BMJ Letters

A collection of the best letters from the British Medical Journal for the week ending 9th October 2011. You may need a Athens password to view these in full

• Is it time for medicine to update its Facebook status?
• Necrosis from needlestick injury with live Actinobacillus pleuropneumoniae porcine vaccine
• Fall assessment in older people : Screening for falls may not be cost effective
• The prescription opioid crisis : How to tackle the prescription opioid crisis
• Islamic Medical Association : Some light on Islam and medical practices
• Cognitive assessment of older people : Routine test batteries for cognitive impairment in older people may not be cost effective

Feeling of presence in Parkinson’s disease

Feeling of presence in Parkinson’s disease — Fénelon et al. 82 (11): 1219 — Journal of Neurology, Neurosurgery & Psychiatry.

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Abstract

Background A feeling of presence (FP), that is, the vivid sensation that somebody (distinct from oneself) is present nearby, is commonly reported by patients with Parkinson’s disease (PD), but its phenomenology has not been described precisely. The objective of this study was to provide a detailed description of FP in PD and to discuss its possible mechanisms.

Patients and methods The authors studied 52 non-demented PD patients reporting FP in the preceding month (38 consecutive outpatients and 14 inpatients). FP characteristics were recorded with a structured questionnaire. The outpatients with FP were compared with 78 consecutive outpatients without FP.

Results About half the patients said they recognised the ‘identity’ of the presence. More than 75% of patients said the FP were not distressing, were short-lasting, were felt beside and/or behind the patient, and occurred while indoors; most patients checked for a real presence, but their insight was generally preserved. In 31% of cases, the patients had an unformed visual hallucination simultaneously with the FP. A higher daily levodopa-equivalent dose and the presence of visual illusions or hallucinations were independently associated with FP.

Discussion Although FP is not a sensory perception, projection of the sensation into the extrapersonal space, along with the frequent co-occurrence of elementary visual hallucinations and the strong association with visual hallucinations or illusions, supports its hallucinatory nature. FP may be viewed as a ‘social’ hallucination, involving an area or network specifically activated when a living being is present, independently of any perceptual clue.

 

An exercise intervention to prevent falls in people with Parkinson’s disease: a pragmatic randomised controlled trial

An exercise intervention to prevent falls in people with Parkinson’s disease: a pragmatic randomised controlled trial — Goodwin et al. 82 (11): 1232 — Journal of Neurology, Neurosurgery & Psychiatry.

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Abstract

Objectives To compare the effectiveness of an exercise programme with usual care in people with Parkinson’s disease (PD) who have a history of falls.

Design Pragmatic randomised controlled trial.

Setting Recruitment was from three primary and four secondary care organisations, and PD support groups in South West England. The intervention was delivered in community settings.

Participants People with PD, with a history of two or more falls in the previous year, who were able to mobilise independently.

Intervention 10 week, physiotherapy led, group delivered strength and balance training programme with supplementary home exercises (intervention) or usual care (control).

Main outcome measure Number of falls during the (a) 10 week intervention period and (b) the 10 week follow-up period.

Results 130 people were recruited and randomised (64 to the intervention; 66 to usual care). Seven participants (5.4%) did not complete the study. The incidence rate ratio for falls was 0.68 (95% CI 0.43 to 1.07, p=0.10) during the intervention period and 0.74 (95% CI 0.41 to 1.33, p=0.31) during the follow-up period. Statistically significant between group differences were observed in Berg balance, Falls Efficacy Scale-International scores and recreational physical activity levels.

Conclusions The study did not demonstrate a statistically significant between group difference in falls although the difference could be considered clinically significant. However, a type 2 error cannot be ruled out. The findings from this trial add to the evidence base for physiotherapy and exercise in the management of people with PD.

Trial registration ISRCTN50793425.

Adaptive motion processing in bilateral vestibular failure

Source: Adaptive motion processing in bilateral vestibular failure — Kalla et al. 82 (11): 1212 — Journal of Neurology, Neurosurgery & Psychiatry.

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Abstract

Background Patients with bilateral vestibular failure (BVF) suffer from oscillopsia during head movements. This is secondary to the loss of the vestibulo-ocular reflex which is responsible for stabilising retinal images during head movements of high frequency or velocity. Previous studies documented decreased visual motion sensitivity in such patients at low velocities. The authors now examine motion coherence tasks, which have two advantages: (1) the task is associated with the functions of the middle temporal area; and (2) it affords testing at low and high motion velocities, as relevant for patients with oscillopsia due to BVF.

Methods Nine BVF patients and nine healthy control subjects were examined with a random dot pattern with variable percentages of dots moving in the target direction. Participants were asked to indicate in which of two possible directions they perceived the coherent motion. Horizontal and vertical planes were tested at speeds from 0.156 to 40°/s.

Results Motion coherence thresholds were lower at higher speeds in both groups (p<0.0001). BVF patients had raised motion coherence thresholds (p=0.002) across all velocities as compared with the control subject group.

Conclusion In a motion coherence paradigm, BVF patients show raised thresholds. This is the first demonstration of diminished visual motion processing at high velocities, supporting the view that the changes allow BVF patients to partly compensate for the oscillopsia. The findings are interpreted as an adaptive process likely to involve the middle temporal visual motion processing areas.

Effects of deep brain stimulation of dorsal versus ventral subthalamic nucleus regions on gait and balance in Parkinson’s disease

Effects of deep brain stimulation of dorsal versus ventral subthalamic nucleus regions on gait and balance in Parkinson’s disease — McNeely et al. 82 (11): 1250 — Journal of Neurology, Neurosurgery & Psychiatry.

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Abstract

Objective Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor function, including gait and stability, in people with Parkinson’s disease (PD) but differences in DBS contact locations within the STN may contribute to variability in the degree of improvement. Based on anatomical connectivity, dorsal STN may be preferentially involved in motor function and ventral STN in cognitive function.

Methods To determine whether dorsal DBS affects gait and balance more than ventral DBS, a double blind evaluation of 23 PD patients with bilateral STN DBS was conducted. Each participant underwent gait analysis and balance testing off Parkinson’s medication under three DBS conditions (unilateral DBS in the dorsal STN region, unilateral DBS in the ventral STN region and both stimulators off) on 1 day.

Results Improvements were seen in Unified Parkinson’s Disease Rating Scale (UPDRS)-III scores and velocity in walking trials as fast as possible (Fast gait) and preferred pace (Pref gait), as well as stride length for Fast and Pref gait, with dorsal and ventral stimulation compared with the off condition (post hoc tests, p<0.05). However, there were no differences with dorsal compared to ventral stimulation. Balance, assessed using the multi-item mini-Balance Evaluation Systems Test (mini-BESTest), was similar across conditions.

Conclusions Absence of differences in gait and balance between the dorsal and ventral conditions suggests motor connections involved in gait and balance may be more diffusely distributed in STN than previously thought, as opposed to neural connections involved in cognitive processes, such as response inhibition, which are more affected by ventral stimulation.

Long term outcome after subarachnoid haemorrhage of unknown aetiology

Source: Long term outcome after subarachnoid haemorrhage of unknown aetiology — Pyysalo et al. 82 (11): 1264 — Journal of Neurology, Neurosurgery & Psychiatry.

This article is available freely via Open Access. Please click on the above link to view it fully.

 

Abstract

Background and purpose The aim of this study was to assess the long term outcome after non-aneurysmal subarachnoid haemorrhage (SAH).

Methods 1154 patients with SAH were treated in our hospital between 1989 and 1999. From this patient population, 97 patients had a non-aneurysmal SAH. All hospital records and death certificates were studied and 33 patients were examined by MRI and MR angiography more than 9 years (mean 12 years) after the initial bleeding.

Results The cohort consisted of 97 patients. Mean follow-up time was 9 years (range 0–19). During the follow-up period, 13 patients (13%) died. Four (4%) died from the initial bleeding less than 5 weeks after the initial haemorrhage. There was no delayed mortality due to SAH or subsequent bleedings. MR angiography revealed no new findings in 33 surviving patients.

Conclusions Excess mortality during the first year after SAH was higher than 4%, and remained thereafter comparable with the general population. There were no rebleedings and MR imaging did not reveal any vascular pathology that could explain the earlier SAH.

 

Neuroanatomy of a neurobehavioral disturbance in the left anterior thalamic infarction

Source: Neuroanatomy of a neurobehavioral disturbance in the left anterior thalamic infarction — Nishio et al. 82 (11): 1195 — Journal of Neurology, Neurosurgery & Psychiatry.

This article is available freely via Open Access. Please click on the above link to view it fully.

Abstract

Background and purpose Cognitive and behavioural symptoms represent primary clinical manifestations of anterior thalamic infarcts (ATIs) in the tuberothalamic artery territory. The aim of the study is to understand the pathomechanism of cognitive and behavioural disturbances in left ATI (LATI).

Methods 6 patients with isolated LATIs were investigated using neuropsychological assessments, MRI stereotactic lesion localisation and positron emission tomography.

Results The patients were characterised clinically by verbal memory impairment, language disturbances dominated by anomia and word-finding difficulty and apathy. The ventral anterior nucleus (VA) proper, magnocellular VA (VAmc), ventral lateral anterior nucleus (VLa), ventral lateral posterior nucleus (VLp) and mammillothalamic tract were involved in all patients. Compared with healthy controls, the regional cerebral blood flow was lower in the thalamus, the dorsolateral, medial and orbital frontal lobes, the anterior temporal lobe, the inferior parietal lobule and the occipital lobe of the left hemisphere.

Conclusions The authors propose that the Papez circuit disruption at the mammillothalamic tract and possibly thalamomedial temporal disconnection at the VA region is responsible for memory impairment and that the thalamo-anterior temporal disconnection is associated with language disturbance in LATI, respectively.

 

 

MRI guides diagnostic approach for ischaemic stroke

MRI guides diagnostic approach for ischaemic stroke — Kumar et al. 82 (11): 1201 — Journal of Neurology, Neurosurgery & Psychiatry.

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Abstract

Background and aim Identification of ischaemic stroke subtype currently relies on clinical evaluation supported by various diagnostic studies. The authors sought to determine whether specific diffusion-weighted MRI (DWI) patterns could reliably guide the subsequent work-up for patients presenting with acute ischaemic stroke symptoms.

Methods 273 consecutive patients with acute ischaemic stroke symptoms were enrolled in this prospective, observational, single-centre NIH-sponsored study. Electrocardiogram, non-contrast head CT, brain MRI, head and neck magnetic resonance angiography (MRA) and transoesophageal echocardiography were performed in this prespecified order. Stroke neurologists determined TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification on admission and on discharge. Initial TOAST stroke subtypes were compared with the final TOAST subtype. If the final subtype differed from the initial assessment, the diagnostic test deemed the principal determinant of change was recorded. These principal determinants of change were compared between a CT-based and an MRI-based classification schema.

Results Among patients with a thromboembolic DWI pattern, transoesophageal echocardiography was the principal determinant of diagnostic change in 8.8% versus 0% for the small vessel group and 1.7% for the other group (p<0.01). Among patients with the combination of a thromboembolic pattern on MRI and a negative cervical MRA, transoesophageal echocardiography led to a change in diagnosis in 12.1%. There was no significant difference between groups using a CT-based scheme.

Conclusions DWI patterns appear to predict stroke aetiologies better than conventional methods. The study data suggest an MRI-based diagnostic algorithm that can potentially obviate the need for echocardiography in one-third of stroke patients and may limit the number of secondary extracranial vascular imaging studies to approximately 10%

Lansley’s ‘shining example’ forced to deny rationing claims | News | Health Service Journal

Source: Lansley’s ‘shining example’ forced to deny rationing claims | News | Health Service Journal.

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A social enterprise held up as a “shining example” by Andrew Lansley has been accused of “rationing” physiotherapy services through its use of the flagship any qualified provider policy

 

Whipps Cross Hospital staff asked to give up annual leave

An east London hospital has urged staff to “sacrifice” some of their annual leave or do unpaid work to save money.

via BBC News – Whipps Cross Hospital staff asked to give up annual leave.

CCGs call for more choice over commissioning support

Source: CCGs call for more choice over commissioning support | News | Health Service Journal.

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Clinical commissioners have called on ministers to allow them to access a greater variety of commissioning support, as soon as possible

 

Council chiefs rebel over public health funding sign-off

Source: Council chiefs rebel over public health funding sign-off | News | Health Service Journal.

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Council chief executives are understood to have staged a backlash over the Department of Health’s bid to get them to “sign off” local public-health spending figures

 

Heroin and crack cocaine users in treatment falls

The number of heroin and crack cocaine users needing treatment in England has fallen by 10,000 in two years

via BBC News – Heroin and crack cocaine users in treatment falls.

Assurances are sought that policy of personal health budgets will follow evidence

Source: Assurances are sought that policy of personal health budgets will follow evidence — White 343 — bmj.com.

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The Department of Health has denied that the government intends to press ahead with personal health budgets in England irrespective of what the final evaluation of the pilot sites—due in October 2012—concludes.

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Pain as a Global Public Health Priority

Abstract | Pain as a Global Public Health Priority.

This article is available freely via Open Access. Please click on the above link to view it fully.

 

Abstract (provisional)

 

Background

Pain is an enormous problem globally. Estimates suggest that 20% of adults suffer from pain globally and 10% are newly diagnosed with chronic pain each year. Nevertheless, the problem of pain has primarily been regarded as a medical problem, and has been little addressed by the field of public health.

Discussion

Despite the ubiquity of pain, whether acute, chronic or intermittent, public health scholars and practitioners have not addressed this issue as a public health problem. The importance of viewing pain through a public health lens allows one to understand pain as a multifaceted, interdisciplinary problem for which many of the causes are the social determinants of health. Addressing pain as a global public health issue will also aid in priority setting and formulating public health policy to address this problem, which, like most other chronic non-communicable diseases, is growing both in absolute numbers and in its inequitable distribution across the globe.

Summary

The prevalence, incidence, and vast social and health consequences of global pain requires that the public health community give due attention to this issue. Doing so will mean that health care providers and public health professionals will have a more comprehensive understanding of pain and the appropriate public health and social policy responses to this problem.

Strike ballot ‘extraordinarily difficult’ for managers, admits MiP

Source: Strike ballot ‘extraordinarily difficult’ for managers, admits MiP | News | Health Service Journal.

This article is solely the work of the HSJ. For a full copy of the article please contact the library.

Managers in Partnership has written to members explaining the “extraordinarily difficult” decision to ballot for strike action over pensions changes