eLetters

24 e-Letters

published between 2020 and 2023

  • Response to Weydt et al

    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.

  • Oh No, Not DaT Again

    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...

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  • Personalising secondary prevention for stroke: the importance of considering multiple aetiologies

    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...

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  • UK Consensus on pregnancy in multiple sclerosis: an update

    Dear 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...

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