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 Old technology is not synonymous with outdated technology.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.
Geraint Fuller's neurological reflections describe the Dunning Kruger
effect (1). This is one expression of illusory superiority, the cognitive
bias that makes us over-rate our attributes (2). Apart from Shakespeare,
whom the author quoted, other eminent people have noted that the less
skilled and less educated are usually unaware of their inadequacy. Charles
Darwin for example says: 'ignorance more frequently begets confi...
Geraint Fuller's neurological reflections describe the Dunning Kruger
effect (1). This is one expression of illusory superiority, the cognitive
bias that makes us over-rate our attributes (2). Apart from Shakespeare,
whom the author quoted, other eminent people have noted that the less
skilled and less educated are usually unaware of their inadequacy. Charles
Darwin for example says: 'ignorance more frequently begets confidence than
does knowledge'. Bertrand Russell has a slightly longer expression: 'one
of the painful things about our time is that those who feel certainty are
stupid, and those with any imagination and understanding are filled with
doubt and indecision'. My own personal favourite is: 'often wrong, but
never in doubt', attributed to Ivy Baker Priest.
Closely allied to the Dunning Kruger effect is the fundamental
attribution error- the tendency to blame personal failures on
circumstances, and to ascribe successes to inherent factors. Paradoxically
this rule is inverted when attributing the achievements and shortcomings
of others. The outcome of this is a failure to learn from personal
mistakes and from errors committed by others.
The author has rightly highlighted the implications of the Dunning
Kruger effect on self assessment in medical training and revalidation.
Just as worrying is the effect on patient safety. The obvious solution is
self awareness and introspection. Everyone needs to be conscious of how
well they know what they know- the concept of knowledge calibration (3).
To avoid the consequences of misplaced confidence, we should aspire to be
well-calibrated. To succeed in this, we must not assume immunity from the
Dunning Kruger effect.
1. Fuller, G. Ignorant of ignorance? Pract Neurol 2011; 11:365
2. http://en.wikipedia.org/wiki/Illusory_superiority
3. Cook RI and Woods DD. Operating at the sharp end. In: Bogner MS, ed.
Human error in medicine. Lawrence Erlbaum Associates, Hove. 1994: 264.
In the Saifee TA et al article (1) regarding the treatment of
"Tardive movment disorders" (TD), the authors recommend the use of
amantadine as second or third line among other possible drugs ("each with
fairly limited evidence for effectiveness" in author?s words).
In 1971, the late Dr. Espejel and I informed for the first time the
benefits of amantadine in drug-induced dyskinesias (2); consequently, I
have f...
In the Saifee TA et al article (1) regarding the treatment of
"Tardive movment disorders" (TD), the authors recommend the use of
amantadine as second or third line among other possible drugs ("each with
fairly limited evidence for effectiveness" in author?s words).
In 1971, the late Dr. Espejel and I informed for the first time the
benefits of amantadine in drug-induced dyskinesias (2); consequently, I
have followed with interest the derived articles. Failures and successes
are reported with the use of this agent. Here, I am interested to comment
the possible cause about the failures in TD treatments with amantadine, to
bring together data that may generate a "personalized" prescription
yielding an increased number of benefited patients.
Drugs-induced dyskinesias are a heterogeneous number of disorders
with different pathophysiological mechanisms in their generation:
presynaptic excess of dopamine formation, postynaptic supersensitive
dopaminergic receptors, or glutamergic overactivity mediated by the N-
methyl-D-aspartic acid (NMDA) receptor, all them grouped in an apparently
homogenous syndrome.
So, it is important to know if the patient we are treating are within
the glutamergic overactivity mediated by the NMDA receptor subset, since
only in these patients will obtain good results when treated with drugs
like amantadine or other well-tolerated NMDA receptor antagonist (3).
However, how do we can investigate this phenotypic feature? Brain MRI
spectroscopy can reveal the NMDA receptors excess but its high cost may
limit its routine use. However, if we bear in mind that patients with low
NMDA activity are clinically hypoactive and anhedonic and have exaggerated
extrapiramidal sensitivity (4), they will be prone to suffer TD amantadine
-resistant. Therefore, give amantadine in affected TD patients with
hyperactivity preferentially (or at least with normal motor activity) to
obtain better responses.
References:
1. Saifee TA, Edwards MJ. Tardive movement disorders: a practical
approach. Pract Neurol 2011;11:341-348
2. Vale S, Espejel MA. Amantadine for dyskinesia tarda. N Engl J Med.
1971;284:673.
3. Del Dotto P, Pavese N, Gambaccini G, Bernardini S, Metman LV,
Chase TN, Bonuccelli U. Intravenous amantadine improves levadopa-induced
dyskinesias: an acute double-blind placebo-controlled study. Mov Disord.
2001;16:515-20.
4. Telfer S, Shivashankar S, Krishnadas R, McCreadie RG, Kirkpatrick
B. Tardive dyskinesia and deficit schizophrenia. Acta Psychiatr Scand.
2011;124:357-62.
Dr. Fuller makes a strong case for coaching in neurology(1). Formal
coaching in neurology usually occurs during residency and fellowship
training. In the United States we have the 360 degree evaluation. The
resident physician in training is evaluated and coached by everyone he
comes in contact with namely the staff attending, nursing staff, other
residents, patient and even the medical student. There...
Dr. Fuller makes a strong case for coaching in neurology(1). Formal
coaching in neurology usually occurs during residency and fellowship
training. In the United States we have the 360 degree evaluation. The
resident physician in training is evaluated and coached by everyone he
comes in contact with namely the staff attending, nursing staff, other
residents, patient and even the medical student. There is little doubt
that this formal coaching is invaluable. Weaknesses and strengths are
identified in a timely fashion and corrective measures are instituted. The
question that needs to be asked by every neurologist is whether this
formal coaching needs to continue in some shape or form throughout one's
professional career. Can I as an assistant professor swallow my pride and
admit that I should have taken a more thorough history? One form of
coaching that has always served me well is the second opinion. When
confronted by a particularly vexing case, I do not hesitate in requesting
a second opinion from a physician whom I respect for his clinical acumen.
The office note which accompanies the patient on his return visit is
always illuminating. If it does not give me the answer I seek, it always
points me in the right direction. Another physician mind has approached
the problem confronting me in a different way. Dr. Fuller is indeed right.
Abundant avenues for coaching already exist in neurology; the trick is to
utilize them in an appropriate and timely fashion.
Reference
1. Fuller G. Do you need a coach? Pract Neurol. 2012;12(1):2-3.
The term generalized in EEG is certainly ambiguous and can be a cause
of confusion, especially to a reader who is not formally trained in
neurophysiology. As a neurology resident in training, the importance of
personally reviewing the patient's CT or MRI scan was impressed upon me
time and time again. Do not just take the radiologist's report at face
value, look at the pictures yourself since you after seeing the patient...
The term generalized in EEG is certainly ambiguous and can be a cause
of confusion, especially to a reader who is not formally trained in
neurophysiology. As a neurology resident in training, the importance of
personally reviewing the patient's CT or MRI scan was impressed upon me
time and time again. Do not just take the radiologist's report at face
value, look at the pictures yourself since you after seeing the patient
know what to look for better than the radiologist, was the pearl of wisdom
imparted to me by a seasoned neurologist. While a similar argument can be
made for reviewing the EEG too, interpretation of EEG is a skill which is
not formally taught during residency training. So is there a way out? The
answer is yes and it requires reading the body of the EEG report and not
just the final impression. Is the background frequency normal or slow?
What is the morphology and distribution of the spike wave discharges: slow
spike and wave (secondary generalized seizure disorder) versus 4-6 Hz
polyspike and wave discharges (primary generalized seizure disorder). EEG
reporting truly is like trying to translate a picture into words. One
though needs to see the entire picture and not just the impression at the
end.
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...
Geraint Fuller's neurological reflections describe the Dunning Kruger effect (1). This is one expression of illusory superiority, the cognitive bias that makes us over-rate our attributes (2). Apart from Shakespeare, whom the author quoted, other eminent people have noted that the less skilled and less educated are usually unaware of their inadequacy. Charles Darwin for example says: 'ignorance more frequently begets confi...
In the Saifee TA et al article (1) regarding the treatment of "Tardive movment disorders" (TD), the authors recommend the use of amantadine as second or third line among other possible drugs ("each with fairly limited evidence for effectiveness" in author?s words).
In 1971, the late Dr. Espejel and I informed for the first time the benefits of amantadine in drug-induced dyskinesias (2); consequently, I have f...
Dear Editor,
Dr. Fuller makes a strong case for coaching in neurology(1). Formal coaching in neurology usually occurs during residency and fellowship training. In the United States we have the 360 degree evaluation. The resident physician in training is evaluated and coached by everyone he comes in contact with namely the staff attending, nursing staff, other residents, patient and even the medical student. There...
The term generalized in EEG is certainly ambiguous and can be a cause of confusion, especially to a reader who is not formally trained in neurophysiology. As a neurology resident in training, the importance of personally reviewing the patient's CT or MRI scan was impressed upon me time and time again. Do not just take the radiologist's report at face value, look at the pictures yourself since you after seeing the patient...
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