neurosurgery, the
acute TBI unit, and on to rehabilitation at The Wolfson Centre for
Neurorehabilitation, which is within the same trust. Our trust has
recently become responsible for community therapy services within the host
primary care trust, so the service will also extend seamlessly into
primary care within the next eighteen months.
The editor may be surprised to hear that the TBI beds are to be found
on a tertiary neurology ward. The consultant neurologist is fully
responsible for all aspects of the patients' care from the point at which
they leave NITU or neuro HDU (where they are under the care of the
consultant neurosurgeon within our team), through their entire acute care
and ongoing inpatient rehabilitation at The Wolfson, until discharge.
The multidisciplinary team now consists of the consultant neurologist
(Dr Colette Griffin), a dedicated TBI neurology SpR, a consultant
neurosurgeon, a trauma dietician, a neurology occupational therapist, a
neurology speech and language therapist, a neurology physiotherapist, a
neuropsychologist, an NITU nursing sister, a neurology nursing sister, a
head injury coordinator, a trauma coordinator and myself. We are also in
the process of appointing a consultant neuropsychiatrist, and aim to
develop clinical nurse specialist posts both based within the trust and
the community, and a dedicated social worker post in addition within the
next year.
Our service has just been nominated for The Health Service Journal
awards and is held as a beacon of best practice.
Hence your readers can now sleep soundly in the knowledge that they
do not need to travel to the Netherlands to see how a neurologist manages
acute head injury.
With kind regards
Annett Blochberger
Conflict of Interest:
I am working within the described service at St Georges' Healthcare NHS Trust.
The formula given in this paper can only be used to calculate a QTc
if the variables QT and RR are entered as time measured in seconds.
The RR is not the "heart beat in beats per min". It is the time
elapsing between R wave peaks eg ten small squares which equals 0.4
seconds.
Sadly, despite the obvious good intentions of this paper, any
neurologist who follows the instructions to calculate the QTc will find a
result that makes no sense.
Could this fact be brought to the attention of those reading the
journal through a printed addendum? My fear is that those who have already
read or copied the article will not return to the web based copy and
therefore will not be made aware of the error.
The irony of the provocative invocation "Get rid of your
stethoscope"(1) is that, for evaluation of systolic blood pressure(SBP) in
the context of hypertension-related neurological disorders such as
stroke(hypertension being the underlying cause of 54% of strokes
worldwide)(2), and reversible cerebral vasoconstrictor syndrome(3),
palpatory measurement of sytolic blood pressure may be a good substitute
for auscultation, a...
The irony of the provocative invocation "Get rid of your
stethoscope"(1) is that, for evaluation of systolic blood pressure(SBP) in
the context of hypertension-related neurological disorders such as
stroke(hypertension being the underlying cause of 54% of strokes
worldwide)(2), and reversible cerebral vasoconstrictor syndrome(3),
palpatory measurement of sytolic blood pressure may be a good substitute
for auscultation, as shown by a study where, on average, palpatory SBP was
only 5.2 mm Hg lower than auscultatiory SBP (4). The same might hold true
also in the context of suspected haemodynamic stroke where confirmation
of the diagnosis might come from evaluation of blood pressure on rising
from the supine position, or on coughing or on exercise, including
transition from a cold to a warm enviroment(5).
The advantage of palpatory measurement of SBP is that it is free of the
error of "auscultatory gap", the latter defined as "the period of abnormal
silence or diminished intensity during one of the Korotkov sound
phases"(6). Auscultatory measurement is liable to this error if the
precaution is not taken to determine the point of obliteration of the
pulse by palpation prior to deflation of the armcuff(6).
References
(1) Hawkes CH
Get rid of your stethoscope!
Practical Neurology 2010;10:344-346
(2) Lawes CM., Vender Hoorn S., Rodgers A for International Society of
Hypertension
Global burden of blood pressure-related disease, 2001
Lancet 2008;371:1513-18
(3) Ducros A., Bousser M-G
Reversible cerebral vasoconstricor syndrome
Pract Neurol 2009;9:256-257
(4)van der Hoeven NV., van den Born B-J H., van Moltfrans GA
Reliability of palpation of the radial artery compared with auscultation
of the brachial artery in measuring SBP
J Hypertension 2011;29:51-55
(5)Klijn CJM., Kappelle IJ
Haemodynamic stroke: clinical features, prognosis, and management
Lancet Neurology 2010;9:1008-1017
(6)Askey M
The auscultatory gap in sphygmanometry
Annals of Internal Medicine 1974;80:94-97
Although it is true that, in patients with suspected meningitis, a
CSF:plasma glucose of >0.5 suggests a viral aetiology(1),
underrecognition of the fact that the ratio may sometimes fall below 0.5
has led to inclusion of a CSF:plasma ratio > 0.5 among the "clinical
case definitions" of aseptic meningitis(2), notwithstanding the fact that
CSF:plasma glucose ratios below 0.5(and even as low as 0.26) may be
encounte...
Although it is true that, in patients with suspected meningitis, a
CSF:plasma glucose of >0.5 suggests a viral aetiology(1),
underrecognition of the fact that the ratio may sometimes fall below 0.5
has led to inclusion of a CSF:plasma ratio > 0.5 among the "clinical
case definitions" of aseptic meningitis(2), notwithstanding the fact that
CSF:plasma glucose ratios below 0.5(and even as low as 0.26) may be
encountered in viral meningitis(3), and in viral encephalitis(4).
In one study, among 22 patients with enterovirus meningitis, the
CSF:plasma glucose ratio fell within the range 0.26-0.76. In the same
study, among 8 patients with varicella zoster virus meningitis the ratio
fell within the range 0.4-0.73, and within the range 0.47-0.57 among 8
patients with herpes simplex type 2 meningitis(3). Even in viral
encephalitis, patients have been encountered with CSF:plasma glucose
ratios < 0.5, as was the case in a multicentre population-based
prospective study of patients in England(4). In that study among 18
subjects with herpes simplex virus encephalitis in whom the CSF;plasma
ratio was evaluated , there were five with a ratio < 0.5. Among 6 with
varicella zoster virus encephalitis in whom the ratio was evaluated there
were two in whom the ratio fell below 0.5(4). Given the fact that some
subtypes of viral meningitis are amenable to treatment(3), and the fact
that management of this disorder may be suboptimal, in part due to its
underrecognition(5), it is important to stress to frontline medical staff
that the diagnosis should be entertained even when the CSF:plasma glucose
ratio falls within the range where the differential diagnosis includes
tuberculous meningitis.
References
(1)Davies N ., Thwaites G
Infections of the nervous system
Practical Neurology 2011:11:121-131
(2) Michael BD., Sidhu M., Stoeter D et al
Acute central nervous system infections in adults-a retrospective cohort
study in the NHS Northwest region
QJ Med 2010;103:749-758
(3)Ihekwaba UK., Kudesia G., McKendrick MW
Clinical features of viral meningitis in adults: significant differences
in cerebrospinal fluid findings among herpes simplex virus, varicvella
zoster virus, and enterovirus infections
Clinical Infectious Diseases 2008;47:783-789
(4) Granerod J., Ambrose HE., Davies NWS et al
Causes of encephalitis and differences in their clinical presentations in
England: a multicentre, population-based prosepctive study
Lancet Infectious diseases 2010;10:835-844
(5)Landrey ML., Greenwold J., Vikram HR
Herpes simplex type-2 meningitis: presentation and lack of standardised
therapy
American Journal of Medicine 2009;122:688-691
As a long term and avid reader of Practical Neurology I was somewhat
surprised by the article and correspondence suggesting that the
stethoscope is now an irrelevancy to clinical neurologists (Practical
Neurology 2010;10:344) On the contrary, I believe neurologists should
still use their stethoscopes. Heres why.
Most neck bruits indicate underlying arterial disease. For instance,
in a study comparing the 'blind...
As a long term and avid reader of Practical Neurology I was somewhat
surprised by the article and correspondence suggesting that the
stethoscope is now an irrelevancy to clinical neurologists (Practical
Neurology 2010;10:344) On the contrary, I believe neurologists should
still use their stethoscopes. Heres why.
Most neck bruits indicate underlying arterial disease. For instance,
in a study comparing the 'blinded' findings at auscultation on asymptomatic
patients with cervical bruits also assessed by Doppler ultrasound, there
was a highly significant correlation. In most cases, bruits represented
arterial stenosis (Neurology 1985;35:742). When examining patients with a
suspected transient ischaemic attack, the finding of bruits in the neck,
abdomen and groins is also a useful index of underlying arteriopathy.
I recently saw a patient referred with an unexplained 'swishing'
sound in her head, already dismissed as probably 'non organic'. No one had
listened with a stethoscope. May be they didn't have one. If they had,
they would have confirmed the existence of a loud bruit over the right
side of the
head, later confirmed as an intracranial arteriovenous malformation.
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...
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...
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...
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...
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...
Dear Editor
Imagine my surprise on reading your recent editorial regarding head injury. Perhaps the editor could have looked a little closer to home before concluding that neurologists in the UK are not involved in the management of patients with head injuries per se.
I am a neurosciences pharmacist who is working very closely with a consultant neurologist who has recently developed a fully comprehens...
The formula given in this paper can only be used to calculate a QTc if the variables QT and RR are entered as time measured in seconds.
The RR is not the "heart beat in beats per min". It is the time elapsing between R wave peaks eg ten small squares which equals 0.4 seconds.
Sadly, despite the obvious good intentions of this paper, any neurologist who follows the instructions to calculate the QTc wil...
The irony of the provocative invocation "Get rid of your stethoscope"(1) is that, for evaluation of systolic blood pressure(SBP) in the context of hypertension-related neurological disorders such as stroke(hypertension being the underlying cause of 54% of strokes worldwide)(2), and reversible cerebral vasoconstrictor syndrome(3), palpatory measurement of sytolic blood pressure may be a good substitute for auscultation, a...
Although it is true that, in patients with suspected meningitis, a CSF:plasma glucose of >0.5 suggests a viral aetiology(1), underrecognition of the fact that the ratio may sometimes fall below 0.5 has led to inclusion of a CSF:plasma ratio > 0.5 among the "clinical case definitions" of aseptic meningitis(2), notwithstanding the fact that CSF:plasma glucose ratios below 0.5(and even as low as 0.26) may be encounte...
As a long term and avid reader of Practical Neurology I was somewhat surprised by the article and correspondence suggesting that the stethoscope is now an irrelevancy to clinical neurologists (Practical Neurology 2010;10:344) On the contrary, I believe neurologists should still use their stethoscopes. Heres why.
Most neck bruits indicate underlying arterial disease. For instance, in a study comparing the 'blind...
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