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PubMed1997

Medical conditions & driving: legal requirements & approach of neurologists.

Licensing of drivers with health problems, particularly epilepsy, has medical, social and legal implications that vary from country to country. Legislation and medical guidelines are based as much on empirical as on statistical data. A questionnaire regarding neurological disorders and driving was given to all adult neurologists in Canada (n = 494) and an assessment made of opinions of neurologists working under mandatory reporting legislation compared to those in a discretionary reporting environment. Of 289 (59%) neurologists responding, 50% reported patients with seizures to the Department of Motor Vehicles compared to only 4% for stroke/TIA, 26% for dementia and 8% for other neurological disorders (p < .0001). In the five provinces with mandatory reporting laws, seizures were reported most of the time by 84% compared to only 19% in the five provinces with discretionary reporting laws (p < .0001). An overall minority agreed with mandatory reporting (44%) but this percentage differed in the provinces with and without mandatory reporting legislation (63% vs. 37%, p < .0001). Seizure disorders are selectively reported more often than other neurological conditions. There is considerable variability in the attitude and practice of neurologists in regard to reporting of medical conditions.

Adult↗

PubMed2004

Multiple sclerosis gender issues: clinical practices of women neurologists.

Substantially more women than men develop multiple sclerosis (MS), but information about the effects of MS and gender-specific issues such as pregnancy, breastfeeding, menstruation and hormone use is lacking. A survey study of neurologists' practice patterns was undertaken to elicit information about gender-specific topics and the use of disease-modifying MS therapies (DMT) including the interferons and glatiramer acetate (GA). A total of 147 surveys were returned. Half of respondents require patients to discontinue DMT during pregnancy, while 35% encourage discontinuation. Among those who allow patients to continue therapy, half consider GA to be safer during pregnancy than the interferons. Nearly 86% of respondents do not use DMT in patients who are breastfeeding. Among the 11% who actually prescribe during breastfeeding, most recommend GA. Neurologists generally leave the decision to breastfeed up to patients, and most refer patients to obstetrician/gynaecologists for counselling about contraception or hormone replacement therapy. The survey results described here provide insight into how neurologists manage reproductive health issues among women with MS.

Breast Feeding↗

PubMed2000

Neurologist or psychiatrist? The public and private domains of Jean-Martin Charcot.

The emergence of neurology as an autonomous, prestigious field in late-nineteenth-century Paris is well known. Less appreciated is the role that neurologists played vis-à-vis the cognate older field of psychiatry. Taking Jean-Martin Charcot, the most influential neurologist of his time, as a test case, this paper contrasts his attitudes and practice in the public setting of teaching and hospital work with his private practice. A staunch defender of a clear distinction between his field and psychiatry, Charcot's private practice displayed more flexibility. Treating hysteria and neurasthenia created a middle ground of nervous diseases for him to cultivate. Unpublished case histories and other materials, especially from the Charcot library, support the conception of neurologists as active agents in constituting a new psychological medicine.

Famous Persons↗

PubMed2002

Abulia: a delphi survey of British neurologists and psychiatrists.

Abulia is the relatively uncommon yet debilitating lack of spontaneous, goal-directed behaviour that is seen predominantly with lesions of the basal ganglia and the frontal lobes. We sought to confirm the existence of abulia as an entity recognized by clinicians, to generate a set of items characteristic of the condition, and to see how clinicians differentiate between overlapping disorders. The Delphi technique was used to survey consultant neurologists and psychiatrists at three hospitals in London. The study consisted of two phases: semi- structured interviews of a small group of neurologists and psychiatrists, followed by a survey of a larger group of consultants using postal questionnaires. Both neurologists and psychiatrists recognized abulia to be a distinct clinical entity but its status as a syndrome was unclear. Features such as difficulty in initiating and sustaining spontaneous movements and reduction in emotional responsiveness, spontaneous speech, and social interaction were identified as being characteristic of abulia. The information generated by this study may help to develop a working classification for disorders of diminished drive and motivation, and instruments for clinical assessment and decision making.

Basal Ganglia↗

PubMed2003

Role of dopamine transporter SPECT for the practitioner and the general neurologist.

The accurate clinical diagnosis of parkinsonism may be impeded by atypical presentations and confounding comorbidity. The presence of parkinsonism is misdiagnosed in up to a quarter of cases in general practice. Movement disorder specialists misdiagnose parkinsonian syndromes using histopathological findings as the "gold standard" in up to 10% of cases. Dopamine transporter SPECT represents a simple and fast method to confirm nigrostriatal degeneration in a given patient. This study provides several case reports to illustrate when dopamine transporter SPECT might be carried out and discusses whether dopamine transporter SPECT should be used in primary health care practice or by general neurologists in uncertain cases. Ideally, all possible cases of parkinsonism should be referred to a neurologist experienced in the field of movement disorders. If this could be achieved then the role of dopamine transporter SPECT in the general practitioner's or local neurologist's practice would be extremely limited. Future studies must clarify whether it is cost effective to generously perform dopamine transporter SPECTs to minimize the time until parkinsonism can be diagnosed.

Adult↗

PubMed1982

Computer consultation in neurology: subjective and objective evaluations of the "NEUROLOGIST" system.

NEUROLOGIST is a computer system for clinical consultation in neurology. The system's strategy is patterned after the 'localize first' paradigm of the expert neurologist. The system gives explanations of its conclusions, including drawings of neurologic lesions. It currently covers 130 diagnoses and is readily expandable. In this paper the NEUROLOGIST system is described and results of objective and subjective evaluations are presented and discussed. Directions for improvement and expansion of the present system are outlined.

Computers↗

PubMed1992

Reflexes and neurologists.

Neurologists are particularly concerned with elicitation of reflexes, interpret them as indicative of levels of the nervous system and its development or dissolution. This article reviews selected aspects of reflex action. No longer simply reflexology, clinical neurology will still make new observations about reflexes and, more relevant, clinical neurologists will enjoy the process. The breadth of interests of George Bruyn is a permanent reminder to future neurologists of what complexities can be constructed on basic observations such as have been done on "our" reflexes.

Brain↗

PubMed1996

Supervised integrated screening of low-back pain patients by a neurologist. A randomized clinical trial.

In a randomized, controlled design, the effect of psychiatric consultation intervention in medical outpatients with low-back pain (N = 104) was assessed for the patients' subjective well-being and satisfaction of general practitioners (GPs) in their cooperation with the neurologists. The goal of the intervention was an integrated approach towards the patients' symptoms and the improvement of the cooperation between primary and secondary medical health services. The intervention was designed at the health care provider level; the psychiatrist did not see or examine the patient. The 104 patients were subdivided into an intervention group (N = 50) and a control group (N = 54). The major outcome measures were the psychological status of the patient and degree of the GPs' satisfaction concerning the cooperation with the medical specialists. After 6 months follow-up, there was a greater overall decline of symptoms in the patient intervention group compared with the control group. However, it was not possible to specify this effect. Contrary to the hypotheses, GPs in the control group were as satisfied about the cooperation with the neurologist as their colleagues in the intervention group. Yet, the information in the specialists' letters of the intervention group was more often in agreement with the integrated model carried out. It is concluded that great diversity of the target group of patients and the focus on the neurologists' behavior may explain the lack of hypothesized effects. It is recommended that the target group be more specifically defined, and that a more intensive intervention might prove to be more effective.

Adolescent↗

PubMed2001

The pediatric neurologist as expert witness with particular reference to perinatal asphyxia.

The frequency of litigation related to alleged medical malpractice is increasing in Canada. For the neurologist, involvement in such litigation most often takes place in the context of acting as an expert witness and, for the pediatric neurologist, the most common clinical situation for which expertise is requested is that of possible perinatal asphyxia. The medical expert's primary role is to provide necessary guidance and assistance to the court, which may permit the rendering of decisions that are scientifically valid. This article will review the attributes of the medical expert witness. Aspects of perinatal asphyxia cases under litigation that commonly require the assistance of pediatric neurology expertise such as etiology, timing, extent of disability and life expectancy will also be reviewed in detail. The aim is to provide for the neurologist a clearer understanding of the responsibilities inherent in this increasing professional role.

Asphyxia Neonatorum↗

PubMed2002

Epilepsy in The Alienist and Neurologist, 1880-1920.

PURPOSE: To study the history of epilepsy from 1880 to 1920. METHODS: We reviewed all 40 volumes of The Alienist and Neurologist and identified articles concerning primarily epilepsy. We analyzed three of these articles in greater detail. RESULTS: The Alienist and Neurologist published "Original Contributions,""Selections," (abstracts from other journals written by the editorial board), "Editorials," and (book) "Reviews." Of 258 epilepsy articles, there were 40 Original Contributions, 164 Selections, 39 Editorials, and 15 Reviews. These articles included 71 on therapy (41 medication, 13 surgery, and 17 other therapies); 66 general discussions; 46 on etiology or symptoms; 34 case studies; 28 social/legal articles; and 13 autopsy or pathology articles. CONCLUSIONS: Analysis of The Alienist and Neurologist provides a unique and valuable perspective on the clinical practice and academic world of epileptology during the decades around the turn of the twentieth century.

Epilepsy↗

PubMed2003

Comparison of clinical gait analysis strategies by French neurologists, physiatrists and physiotherapists.

Clinical and functional gait analysis is used widely by different professionals dealing with patients with hemiplegia. The aim of this study was to examine the gait analysis strategies of neurologists, specialists in physical and rehabilitation medicine (physiatrists) and physiotherapists. Differences in global analysis strategy and choice of indicators between different clinicians have not previously been studied precisely, and we believe that a standardized approach would enhance the training of young practitioners. The knowledge acquisition phase (specialists' expertise identification) was completed by an identified expert with a subject groups of 5 neurologists, 5 specialists in physical and rehabilitation medicine and 5 physiotherapists, who were asked to comment on a videotape of patients with hemiplegia walking, followed by a semi-directed interview. The results show that specialists use a wide variety of gait indicators. The total number of different medical vocabulary and expressions used to describe gait was 396, semantically grouped as 60 general indicators. Specialists highlighted an analysis strategy (order, type and number of indicators) typical to each professional specialty. The neurologists tried to identify the elements allowing localization of lesions and characterized the hemiplegia globally,while the specialists in physical and rehabilitation medicine conducted a bio-mechanical analysis and the physiotherapists were highly descriptive. The differences in strategies adopted by each specialty contribute to an enrichment of gait analysis. This should be taken into account in teaching and determining gait assessment scales.

Adult↗

PubMed2005

The neurologist and patient safety.

BACKGROUND: The objective of this article is to acquaint neurologists with the current status of evidence and opinion on patient safety in neurology. Research data on errors and preventable adverse events (harm from medical management) in neurology are sparse, with little light being cast thus far on the vulnerabilities of individual neurologists and neurologic office practices. However, areas of particular concern and lines of appropriate action are now becoming apparent. REVIEW SUMMARY: This review draws on the few studies of neurologic malpractice claims, inpatient incident reports and chart reviews, and articles and abstracts in the journal literature. These are placed in the context of the general epidemiology of medical errors, adverse events, and approaches to remediation. CONCLUSION: Accurate and timely diagnosis in all its aspects represents the single largest category of error. Most neurologists have their first interaction with a patient and family at the time of a critical illness, underlining the importance of improved communication, not only with them but with other caregivers. Systems of information transfer, such as those enabling timely imaging reports, are critical. Better consultative follow-up may be pivotal. Education in patient safety competencies and closer supervision of trainees can be expected to improve protection. Venues, such as emergency departments, in which relevant knowledge and skills may be insufficient to maximize patient safety, deserve particular attention.

Adult↗

PubMed2006

Severity of cerebral white matter lesions and infarcts in patients with transient or moderately disabling cerebral ischaemia: reproducibility of grading by neurologists.

Diffuse or multifocal ischaemic white matter lesions increase the risk of intracranial haemorrhage in patients using oral anticoagulants for secondary prevention after cerebral ischaemia of arterial origin. We studied whether neurologists could reliably assess the presence of these white matter abnormalities. As part of the European/Australian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT), the severity of white matter lesions and presence of ischaemic lesions were twice assessed in a consensus meeting of three neurologists (from a pool of nine) as absent, moderate or severe, in a sample of 126 randomly selected CT or MRI scans. The neurologists were not aware of the duplicate grading. The degree of agreement between the first and second observation was calculated with kappa statistics. The kappa value for agreement between the first and second assessment of white matter lesions was 0.58 (95% CI 0.40-0.76). The kappa value for the presence of clinically relevant and/or irrelevant ischaemic lesions was 0.68 (95% CI 0.58-0.78). Clinicians can assess the presence of white matter lesions with sufficient reliability. Such assessment may prevent unnecessary risk with oral anticoagulation in secondary prevention after cerebral ischaemia of arterial origin, of which the efficacy is currently being assessed in ESPRIT.

Brain Infarction↗

PubMed2006

Is uncertain diagnosis a more frequent reason for referring migraine patients to neurologist than other headache syndromes?

The objective was to assess whether the physician's uncertainty of diagnosis was a more frequent motivation for referring migraine patients than other headache patients to a neurologist. In this population based survey we included 846 consecutive patients referred to and examined at a specialist centre for headache during a period of 2 years. As primary outcome we compared cross-sectionally frequency of referring patients with migraine and other headaches to neurologist. According to the patients, uncertainty of diagnosis was the main reason for referral to a neurological specialist consultation, i.e. in 51% of cases. Thirty-nine per cent of patients classified as having migraine were referred because of an uncertain diagnosis, compared with 62% in patient with other headaches (95 CI 0.13-0.33), (P < 0.0001). Headache subtypes other than migraine and younger age were associated to more uncertainty of diagnosis. We conclude that diagnostic uncertainty was an important factor amongst half the headache patients seen by neurologists and uncertain diagnoses as reason for referral was more important amongst patients with non-migrainous headache.

Diagnosis, Differential↗

PubMed1993

Neurologists' perspective in the evaluation of ischemic stroke.

The evaluation of victims of ischemic stroke has evolved over the last few years, primarily as a result of the introduction of innovative, sensitive, and informative diagnostic procedures. The role of the neurologist appears to have been redefined as one in which the identification of the presumptive cause and mechanism of the stroke is one of the primary responsibilities. The trend towards classification of patients into stroke subtypes, based upon etiology and pathogenesis, has led to a shift in care to a more etiology-specific approach. The inclusion of results of ancillary tests in the criteria utilized for stroke subtype classification has expanded the neurologists' ability to ascertain the presumptive etiology of many strokes that in the past were considered of unknown etiology. This has also resulted in an apparent increase in the proportion of ischemic strokes presumably due to cardiogenic embolism. The impact of transesophageal echocardiography upon changes in the presumptive etiology of ischemic stroke is illustrated, underscoring the future collaboration of neurologists and cardiologists in the evaluation of victims of presumed cardiogenic ischemic stroke.

Cerebrovascular Disorders↗

PubMed1999

What do neurologists think about their role in neuroimaging training and practice?

In 1996, a survey of the members of the American Academy of Neurology revealed the following facts and opinions: (1) On an average month, each respondent ordered 15 computed tomography, 22 magnetic resonance imaging, 13 ultrasound and 1 single-photon emission computerized tomography studies. (2) Most respondents did not read their own studies for reimbursement, but relied on their own reading for patient management. (3) Respondents felt that neurologists are appropriate specialists to read imaging studies; however, they favored certification for neurologists credentialed in neuroimaging. (4) Organized neurology should provide certification in neuroimaging for neurologists with appropriate training and defend their right and their need to practice neuroimaging, including endovascular procedures.

Diagnostic Imaging↗

PubMed1984

Psychiatric illness in inpatients with neurological disorders: patients' views on discussion of emotional problems with neurologists.

The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient's physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients.

Affective Symptoms↗

PubMed2004

Patients whom neurologists find difficult to help.

BACKGROUND: All doctors recognise that some patients are more "difficult to help" than others, but the issue has received little systematic investigation in neurological practice. OBJECTIVE: To test the hypothesis that patients whose symptoms were less explained by organic disease would be perceived as more difficult to help. METHODS: In a consecutive series of 300 new neurology outpatients, neurologists indicated on four point Likert-type scales how "difficult to help" they found the patient and to what extent the patient's symptoms were explained by organic disease. The patients' demographics, health status, number of somatic symptoms, and mental state were also assessed. RESULTS: The neurologists rated 143 patients (48%) as "not at all difficult" to help, 111 (37%) as "somewhat difficult", 27 (9%) as "very difficult", and 18 (6%) as "extremely difficult". A logistic regression model was constructed and the hypothesis that patients whose symptoms were less explained by organic disease would be perceived as more difficult to help was supported. The only other measured variable that contributed to perceived difficulty was physical disability, but it explained only a small amount of the variance. CONCLUSIONS: Neurologists find patients whose symptoms are not explained by organic disease more difficult to help than their other patients.

Adolescent↗