16 Apr, 14 | by Steve Vucic, Web Editor
Amyotrophic lateral sclerosis/Lou Gehrigs’ disease is a devastating neuromuscular disorder of the motor neurons with a median survival of 3-5 years. While the pathophysiological mechanisms underlying ALS development remain uncertain, the possibility of being with a predisposition to develop ALS is a popular theory. Clearly, additional events are needed to develop ALS, although these factors remain elusive. In this issue of JNNP, Fratta and colleagues report on yet another genetic mutation (possibility polymorphism) that increases the risk of ALS development. namely, E117G mutations in the Profilin1 are more frequent in ALS and could predispose to ALS development. I suspect over the next decade the ALS physician will be able to test for a myriad of genetic mutations (predisposing to ALS), that will undoubtedly enable better counseling. The question remains, WILL THIS ADVANCE IN GENETIC MUTATIONS lead to better disease understanding and development of more effective therapies.
I hope so?
Read more at : http://jnnp.bmj.com.ezproxy2.library.usyd.edu.au/content/85/5/506.abstract
Lou Gehrig with Babe Ruth-just after diagnosis.
16 Apr, 14 | by Arun Krishnan, Web Editor
A common theme in JNNP blogs has been the major paradigm shift in neurological practice, with a change from diagnosis (without treatment) to another in which making a diagnosis was a prelude to providing effective treatment. There have been few disorders in which this has been more clearly visible than that of myasthenia gravis, an autoimmune disorder in which there are antibodies directed against the neuromuscular junction. Patients typically report significant muscle weakness, which may affect the eyes, limbs, respiration and muscles that control speech and swallowing. There is a beautiful diagram in Engel’s textbook on myasthenia which outlines the marked reductions in mortality from myasthenia have paralleled the major advances in critical care medicine, particularly in the provision of assisted ventilation (reproduced here in a review in Muscle and Nerve: http://onlinelibrary.wiley.com/enhanced/doi/10.1002/mus.20030). The diagram also notes that steroids and plasma exchange have been important treatment strategies in combating this illness.
However, one issue that not infrequently rears its head in management of these patients is how to advise and treat a patient with myasthenia who is pregnant. Managing patients with neurological disease who are pregnant is hard and can be quite anxiety-provoking, whether we are talking about epilepsy, multiple sclerosis or myasthenia. As neurologists, we may feel that we need to treat the mother first, but pregnant women are often very understandably concerned about the potential teratogenic effects of the treatments that we use. A lot of my own patients would rather go without treatment than run the risk of congenital anomalies. Of course, this has to be balanced against the risks to the foetus from the mother’s neurological diagnosis itself. Myasthenia at its worst causes respiratory failure, dangerous for the pregnant patient and for her foetus. As neurologists, what should we do?
In this month’s issue of JNNP, Norwood and colleagues have taken on the challenge of providing guidelines for the management of myasthenia and pregnancy http://jnnp.bmj.com/content/85/5/538.abstract . They have done a stellar job in providing guidelines that will assist neurologists around the world. This is an excellent paper, which should be read by all.
We would also be interested in hearing from neurologists around the world about their own experiences in this area. How do you treat these patients and what have you learnt from managing this condition?
14 Apr, 14 | by Steve Vucic, Web Editor
Amyotrophic lateral sclerosis (ALS) is a rapidly progressive and devastating neurodegenerative disorder of the human motor neurons and the systems that supply it. Advances in the genetics of ALS have been staggering over the last two decades, although are we much the wiser? The presence of a specific ALS genetic mutation may predispose a family member to develop ALS, although the age of onset, or indeed whether one will express the phenotype remains uncertain. factors other than inherited genetic mutations appear to trigger the process since a patient “carrier” live with the genetic mutation for 30, 40, 50 or even more years with a seemingly devastating genetic mutation.
As such, the management of ALS patients has become complicated. The question remains: “To test or not to test for a genetic mutation”. A myriad of ethical and other issues have been borne out with the explosion of the number of ALS genetic mutations.
In this issue of JNNP (may 2014), Chio and colleagues write a very important reviewed discussing these issues. This must read review for all ALS physicians (neurologists, geneticist etc) highlights the poor phenotype/genotype correlation, phenotype pleiotropy and the psychological, social and ethical implications of genetic testing.
READ MORE AT : http://jnnp.bmj.com/content/85/5/478.abstract
J Neurol Neurosurg Psychiatry 2014;85:478-485 doi:10.1136/jnnp-2013-305546
Genetic counselling in ALS: facts, uncertainties and clinical suggestions
- Adriano Chiò1,
- Stefania Battistini2,
- Andrea Calvo1,
- Claudia Caponnetto3,
- Francesca L Conforti4,
- Massimo Corbo5,
- Fabio Giannini2,
- Jessica Mandrioli6,
- Gabriele Mora7,
- Mario Sabatelli8,
- the ITALSGEN Consortium,
- Clara Ajmone5,
- Enza Mastro1,
- Debora Pain7,
- Paola Mandich3,
- Silvana Penco9,
- Gabriella Restagno10,
- Marcella Zollino11,
- Antonella Surbone12
14 Apr, 14 | by Arun Krishnan, Web Editor
Recently I was at a weekend lunch when I was quizzed by a recently retired general practitioner about what exactly I did on a day-to-day basis. I went through the usual spiel about research and teaching and the need to quarantine time for these pursuits, given the potentially large clinical load that one could end up taking on. I mentioned that I saw patients in areas of research interest, mainly neuromuscular disease and MS. After listening to this for about a minute, he turned to me and said, “so you are gradually getting to know more and more about less and less”. Bullseye.
On reflection though, that has to be the way of the future and this month’s cracking issue of JNNP http://jnnp.bmj.com/content/current only serves to highlight this point: SOD1, C9ORF72, TARDP, FUS, C12ORF65, ADCK3, Profilin1 E117G. What are these? They are not secret CIA codes, just names of genes that may play a role in both rare and relatively common neurological disorders. In this regard, Neurologists, it is time to starting becoming ‘neurogenetically literate’. With respect to this issue of the journal, I am talking about conditions such as amyotrophic lateral sclerosis, inherited neuropathy and cerebellar ataxia. Patients with these conditions may appear to all and sundry as suffering from rare diseases, but ultimately discussions of incidence and prevalence or of little value to these people….suffering is suffering, discomfort is discomfort and to deliver truly excellent subspecialist care for these patients, we are being called upon to rapidly integrate recent research findings, which seem to be accruing at lightning speed, with what we are seeing at the bedside. This speed of Bench to Bedside translation is not for the faint hearted!
The most fascinating aspect of this new genetics is that we are no longer talking about conditions which follow true Mendelian inheritance. These are not disorders that can be conveniently segregated into dominant and recessive inheritance-sometimes yes, but not always. We are now increasingly looking at the role of ‘genetic’ factors in ‘sporadic’ disease. While this may sound like an oxymoron, I use one of the papers in this issue as an example. Han and colleagues (1) http://jnnp.bmj.com/content/85/5/499.abstract have investigated the role of genetic mutations in the development of small fibre neuropathy, a condition which causes intense pain and burning in limbs. This is a common condition that causes significant morbidity and poor quality of life. Many patients with this condition are either of middle age or elderly and there is hardly ever any point in taking a genetic history or drawing a pedigree. In many patients, we never identify a cause for the small fibre dysfunction and simply label the condition as ‘idiopathic’, which is frustrating for everyone and most of all for the patient. In this paper, the authors have provided strong evidence that a mutation in a gene coding for a sodium channel may be the underlying cause in many of the cases which we (possible erroneously) label as idiopathic. Will these findings change the way that we manage these patients? Not at the moment it won’t, but very possibly in the future as we develop drugs that are capable of targeting certain type of sodium channels. In the meantime, as most neurologists would know, we may soon be able to alleviate some of the mental anguish that a patient feels when a doctor tells them that there is simply no known reason for why they developed a particular neurological disorder and that is progress in itself.
(1) Han et al., The G1662S NaV1.8 mutation in small fibre neuropathy: impaired inactivation underlying DRG neuron hyperexcitability. J Neurol Neurosurg Psychiatry2014;85:499-505 doi:10.1136/jnnp-2013-306095
10 Apr, 14 | by Steve Vucic, Web Editor
The detection of autoantibodies in autoimmune CNS disorders has been if immense interest, with implications for undelrying pathophysiology. A variety of autoantibodies have been detected and associated with various CNS syndromes, although the question remians whether these antibodies are pathogenic, an epiphenomenon, or both.
In this issue of JNNP, Hacohen and colleagues report on antibody biomakers in CNS demyelinating disorders of childhood. A variety of anibodies and syndromew were reported, with the bottom line being that specific antibodies are associated with specific syndromes. Consequently, the principles of good medical practice remians to define the phenotype and then look for the “genotype” or in thid case the antibody. In addition, the relevance of antibodies in the underlying pathophysiology needs further research.
Do you think it is worthwhile looking for these antibodies? let me know your thoughrs via twitter.
Read more at http://jnnp.bmj.com/content/85/4/456/T1.expansion.html
J Neurol Neurosurg Psychiatry 2014;85:456-461 doi:10.1136/jnnp-2013-306411
Autoantibody biomarkers in childhood-acquired demyelinating syndromes: results from a national surveillance cohort
- Yael Hacohen1,
- Michael Absoud2,3,
- Mark Woodhall1,
- Carole Cummins3,
- Christian G De Goede4,
- Cheryl Hemingway5,
- Philip E Jardine6,
- Rachel Kneen7,8,
- Michael G Pike9,
- William P Whitehouse10,
- Evangeline Wassmer11,
- Patrick Waters1,
- Angela Vincent1,
- Ming Lim1,2,
- On behalf of UK & Ireland Childhood CNS Inflammatory Demyelination Working Group
8 Apr, 14 | by Arun Krishnan, Web Editor
Over the last few decades, there have been unprecedented advances in our capacity to treat medical disorders. Neurological disease in particular has made significant strides. While a cure may still be beyond our reach in many conditions, we are able to reduce suffering and improve quality of life in a way that would have been unimaginable some decades ago.
In my own multiple sclerosis clinic, older patients lament the fact that they were diagnosed with this disabling illness at a time when there was little that could be offered in the way of treatment, aside from steroids. While the interferons proved to be a significant step forward, it is only recently that we have had the means to offer MS patients a wide variety of potential therapies, acting on different pathophysiological pathways.
This progress also means that it is highly possible for many patients to become very confused and overwhelmed by the possibilities that exist. As if thinking about the impact of the illness on one’s life is not enough in itself, suddenly they are forced to make decisions that require a lot of background knowledge. Doctors these days also stand back more than they used to. We provide information and we say “well here it is…let me know what you want to do”. Welcome to informed choice.
In this issue of JNNP, Kopke and colleagues make an important contribution that underscores the importance of education in empowering MS patients. They undertook a randomised study that explored the potential benefits of an evidence-based educational programme, compared with an MS-specific stress management programme. They demonstrated increased autonomy and a substantial increase in knowledge in the treatment arm compared to the control arm. In their conclusions, they highlight the fact that their study also provides some evidence that patients are more likely to opt for treatment, rather than less likely, once they have been educated regarding key aspects of the disease and the potential treatments. As Hippocrates said, “cure sometimes, treat often, comfort always”.
How do you educate patients regarding illness? Do you think the intervention administered by Kopke is workable in clinical practice?
(1) Kopke et al. Evidence-based patient information programme in early multiple sclerosis: a randomised controlled trial. 2014;85:411-418 doi:10.1136/jnnp-2013-306441
7 Apr, 14 | by Steve Vucic, Web Editor
The holy grail of MS therpay is to prevent the onset of the debilitating MS phase. All of the current therpaies are aimed at preventing such developments, and more importantly early treatment with immunomodulatory therapies was shown to be more efficacious at preventing disability development. The issue of whether multiple relapses or “attacks” govern diability development has been one of active research, and certainly all therapeutic trial assess the anualised relapse rates.
In the January issue of JNNP, Scalfari and colleagues assess the the factors that govern development of secondary progressive MS. Importantly, a higher annualised relpase rate (increased relapse frequency), older age at disease onset and male sex all predict diasbility development in MS. Clealry, the only modifiable factor is the relapse rate and consequently, early therpy does seem to make sense. It would be interesting tokow whether “non-clinical” biomakers, say peratining to lesion load or neurophysiological parameters could further stratify risk for progresison in MS.
Let me know your thoughts? Read more at http://jnnp.bmj.com/content/85/1/67.abstract
Onset of secondary progressive phase and long-term evolution of multiple sclerosis
- Antonio Scalfari1,
- Anneke Neuhaus2,
- Martin Daumer2,
- Paolo Antonio Muraro1,
- George Cornell Ebers3
3 Apr, 14 | by Steve Vucic, Web Editor
Acute neurological deficits, otherwise known as relapses, characterise relapsing-remitting forms of MS. A high annualised relapse rate is associated with disability development in the future, and current therapeutic endeavours are aimed at reducing such relapses. Clinically, relapses are typically represented by sensorimotor deficits, gait unsteadiness, optic neuritis etc. While cognitive decline and worsening fatigue may accompany relapses, these are not regarded as relapses.
In an upcoming issue of JNNP (read as “on-line” publication) Pardini and colleagues report on isolated cognitive relapses in MS, and link these with development of disability. Importantly, the traditional sensorimotor symptoms were absent. An isolated cognitive relapse was defined as
(1) a transient significant cognitive decline in objective neuropsychological performance, as measured by a battery of tests (see manuscript)
(2) without clinical or subjective evidence of other new neurological signs and symptoms
(3) associated with brain disease activity defined as a positive gadolinium enhancing scan (although this was a non-essential criteria).
Read more at http://jnnp.bmj.com/content/early/2014/03/31/jnnp-2013-307275.full
J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2013-307275
Isolated cognitive relapses in multiple sclerosis
- Matteo Pardini1,2,3,
- Antonio Uccelli1,
- Jordan Grafman4,
- Özgür Yaldizli3,5,
- Gianluigi Mancardi1,2,
- Luca Roccatagliata2,6,7
1 Apr, 14 | by Steve Vucic, Web Editor
Psychogenic motor disorders may be frequently encountered in “organic” neurology, especially in the world of movement disorders. This group of disorders needs to be distinguished from malingering as the patients really feel that they have a functional deficits even though neurology can not explain the site and origins of deficits. Indeed, transcranial magnetic stimulation studies have documented abnormalities of cortical function, suggesting a potential organic component to these vexing disorders.
In the February issue of JNNP, Alan Carsons’ group report an interesting systemic review on the prognosis of psychogenic, or functional, disorders. Not surprisingly, this field of neurology is in need of more and better controlled studies. The findings, however, are important underscoring the persistent physical burden on patients classified to be “functional”. As such, hiding such patients in closets, as fearful English neurology registrars of the 1930s and 1940s embarked upon to prevent the ire of their more senior colleagues, or galvanic stimulation, will simply not work. The authors are correct to highlight the need for more studies in order to develop better risk factor paradigms so as to enable more efficacious treatment.
READ THIS REVIEW at: http://jnnp.bmj.com/content/85/2/220.abstract
1 Apr, 14 | by Arun Krishnan, Web Editor
There are social perks to being a neurologist. Once you drop this little fact into a conversation, it is possible/probable that you will engender a feeling of intellectual inferiority amongst your companions. Mind you, there is nothing that says that because you are adept at diagnosing illnesses of the brain that you necessarily have a better brain or that you use a larger proportion of your brain than anyone else. Despite this, there are fairly widespread misconceptions that you are the veritable polymath and that you are as comfortable with written English as you are with conversational Latin. For a more visual description of how such a person would look, I’m thinking of Bradley Cooper’s character in Limitless, after ingestion of the GABA-inhibiting wonder-drug and before the inevitable slide into pharmacological tolerance and drug dependent behaviour (N.B only to be used as a general guide, and any hopes you may have regarding improving your chances with the opposite sex should be discarded immediately).
One of the major reasons behind this ‘only Einsteins need apply’ approach is that neurological disorders have remained largely inaccessible to investigation, until the relatively recent developments in neuroimaging. While MRI scans have been truly revolutionary in our ability to diagnose and treat, they are not a cure for neurophobia. In this issue of JNNP, Seneviratne and colleagues (1) examine one of those areas where an MRI scan will not help you, differentiating the appearance of epileptic seizures from psychogenic non-epileptic seizures. In their study, a video-based training approach was implemented in medical student education. The results were impressive, with students achieving a similar level of competency to emergency medicine trainees over a six month period. They conclude that this form of teaching is effective in teaching students about seizures and they recommend other potential indications for such technology, such as in educating students regarding the presentation of movement disorders.
So, neurologists out there…once you have finished translating the Aeneid into Ancient Greek, perhaps let us know the reactions you have received when you tell people how you make a living.
(1) Seneviratne et al. Video-based training improves the accuracy of seizure diagnosisJ Neurol Neurosurg Psychiatry. 2014;85:466-470