16 Feb, 15 | by Arun Krishnan, Web Editor
Around the world, spinal cord injury (SCI) is a common and devastating long-term complication of trauma that can result in lifelong disability or even death. There are frequent media reports of treatments that may help patients with SCI walk again and these range from new drugs, to robotic devices to new developments in stem cell research. Despite the hype, the fact remains that there are no treatments that have been proven to definitively alter outcomes in this condition.
One of the major problems with drug trials in SCI is finding a way to measure the response to the drug. Many drugs that are potentially useful may fail in clinical trials because we are not able to accurately determine which patients benefit the most. In other neurological conditions such as multiple sclerosis, the ability to use biomarkers such as MRI has revolutionised our diagnostic and treatment approach, leading to significant gains for patients.
In the current issue of JNNP, Kuhle and colleagues http://jnnp.bmj.com/content/86/3/273.abstract have published a paper which demonstrates that measuring levels of neurofilaments, structural proteins that are present in neurons, may be useful in determining the degree of spinal cord injury. The exciting fact about this paper is that neurofilament levels correlated closely with acute severity of SCI and with the eventual neurological outcomes. The other benefit with this assay was that levels were measured in the blood of patients with SCI, rather than in the cerebrospinal fluid. This makes the assay for more acceptable in the clinical setting. The authors also provide some evidence that neurofilament levels may be responsive to drug treatments and in this case, they have assessed how levels vary according to treatment with minocycline, a medication that has been previously trialled in SCI.
This is a well-designed study. It represents an important step forward in diagnostic methods and treatments for SCI.
4 Feb, 15 | by Arun Krishnan, Web Editor
It has been around 200 years since James Parkinson first outlined the clinical features of the condition that would later bear his name. While his descriptions of Parkinson’s Disease (‘shaking palsy’) may have focussed largely around the motor manifestations of this condition, recent insights have provided strong evidence that non-motor manifestations contribute significantly to poor quality of life for patients with this neurodegenerative condition (for an excellent review see the reference below by Jankovic).
Depression, cognitive impairment, sexual dysfunction and constipation are just some of the problems that these patients can develop and it is a source of immense frustration for both patients and clinicians that these problems are so hard to treat. Our current approaches to treating Parkinson’s disease are focussed on medications that really only improve motor outcomes, so what is a neurologist to do when a patient describes the effects of non-motor manifestations on his/her quality of life?
In this issue of JNNP, Wang and colleagues provide a thorough overview of the role of cholinesterase inhibitors as treatments for cognitive impairment in Parkinson’s Disease http://jnnp.bmj.com/content/86/2/135.abstract . These are drugs that have been used in the setting of Alzheimer’s Disease for a number of years. In addition to suggesting that these medications have benefits in Parkinson’s Disease as well as an excellent safety profile, the paper also highlight the fact that the treatments have only been assessed in small clinical trials and that larger studies in this population may be required before they can become an established part of treatment for this condition. Nevertheless, their study provides hope for a major problem which currently remains untreatable.
(1) Jankovic J. Parkinson’s disease: clinical features and diagnosis. J Neurol Neurosurg Psychiatry 2008;79:368-376 doi:10.1136/jnnp.2007.131045
21 Jan, 15 | by Arun Krishnan, Web Editor
There have been numerous postulated links between the development of cancer following exposure to infectious organisms. In the case of the connection between human papilloma virus and cervical cancer, this association has led to ground-breaking treatments in the form of vaccination. A similar connection has been developed between hepatitis B and liver cancer. While many forms of malignancy carry a poor prognosis, malignant brain tumours are often cited as a particularly aggressive form of cancer and this is borne out in survival rates which are dismal.
A question that has been raised in many previous scientific reports is the putative association between cytomegalovirus infection and the development of glioma, a form of malignant brain tumour. There have been previous studies that have suggested a strong link while others have cast doubt on any association. A recent letter in the New England Journal of Medicine has elicited much controversy regarding the possible benefits of anti-viral drugs for CMV being used as treatments for the most aggressive of brain tumours, glioblastoma. Clearly, this is a contentious area and at some point we need to take an objective unbiased view of the data. To that end, in the current issue of JNNP Dey and colleagues have provided an insightful review of the area and have addressed the arguments for and against a role of CMV in glioma development http://jnnp.bmj.com/content/86/2/191.abstract (2). They have addressed the criteria of Koch’s postulates for causation in developing their argument and have taken a close look at the key studies in this area.
This is a timely and interesting review of a very controversial topic.
- N Engl J Med 2013; 369:985-986September 5, 2013DOI: 10.1056/NEJMc1302145
- J Neurol Neurosurg Psychiatry 2015;86:191-199 doi:10.1136/jnnp-2014-307727
7 Jan, 15 | by Arun Krishnan, Web Editor
Happy New Year to all JNNP readers!
In order to ensure that we start 2015 with an optimistic outlook, I thought that the first post of this year should concern a clinical trial with a positive outcome! Epilepsy is a common and very debilitating condition which leads to significant impairments in quality of life. While a lot of patients with epilepsy can be successfully treated with medication, there remains a significant minority in whom seizures remain resistant to anticonvulsant drugs. There is little consensus on how these patients should be managed. Surgical treatment may be useful if a seizure focus is identified, but in other patients in whom the seizure origin remains elusive, treatment can be problematic.
There has been a vast literature that has focused on the role of dietary strategies in patients with drug resistant epilepsy and most of these studies have focussed on use of the ‘ketogenic diet’. The use of fish oil has also been considered, particularly given studies in animal models that have demonstrated a possible benefit at low doses.
In this issue of JNNP, DeGiorgio and colleagues undertook a randomised placebo-controlled diet of fish oil in 24 patients with drug resistant epilepsy http://jnnp.bmj.com/content/86/1/65.abstract . Their study demonstrated a possible benefit of fish oil at low doses, but no significant benefit at higher doses. This is consistent with studies in animal models which have shown anticonvulsant effects at low doses and proconvulsant effects at higher doses.
As most neurologists would know, drug resistant epilepsy ruins quality of life for sufferers. The present study is encouraging and may provide the impetus for larger randomised studies.
12 Dec, 14 | by Steve Vucic, Web Editor
Corticla tarophy has been proposed as an imprtant pathophysiological mechanisms in disability development in progressive forms of multiple sclerosis. A number of studies utilsing sophistcated MRI tehcniques have yielded such evidence. In this issue of JNNP and elegant study demonstrated the importance of neurodegeneration at a pathological level, “reflected by a global reduction of neuronal density, the presence of acutely injured axons, and the accumulation of oxidised phospholipids and DNA in neurons, oligodendrocytes and axons“. As such preventing degenration is the key, although the real question must be how can we revearse the process. Will antioxidants, antiexcitotoxic agents work??
Read more at http://jnnp.bmj.com/content/85/12/1386.abstract
12 Dec, 14 | by Steve Vucic, Web Editor
It gives me great pleasure to announce that Matthew Kiernan was awarded the highly prestigious Forbes Norris Award by the International ALS Alliance.
The Forbes Norris Award, first presented in 1994, honours the memory of Dr. Forbes “Ted” Norris (1928 – 1993), a neurologist who dedicated his career to helping people with ALS/MND. The purpose of this prestigious Award is to encourage a combination of two major qualities: management of and advances in understanding ALS/MND, to the benefit of people living with the disease. Some previous recipients have included Professor Nigel Leigh, Stanley Appel, Andrew Eisen, Pamela Shaw and more recently Leonard van den Berg to name a few, all very important names in the filed of ALS.
Once again well done Matthew for a wonderful achievement.
28 Nov, 14 | by Arun Krishnan, Web Editor
There are a number of risk factors that we commonly associate with stroke, including hypertension, smoking history, and diabetes. The current issue of JNNP explores the role of stress resilience in the aetiology of stroke http://jnnp.bmj.com/content/85/12/1331.abstract . The authors have assessed a large Swedish male population and have provided interesting insights into the role of stress in the development of stroke. They have demonstrated that low stress resilience during adolescence was associated with a subsequent higher stroke risk. They also note that the association was independent of socio-economic status and general physical health. The results are particularly interesting given the emerging associations between early life stress and the development of metabolic conditions, such as diabetes.
The authors suggest that their study highlights the importance of measures for stroke prevention incorporating ways of reducing psychosocial stress.
20 Nov, 14 | by Steve Vucic, Web Editor
The issue of whether excessive work may lead to increased weakness in hereditary neuropathy is a vexing one and critical for patient management. in this issue of JNNP this notion has been categorcially dismissed. There was no worsening weakness with overwork in a large CMT1A cohort.
Read more: http://jnnp.bmj.com/content/85/12/1354.abstract
Neurol Neurosurg Psychiatry 2014;85:1354-1358 doi:10.1136/jnnp-2014-307598
Is overwork weakness relevant in Charcot–Marie–Tooth disease?
- G Piscosquito1,
- M M Reilly2,
- A Schenone3,
- G M Fabrizi4,
- T Cavallaro4,
- L Santoro5,
- G Vita6,
- A Quattrone7,
- L Padua8,
- F Gemignani9,
- F Visioli10,11,
- M Laurà2,
- D Calabrese1,
- R A C Hughes2,
- D Radice12,
- A Solari1,
- D Pareyson1
- for the CMT-TRIAAL & CMT-TRAUK Group
+ Author Affiliations
18 Nov, 14 | by Arun Krishnan, Web Editor
In the last decade or so, we have seen numerous major advances in our understanding of multiple sclerosis (MS). While the condition was traditionally viewed as a disease of the brain white matter, this hypothesis has been turned on its head with the discovery that grey matter involvement occurs in MS. Furthermore, we now know that this can happen quite early in the disease course and that it may underlie physical disability. A lot of MS patients report cognitive changes that occur even in the earliest stages of the disease and it is very possible that these changes may be due to the loss of grey matter.
In the current issue of JNNP, Haider and colleagues present a very interesting study that demonstrates that involvement of the deep grey matter may play an important role in the development of disability in MS http://jnnp.bmj.com/content/85/12/1386.abstract . In addition, they also show that these changes were associated with accumulation of iron in the brain. This is a very important finding as iron has been postulated to play a role in the development of brain oxidative injury.
This is a very interesting study which provides important insights into our understanding of the pathology of MS.
4 Nov, 14 | by Steve Vucic, Web Editor
ALS is a rapidly progressive neurodegenerative disorder of the motor neurons with median survival of 3-5 years. The site of disease onset, and the timing of disease onset remain controversial, although
a sudden and catastrophic degeneration of the motor neurons does occur. In this issue of JNNP a though provoking review by Eisen and colleagues suggests a long term pre clinicla period, perhaps stretching beck to the in utero period. In an
accompanying letter, neuronal dysfunction (preceding degeneration) was reported in a zebra fish model. Interestingly, this dysfunction was slowed down by riluzole. The question remains as to whether we are too late by the time the patients present. But then, who should be treated/monitored. The genetic cases, or all relatives of sporadic cases. Clearly there are more answers than questions, although headway has been made, and more research is needed.