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PubMed1993

Can neurologists survive or thrive with health care reform?

The economics of present-day health care and the politics of recent elections will forever change the practice of neurology. Managed care, outcomes research, limits on price and volume of services, diagnostic and treatment restraint, divestiture of ownership in health facilities, malpractice reform, increased use of preventive services, and administrative simplifications will all be part of the new practice of medicine, and hence neurology. The challenge for neurologists will be to define cost-effective neurological services, put greater emphasis on the most prevalent and costly diseases of the nervous system, and convince primary care providers and patients of their value. Health care reform is an opportunity and challenge for neurologists to improve patient access while achieving acceptable financing mechanisms.

Delivery of Health Care↗

PubMed1994

Reliability among neurologists in the severity assessment of blepharospasm and oromandibular dystonia: a multicenter study.

The reliability of a scale of 0 to 4 (where 0 is normal) in rating the severity of blepharospasm (BS) and oromandibular dystonia (OMD) was evaluated by the concordance among six neurologists from different neurological institutions. As expressed by k index, interobserver agreement was moderate either for BS or for OMD according to the Landis classification. Neurologists showed different rating attitude toward BS and OMD. In fact, the category analysis showed that raters were inclined to overestimate BS and to underestimate OMD. The familiarity with dystonia influenced reliability more than the length of professional experience in neurology. In fact, when examiners were subdivided into subgroups (each of three raters) according to the former criteria, the level of interobserver agreement increased significantly. Almost perfect agreement was obtained in intrarater comparisons. These results may be of value with regard to the conduct of multicenter epidemiologic and clinical studies on focal dystonias.

Adult↗

PubMed2000

Psychosis of Epilepsy: A Neurologist's Perspective.

Psychosis of epilepsy (POE) comprises a group of disorders that are closely associated with epileptic seizures. These include interictal POE, postictal psychosis, and alternative psychosis (also known as "forced normalization"). Neurologists have, in general, played a limited role in the evaluation and management of patients with POE. Yet, as reviewed in this paper, a good understanding of electrophysiologic, neuroradiologic, and neuropathologic variables associated with POE can yield valuable data in the evaluation of the seizure disorder of these patients. The purpose of this review article is to highlight the clinical, neuroradiologic, neurophysiologic, and neuropathologic aspects of POE that can assist in the evaluation and management of the associated seizure disorder and to identify the circumstances in which a timely therapeutic intervention by neurologists can avert or minimize the occurrence of a psychotic episode. Specifically, the clinical characteristics of interictal POE and ictal, postictal, and alternative psychotic episodes are highlighted together with their potential pathogenic mechanisms and the associated treatment issues. Finally, discussions of psychotic disorders following epilepsy surgery and the pharmacotherapy of psychotic disorders in patients with epilepsy are presented.

Journal Article↗

PubMed1992

Italian neurologists and euthanasia: a poll.

We have tried to sound out Italian neurologists regarding their attitude to euthanasia, a very controversial issue today. We gave a short multiple-choice questionnaire to neurologists attending a national conference, asking their opinion on some issues related to euthanasia. 75 (25%) of the 300 doctors polled completed the questionnaire. Answers were often contradictory. A trend in favor of passive euthanasia among the respondents and a strong demand for guidelines are evident. Emotional rather than professional or rational factors seem to play a major role in the approach to this dilemma.

Attitude of Health Personnel↗

PubMed2004

[Doctor reports of a neurological clinic in the view of permanent resident neurologists and nerve doctors].

Eight discharge reports involving five diagnoses (anterior territory ischemic stroke, epilepsy, Parkinson's syndrome, multiple sclerosis, polyneuropathy) from five neurological departments were peer-reviewed by five neurologists working in out-patient (private) practice. The review considered the diagnosis, case history, clinical status, laboratory investigation, differential diagnosis and treatment. Criticism mainly involved the quality of the clinical assessment, lack of clinical status at discharge, narrow or incomplete differential diagnosis and the quality of the neurophysiological investigations for epilepsy and polyneuropathy. Improvement potential was seen for the speed of reporting, better comprehensibility, omission of irrelevant information, greater participation of experienced neurologists in report writing, and standardization.

Ambulatory Care Facilities↗

PubMedDate not supplied

The neurological legacy of psychoanalysis: Freud as a neurologist.

The discipline of psychoanalysis was significantly influenced by Freud's experience in neuroanatomy and clinical neurology. Sigmund Freud began his medical career as a neuroanatomist and neurologist before he later established the theories and techniques of psychoanalysis. Freud made several significant contributions to research in neuroanatomy and clinical neurology that were overshadowed by his later accomplishments. As the "Father of Psychoanalysis," Freud was, and his legacy always will be, that of a neurologist.

Austria↗

PubMed2006

Neurologists and the threat of bioterrorism.

Neurologists are most likely to become involved in primarily diagnosing those bioterrorist attacks utilising botulinum toxin. Oral ingestion, or possibly inhalation, are likely routes of delivery. The characteristic descending paralysis starts in the extraocular and bulbar muscles, with associated autonomic features. Repetitive nerve stimulation usually shows an incremental muscle response. Treatment is supportive. The differential diagnosis is from naturally occurring paralysing illnesses such as Guillain-Barré syndrome, myasthenic crisis or diphtheria, from paralysing seafood neurotoxins (tetrodotoxin, saxitoxin), snake envenomation, and from chemical warfare poisoning by organophosphates. Primary neurological infections are less feasible for use as bioweapons. There are theoretical possibilities of Venezuelan equine encephalitis transmission by inhalation and secondary zoonotic transmission cycles sustained by horses and mosquitoes. Severe haemorrhagic meningitis regularly occurs in anthrax, usually in the aftermath of severe systemic disease likely to have been transmitted by spore inhalation. Panic and psychologically determined 'me-too' symptomatology are likely to pose the biggest diagnostic and management burden on neurologists handling bioterrorist attack on an institution or a random civilian population. Indeed civilian panic and disablement of institutional operations are likely to be prominent intentions of any bioterrorist attack.

Animals↗

PubMed2005

Should neurologists be trained to recognize and treat comorbid depression of neurologic disorders? Yes.

Depression is a relatively common psychiatric comorbidity of most neurological disorders, with prevalence rates ranging between 20 and 50% among patients with stroke, multiple sclerosis, epilepsy, Parkinson's disease and dementia. Furthermore, depression is an independent predictor of poor quality of life in these patients and has a negative impact on the response to treatment, course and recovery of neurological deficits. Thus, treatment of depression has become an integral part of the management of these neurologic disorders. This article discusses the rationale for neurologists to be trained in recognizing depressive disorders in neurologic patients and identifies the type of mood disorders in which neurologists can provide pharmacotherapy and those that need to be referred to the care of the psychiatrist.

Animals↗

PubMedDate not supplied

Predictive and prenatal diagnosis of Huntington's disease: attitudes of Mexican neurologists, psychiatrists, and psychologists.

BACKGROUND: Huntington's disease (HD) is a hereditary disease of the central nervous system. Its molecular diagnosis has allowed predictive and prenatal diagnosis to be done, and it is now a model for the study of the ethical, legal, and social problems arising from the diagnosis of such diseases. METHODS: This study explores the knowledge and attitudes of a group of Mexican specialists regarding the disease and its diagnosis. A self-administered, 30-item multiple-choice questionnaire was completed anonymously by neurologists, psychiatrists, and psychologists. RESULTS: Fifty-five percent of the professionals had experience with HD patients, 59% claimed to know the hereditary risks, and 20% answered incorrectly concerning the risks. Neurologists had the most exposure to HD; 74% acknowledged the existence of predictive diagnosis, although only 10% knew the international guidelines for testing. Eighty-six percent of the participants recommended predictive diagnosis, the reasons being: 55%, if the patients considered having offspring; 41%, for the patient's professional reasons; 6%, if a treatment was available, and 12% did not answer. In cases in which the patient wanted to have offspring, 38% thought that this should be avoided. Thirty-six percent of the subjects considered prenatal diagnosis justified in a couple with a carrier, and 51% justified abortion for affected fetuses. CONCLUSIONS: Genetic counseling and predictive diagnosis in Mexico must be the responsibility of genetics units and specialists who are aware of inheritance risks and of guidelines for HD programs. The number of patients requiring such attention is increasing rapidly.

Adult↗

PubMed2001

Relapse prevention in schizophrenia: attitudes of neurologists-psychiatrists.

The overall high relapse rates observed in schizophrenia are attributed to several causes. One important factor influencing satisfactory prevention of relapse is the lack of consistent treatment strategies among medical doctors, especially neurologists-psychiatrists. Nearly one-third of the members of the Hellenic Society of Neurology and Psychiatry were asked to fill in anonymously a structured questionnaire on their treatment attitudes and prescribing tactics regarding schizophrenic patients both after the first schizophrenic episode and after multiple episodes. The majority of Greek neurologists-psychiatrists seem to adopt prescribing habits that approximate the current international standards for prevention of schizophrenic relapse. Their attitudes regarding the treatment and prevention of relapse for the first schizophrenic episode and first relapse are determined from multiple factors. These are: the expected relapse rates after the first episode, the expected prevalence of extrapyramidal side effects following a long-term neuroleptic treatment, the patient's expected treatment compliance after the first episode, the doctor's experience with treating schizophrenics, and lastly the knowledge of current literature on the topic. These results point to the need for continuing education, especially of the younger mental health professionals and those working in the private sector, addressing the issue of the actual risk of developing side effects from the treatment. In due course, benefits could result for everyday psychiatric practice and the patients' compliance with treatment.

Adult↗

PubMed2001

Extended thymectomy in myasthenia gravis: a team-work of neurologist, thoracic surgeon and anaesthesist may improve the outcome.

OBJECTIVE: We reviewed our overall experience on 163 patients, affected by myasthenia gravis, who underwent thymectomy between 1976 and 1998. A comparison between the oldest series of 72 patients (January 1976-December 1992), referred by various neurologists and operated on through different approaches, and the last 91 patients (January 1993-December 1998), taking part in a strict diagnostic-therapeutical programme, was made. METHODS: Anagraphic data, duration of symptoms, the surgical approach, necessity of respiratory assistance, the hospital stay, histopathological findings, preoperative and postoperative Osserman classification, as well as medications, were globally analyzed and then compared in the two groups. RESULTS: Significant differences in the length of hospitalization (8.7 days vs. 4.2 days; P=0.00001) and in the prolonged intubation rate (18 vs. 0; P<0.000001) were observed in the most recent series. Patients in the pre-operative Osserman stage I and operated on in the second period had a higher complete remission rate at the univariate analysis (P<0.001 and P<0.0001, respectively). At the multivariate analysis the only parameter which affected the outcome was to be operated on in the second period (P<0.01). CONCLUSIONS: Our experience confirms the role of the extended thymectomy in the treatment of myasthenia gravis. Whenever an extended thymectomy was performed through a complete sternotomy it was a quick procedure, with short hospitalization and acceptable cosmetic results. A careful pharmacological control of the myasthenic symptoms and the presence of team-work among neurologist, thoracic surgeon and anaesthesist in the peri-operative setting reduce the incidence of complications and might increase the efficacy of the thymectomy.

Adolescent↗

PubMed2002

Epilepsy--giving the diagnosis. A survey of British paediatric neurologists.

Adult-centred studies continue to show poor information provision and understanding in people with epilepsy. This study explores whether paediatric neurologists work within a consultation framework designed to meet information needs. A questionnaire on how to give the diagnosis was sent to 32 UK Paediatric Neurologists. Consultation content was largely determined intuitively rather than on a shared knowledge of the process involved. Little consensus was identified in relation to analogy and the usefulness or awareness of available unevaluated literature; but most acknowledged the value of a specialist epilepsy nurse. Most responses were based on a typical medical agenda but less than 20% addressed emotional responses and adaptation. Three approaches were identified-'pro-active' (running the risk of overload but recognising the right of parents to information), 'reactive' (more individually tailored, but assumes doctors can judge parental reactions) and 'drip-feed' (protective and pre-selecting topics to meet the situation). Our aim to establish a guideline proved impossible. Further study should develop more detailed models of the disclosure process, and identify epilepsy explanations that can be consumer-tested.

Adult↗

PubMed1997

Multicentre clinical evaluation of vigabatrin (Sabril) in mild to moderate partial epilepsies. French Neurologists Sabril Study Group.

Vigabatrin (VGB) has been shown through several studies to be safe and effective as add-on therapy, particularly for the treatment of partial seizures in patients with severe epilepsies followed for years in hospital-based clinics. We now report additional clinical experience with VGB arising from an open trial of add-on VGB therapy in patients with relatively few seizures followed by qualified neurologists in private practice (the French Neurologists Sabril Study Group). VGB was administered to 397 patients aged 12-74 years (mean age = 37.5 +/- 13.8 years) who presented with no more than seven partial seizures of any type per month during a 3-month baseline period (mean number of seizures = 3.7 +/- 1.9/month). Simple partial seizures were reported in 121 (30.5%) patients, complex partial seizures in 282 (71.0%) and seizures with secondary generalization were reported in 111 (28.0%). The mean number of associated antiepileptic drugs (AEDs) was 1.9 +/- 0.9 and the mean dose of VGB was 2.21 +/- 0.64 g/day. Following introduction of VGB, 53 (13.4%) became seizure-free and remained so during the whole trial. During the fourth month of treatment, 158 patients (39.8%) had no seizures at all and a further 69 (17.4%) had their seizure frequency reduced by more than 50%. Secondary generalization was controlled during the whole period of treatment in 55 out of 97 patients (56.7%), 17 of which remained free of all types of partial seizures. VGB showed a good tolerability profile; adverse experiences more frequently reported were drowsiness and sleep disturbances. No action was necessary in the great majority of cases; the dose was reduced in 26 (6.5%) and VGB was discontinued in 32 (8%) patients. These data provide additional evidence that VGB can be used safely early on to treat patients with mild to moderate partial epilepsies. Secondary generalization was controlled in the majority of patients. Factors associated with the everyday clinical use of VGB, that resulted from a series of organized meetings with the investigators, are discussed.

Adolescent↗

PubMed1999

The role of the pediatric neurologist in the management of children with congenital heart defects: a commentary.

Central nervous system integrity is the major extracardiac determinant of the quality of life for children with congenital heart disease. As the specialist in the evaluation of the pediatric nervous system, the child neurologist has particular skills and expertise to offer the interdisciplinary team responsible for the management of this clinical entity. This article highlights the ways in which the child neurologist can make a difference in congenital heart disease.

Child↗

PubMed2002

A neurologist in Zambia.

Those uninitiated to medicine in the tropics may consider neurology and neurologists superfluous in this environment. In actual fact, the high burden of neurologic disorders combined with a dearth of physician-level care providers brings such expertise into high demand. Clinical work in sub-Saharan Africa offers the neurologist an opportunity to care for a wide range of conditions, including disorders Westerners may only be familiar with via historical accounts. Physicians starved of academic exchange and paramedical-care providers who frequently function without physician-level support are equally enthusiastic for additional training in the diagnosis and treatment of the nervous system disorders which are encountered daily.

Female↗

PubMed1993

The use of antiepileptic drug levels in children: a survey of Canadian pediatric neurologists.

There are 60 pediatric neurologists in Canada. Replies were received from 56 in response to a survey regarding the use and perceived value of antiepileptic drug (AED) levels. AED levels are frequently ordered and influence clinical care. There were, however, discrepancies among pediatric neurologists regarding the upper and lower limits of the "therapeutic ranges" and the clinical application of levels. We suggest that both the value and use of AED levels needs further study.

Adolescent↗

PubMed1981

Features of migraine--comparison of a questionnaire study and a neurologist-examined random sample.

In a community survey on headache in which a questionnaire was used, the responders were asked to state if their headaches were accompanied by symptoms usually associated with migraine. A random sample of 200 out of the 3,067 who returned the questionnaire were examined by a neurologist and the answers compared with those given in connection with the case history. Migraine features occurred sometimes in a very large percentage of the 2,018 who suffered form headache. When the answers were compared, "warning" and "nausea" occurring sometimes were reported significantly more often in the questionnaire. No difference was found when these features were reported as occurring usually or always. When interviewed by the neurologist, 20% of those with a clinical diagnosis of tension headache reported two of the three features "unilaterality", "warning" and "nausea", also. It is concluded that the questionnaire is a satisfactory tool if the aim is to select a population with distinct features of migraine, but the reliability rapidly decreases if efforts are made to include more elusive forms of the condition.

Adolescent↗

PubMed2001

Lluis Barraquer-Roviralta (1855-1928): Spanish neurologist described progressive lipodystrophy.

Lluis Barraquer-Roviralta, a Spanish neurologist, described the syndrome of progressive lipodystrophy in 1907. This syndrome was subsequently known as Barraquer's syndrome. The main feature of Barraquer's syndrome is the progressive atrophy of the subcutaneous fat of the face. Plastic surgeons are familiar with Barraquer's name because they often correct the facial deformity associated with Barraquer's syndrome. Although plastic surgeons recognize Barraquer for his description of progressive lipodystrophy, his main contributions were to the field of neurology. Barraquer, who is considered the founder of the specialty of neurology in Spain, contributed to the start of neurosurgery in Spain, as well. Barraquer was an expert in diseases of the peripheral nervous system and developed medicines to treat tabes dorsalis. His drawings and photographs of the nervous system were unparalleled. His iconographic collection helped to define the anatomy and pathology of numerous neurological diseases. His pictures were featured in the main neurology textbook of the time and are presently housed in the Museum of Medical History in Spain. During his career at the University of Barcelona Barraquer was well known for his lecturing ability and for training the first neurologists in Spain. In addition to describing progressive lipodystrophy, Barraquer also was the first to describe the grasp reflex of the foot, now known as Barraquer's reflex. Of his remarkable accomplishments, Barraquer is best remembered for his description of two phenomena that now bear his name, Barraquer's reflex and Barraquer's syndrome. Although Lluis Barraquer-Roviralta's main contributions were to the field of neurology, his description of progressive lipodystrophy in 1907 will forever endear him to future generations of plastic surgeons.

History, 19th Century↗