bluuebunny/crossref_metadata_2025 huggingface dataset:
Late-onset epilepsy predicts future stroke: a systematic review and meta-analysis
Authors: Wall Jasmine , Knight Jo , Emsley Hedley
Published: May 2022

Late-onset epilepsy (LOE) is closely associated with cerebrovascular disease. LOE also appears to be a harbinger of dementia. We performed a systematic review of observational studies, clinical studies and radiological studies relating to LOE. We conducted a meta-analysis of 5 observational studies and have found that patients presenting with LOE experience an increased risk of subsequent stroke, weighted OR 3.88 (95% CI 2.76 - 5.46). Above the age of fifty, incidence of new onset epilepsy is approximately 400/100,000 person years. Of these, 9.8–11.9% will have a stroke in the decade following epilepsy onset, translating to an incidence of «pre-stroke epilepsy» of 25–55/100,000 person years. The additional studies demonstrated clinical and radiological evidence to support the premise that LOE is likely to reflect underly- ing cerebrovascular disease. Cerebrovascular risk factors convey increased risk of LOE, and LOE can act as a «harbinger» for stroke and dementia, with various proposed pathophysiological mechanisms. The onset of LOE may represent a potential point for intervention, with the aim of stroke prevention. Current data supports the need for prospective research in order to better understand the natural history of LOE, disease mechanisms and opportunities for intervention to reduce the apparent sequelae of stroke and dementia.

jasminewall@googlemail.com
116  Management of acute neurological conditions: an e-learning course to support clinical pathways
Authors: Wu Kit , Farag Mena , Tamborska Arina , Mahmood Amira , Theochari Evangelia , Larcombe Karen , Ellis Cathy
Published: May 2022

Introduction andAim

Acute neurological problems are prevalent, accounting for 10–20% of medical admissions, but management is often challenging and require input from different teams (A&E, acute medicine, neurology). There is no standardised training for staff in the management of acute neurological conditions and existing clinical pathways for these conditions are often underutilised with variable impact on patient outcome. The use of e-learning has gained popularity in the last decade, showing that it can be as effective as conventional didacticism [Warnecke et al, 2011]. Here, we detail the development of an e-learning course on management of acute neurological conditions to support use of integrated clinical pathways and to facilitate self-directed learning.

Method andResults

Using principles of People, Analysis, Content and Technology (PACT), we defined target learners, their learning needs, challenges in assimilating knowledge and the resources required. Topics were derived from three themes: acute neurological emergencies, commonly seen conditions, and ‘lessons from serious incidents’. Each module lasts 10 minutes and is embedded with a pre- and post-course knowledge quiz. In collaboration with the Neurosciences Institute Programme at King’s Health Partners, an academic Health Science Centre, the course will be hosted and supported by the KHP e-learning platform.

This e-learning course supports the use of clinical pathways and facilitates clinicians in consoli- dating knowledge. It is flexible, highly transferable, and can be integrated into work-based learning for continuous professional development.

kitwu@doctors.org.uk
121  The Queen Square tests of auditory cognition: defining hearing deficits and dis- ability in dementia
Authors: Johnson Jeremy , Benhamou Elia , Sivasathiaseelan Harri , Requena-Komuro Mai-Carmen , Nelson Annabel , Rohrer Jonathan , Bamiou Doris-Eva , Hardy Chris , Warren Jason
Published: May 2022

Background

Hearing impairment has emerged as a potent association of cognitive decline in dementia and a promising treatment target. To realise this promise, we need to resolve fundamental questions concerning the roles of peripheral versus central auditory deficits in different dementias.

Methods

Using a novel psychoacoustic battery – the Queen Square Tests of Auditory Cognition (QSTAC)

– we combined pre-existing and novel measures of peripheral and central hearing functions, to charac- terise discrete ‘auditory phenotypes’ across dementia syndromes. Customised auditory symptom ques- tionnaires (completed by patients’ caregivers) were used to capture daily-life hearing-related disability and care burden. Patient groups: Alzheimer’s disease, frontotemporal dementia, primary progressive aphasia (PPA) and control. Neuroanatomical associations of specific hearing deficits were assessed using voxel-based morphometry.

Results

Syndromic signatures of peripheral and central auditory dysfunction were identified. Alzheimer’s disease was associated with prominent impairments of auditory scene analysis and dichotic listening. PPA syndromes and behavioural variant FTD (BvFTD) were principally associated with deficits of sound pattern analysis, sound identity, emotion recognition and degraded speech perception, which stratified according to sub-syndrome (logopoenic, semantic, nonfluent).

Conclusions

Taken together, our findings suggest that major dementias have characteristic and differenti- ated auditory phenotypes, reflecting a complex interplay of peripheral hearing and auditory cognitive dysfunction.

jeremy.johnson@doctors.org.uk
How prolonged is a prolonged disorder of consciousness? Longterm follow-up of 71 consecutive admissions
Authors: Allanson Judith , Holland Tony , Pickard John , Kamau Evelyn , Bareham Corinne , Roberts Neil , Stamatakis Emmanuel , Menon David , Hutchinson Peter , Barclay Stephen
Published: May 2022

There is little Uk data on outcome after Prolonged Disorders of Consciousness(PDOC) and yet, in the light of recent case law and professional guidelines, this is essential for reliable prognostication and thus for best interests discussions about provision of clinically assisted nutrition and hydration.

This study reports the very longterm outcome of 69/71 consecutive admissions to a UK fMRI study of PDOC after brain injury. (mean age 47y; 52 male; initially seen at mean 20 m post injury; 47 traumatic brain injury, 18 hypoxia).

Status of those alive at follow up (mean 8y7m post injury) was determined after direct examination or use of the Coma-recovery-scale-revised telephone version, with clinicians and families.

Mortality data revealed 33/71 (47%) had died naturally at mean of 55m post injury; mean age 49y; this included 27/50 of those initially in Vegetative or Minimally Conscious minus; 21/47 with TBI.

Of note 13/69 (19%) who had not emerged at first assessment had recovered to emergence or higher level at followup. 11 were fully active; eg snow-boarding. One regained speech 5 years after injury. 11 were living in domestic settings; 9 with care packages. Only 2/11 with evidence of covert awareness on initial fMRI had emerged.

Although these data are from a very selected cohort this data reveals recovery from PDOC can occur very late after injury in those confirmed to be in PDOC after detailed clinical assessment.

judith.allanson.1@gmail.com
127  Hypocupraemia-induced anaemia, sensory ataxia and cognitive impairment secondary to zinc-containing dental adhesive
Authors: Dihmis Omar , Jamal Rayyan , Carroll Liam Stuart , Pengas George
Published: May 2022

A previously fit and well 67 year old male presented with a 5-month history of gradually worsening memory impairment and sensory gait ataxia on the background of recent symptomatic anaemia. He experienced multiple falls and became agitated and socially withdrawn over a 3-week period, resulting in hospital admission. On examination, he had sensory gait ataxia consistent with a dorsal column syndrome. He had a Montreal Cognitive Assessment score of 13. Serum analysis showed normocytic anaemia and leukopenia, severe hypocupraemia, reduced caeruloplasmin and normal zinc levels. Overuse of zinc- containing denture cream was identified as being a cause of excess zinc ingestion and resultant copper deficiency, leading to blood dyscrasia and myelopathy. The cream was withdrawn and IV copper followed by oral supplementation was implemented. Direct questions with regards to excess zinc in the diet and serological testing of copper and zinc should be considered in any patient with a dorsal column syndrome, particularly with concurrent anaemia. Copper deficiency may also have a role in exacerbat- ing pre-existing cognitive impairment.

rnj1e16@soton.ac.uk
136  New valproate guidelines and adherence to the pregnancy prevention programme: experience in a tertiary clinic
Authors: Prabhakaran Asmithaa , Coyle Helen , Mohanraj Rajiv
Published: May 2022

Objectives: To establish the proportion of women of childbearing age on Sodium Valproate (VPA) for epilepsy who met the requirements of the Pregnancy Prevention Programme (PPP) in accordance with the Medicines and Healthcare products Regulatory Agency (MHRA) guidelines, with a view to identifying rates of compliance and the reasons for non-adherence.

Methods

128 female participants of childbearing age currently on VPA, who had completed an annual risk assessment from Greater Manchester, were included in the study. Patient data was gathered review of Electronic Patient Records.

Results

The majority of women (n=86, 67%) did not meet the conditions of the PPP: 59 (69%) were on no contraception, and 27 (31%) were on inadequate contraception such as OCP, Depo injection, and condoms. Non adherence to PPP was due to 11 different reasons, the most common (n=27) being learning disability, followed by, no intention of becoming pregnant (n=7), not sexually active (n=13), and patient choice (n=9)

Conclusions

PPP does not appear to be relevant to the majority of women of child bearing age pre- scribed VPA. Further patient education about rates of unplanned pregnancies and risks of VPA might help improve adherence to PPP.

asmithaa.prabhakaran@student.manchester.ac.uk
142  Ictal asystole case series
Authors: Khalil Mohamed , Shukrallah Arif , Delanty Norman , Elnaggar Hany
Published: May 2022

Ictal arrhythmias are disturbances of cardiac conduction that occur during clinical or electrographic seizures. Ictal asystole is rare and its incidence can range from 0.3–0.4 % in patients with epilepsy.

We reported eleven patients (Seven males and four females) with an age range (31–70 years old) who were monitored in our telemetry unit over the last eight years. Patients were selected based on the history of documented ictal asystole or bradycardia during inpatient VEEG monitoring). In our series the mean latency was 22 seconds and the mean duration of the ictal asystole was 15.8 seconds. During the asystolic phase the seizures may clinically continue or syncopal signs may take over.

We found two patterns in ictal semiology in our series. The first group of patients included three patients who experienced a rapid onset of ictal asystole in their seizure and the second group where the latency of ictal asystole was relatively late. Both groups of patients have temporal lobe epilepsy.

In our case series all the patients had either left or right temporal lobe epilepsy, six of which were lesional. Ten of our cohort had permanent pace maker following the diagnosis, Six of which had been event free since.

dm.neuro@hotmail.com
147  Long-term cenobamate retention in people with focal onset seizures: pooled data from open-label studies
Authors: Sander Josemir W , Alvarez-Baron Elena , Finlan Lee , Toledo Manuel
Published: May 2022

Purpose

Most people with epilepsy receive chronic, long-term treatment with ≥1 anti-seizure medication. Retention rates provide can act as a proxy measure for clinical efficacy/safety over time. We present long-term exposure and retention data from open-label extensions (OLEs) of 3 trials in adults with uncon- trolled focal onset seizures (FOS) receiving adjunctive cenobamate.

Methods

Of the three trials, two were OLEs of randomized, placebo-controlled trials (C013 & C017). The third, was a large safety OLE study (C021). Retention rates of cenobamate were estimated using Kaplan- Meier survival analysis.

Results

1945 patients were exposed to cenobamate during clinical development, of whom 1844 (95%) took part in OLEs. Exposure for the combined double-blind (DB) studies OLEs (C013OLE, C017OLE) was 4.5 years (55 (0.3–94) months (N=504)), and for the C021 (N=1340) 1.9 years (23 (0.03–35 months)). As of

July 2019, retention rates at month 94, 69 and 36 were 57%, 59%, and 72% for the three trials (C013OLE, C017OLE, C021). After 1 year, retention rates were 71% (C013OLE), 80%(C017OLE) and 80%(C021) and 65%, 70%, 72% at the end of year 2. The most common reason for discontinuation was withdrawal of consent (19.5%; C013OLE), lack of efficacy (16.6%; C017OLE), and adverse events (12.4%; C021).

Conclusions

Cenobamate showed high retention rates through an exposure time up to over 7 years (94 months). These results compare favorably with that of other anti-seizure medications.

lee.finlan@arvelletx.com
149  Mesial temporal lobe epilepsy with amygdala enlargement: a phenotype of autoimmune epilepsy?
Authors: Glasse Hannah , Hotchkies Angus , Bailey Matt , Mohanraj Rajiv , Cahill Varduhi , Cooper Paul
Published: May 2022

Background

Mesial temporal lobe epilepsy with amygdala enlargement (MTLE-AE) is a relatively newly described subtype of focal epilepsy. The aetiology of MTLE-AE remains unclear. We investigated the prevalence of antibodies to neuronal antigens in a cohort of adult patients with MTLE-AE

Methods

Patients with MTLE-AE presenting to a tertiary epilepsy clinic were identified. Demographic and characteristic data were collected by review of records. The antibody prevalence in epilepsy (APE2) score was calculated for all patients.

Results

25 cases of TLE-AE who had undergone antibody testing were identified. 5 cases had positive antibodies (2 VGKC+LGI-1, 1 VGKC alone, 2 GAD). Mean age of epilepsy onset was 46.2 and 35.4 years for antibody positive and negative groups respectively. The antibody positive group had a higher mean APE2 score (6) than the negative group (3.8), partially due to a higher incidence of neuropsychiatric features and prodromal illness. All VGKC positive patients achieved seizure freedom with immunotherapy.

Discussion

MTLE-AE may be related to autoimmune processes in a proportion of cases. This potentially treatable cause may be missed in patients with epilepsy, if antibody testing is not undertaken.

hannah.glasse@doctors.org.uk
153  Perampanel in patients with a history of psychiatric illness: a post hoc analysis
Authors: Malhotra Manoj , Patten Anna , Kanner Andres M
Published: May 2022

Background

Psychiatric safety data from perampanel randomised controlled trials (RCTs; Studies 304/305/306/335) and open-label extensions (OLEx; Studies 307/335 OLEx) in patients with focal epilepsy with/without psychiatric history were analysed.

Methods

Treatment-emergent adverse events (TEAEs) were analysed for patients with/without psychi- atric history.

Results

In RCTs, 352/2187 (16.1%) patients had psychiatric history; psychiatric TEAEs occurred in 73/244 (29.9%) and 21/108 (19.4%) patients with perampanel and placebo, respectively. Psychiatric TEAEs with perampanel 2 and 4 mg/day were 11.1% and 15.4%, respectively, vs placebo (19.4%). In patients without psychiatric history, psychiatric TEAEs were observed in 157/1325 (11.8%) and 47/510 (9.2%) patients with perampanel and placebo, respectively. Psychiatric TEAEs were more frequent in patients with psychiatric history for all combined doses and placebo (both P<0.01). Most common psychiatric TEAEs with peram- panel: anxiety (5.3%)/insomnia and aggression (both 2.0%) with/without psychiatric history.

In OLEx, 283/1895 (14.9%) patients had psychiatric history. Psychiatric TEAEs occurred in 151 (53.4%)/521 (32.3%) patients with/without psychiatric history (P<0.01); most common psychiatric TEAE: irritability (16.3%/10.4%, with/without psychiatric history).

Conclusion

Psychiatric TEAEs were reported by more patients with psychiatric history and were dependent on perampanel dose irrespective of previous psychiatric illness; 2 mg/day and 4 mg/day doses did not increase psychiatric TEAEs.

Funding

Eisai Inc.

manoj_malhotra@eisai.com
157  Efficacy of adjunctive cenobamate: post-hoc analysis in patients grouped by concomitant anti-epileptic drug type
Authors: Brandt Christian , Serratosa Jose , Sanchez-Alvarez Juan , Alvarez-Baron Elena , Finlan Lee , Milanov Ivan , Steinhoff Bernhard J
Published: May 2022

Purpose

There has been little success with polytherapy for patients with drug-resistant epilepsy. The need for optimizing AED combinations is high. Cenobamate is a novel AED with a unique, dual, complementary mechanism of action (MoA) combining GABA-A positive allosteric modulation (via a binding site different from benzodiazepines) together with broad spectrum sodium channel blockage. Here we assessed the efficacy of cenobamate when combined with AEDs grouped by MoA.

Methods

A post-hoc exploratory analysis of the study C017, in adult epilepsy patients with uncontrolled focal onset seizures who had ≥4 seizures/month despite treatment with stable doses of 1–3 AEDs.

Results

In the maintenance phase, 183/397 (46%) patients were receiving at least one GABA modulator (felbamate, valproate, topiramate, tiagabine, vigabatrin) and 329/397 (82%) a sodium channel blockers (carbamazepine, oxcarbazepine, lamotrigine, lacosamide, eslicarbazepine). Added onto GABA modu- lators, cenobamate 100/200/400mg achieved seizure freedom rates (SFR) of 7.3%/15.6%/30.6% vs 2.1% for placebo; when added onto sodium channel blockers, cenobamate 100/200/400mg/day showed SFR of 2.3%/9.3%/17.5% vs 1.2% for placebo. Both results were statistically significant for 200 and 400mg. A consistent SFR with cenobamate for a subset of patients receiving background levetiracetam (11% 200mg and 25% 400 mg vs 2.5% placebo) as well as those with background benzodiazepines (20% 400 mg vs 0% placebo) occurred.

Conclusions

Adjunctive cenobamate achieved significant dose-dependent SFR when combined with AEDs across multiple MoAs in patients with uncontrolled FOS.

lee.finlan@arvelletx.com
159  Lessons learned initiating a RCT using an approved drug in a new setting (SPRING Study)
Authors: Grant Robert , Lessels Sarah , Jenkinson Michael , Watts Colin , Marson Anthony , Erridge Sara , Bulbeck Helen , Chisholm Eve Macdonald
Published: May 2022

Background

Trials of approved medications for new indications are becoming increasingly common (repurposing). SPRING – Seizure Prophylaxis IN Glioma is a trial of prophylactic Levetiracetam in adults without prior history of seizure versus no AED. Significant delays were encountered in the set up phase.

Issues

Legal contracts between Sponsor and NIHR/UCB (£1.76m) were prolonged.UCB (Belgium) would only transfer drug when ethics had been granted and BREXIT loomed. Company to package levetiracetam required national procurement exercise.

Conflicting IRAS advice (Ireland, Scotland, England). Inclusion criteria included patients must have capacity. As patients could lose capacity during study this required Adults with Incapacity REC (Essex), secondary review in Scotland and screening for capacity at each visit. MHRA – mandated monitoring for suicidal ideation at each visit, and detail on contraception during study. HRA – suggested changes to the Patient Information Leaflet and a Schedule of Events Cost Attribution Template – requiring multiple substantial amendments.

Neurosurgical centres may feed several oncological departments - site contracts are complex. Electronic eCRF takes time to build and test.

Conclusions

Consider planning for longer set up phase in grant submissions. Views expressed are those of the author(s) and not necessarily those of the NHS, NIHR or DOHSC.

robin.grant@luht.scot.nhs.uk
Pathological emotionalism following limbic encephalitis: the neural foundations of a novel disorder
Authors: Butler Christopher , Argyropoulos Georgios , Moore Lauren , Loane Clare , Roca-Fernandez Adriana , Lage-Martinez Carmen , Gurau Oana , Irani Sarosh , Zeman Adam
Published: May 2022

Objective

We investigated pathological emotionalism in a large cohort of patients that had presented with autoimmune limbic encephalitis(a-LE).

Methods

38 patients in the post-acute phase of a-LE completed questionnaires probing emotion regula- tion. They all underwent structural/functional MRI post-acutely, along with age- and sex-matched healthy controls. We investigated correlations of questionnaire scores with demographic, clinical, neuropsycho- logical and brain MRI data across patients. We also compared patients with pathological emotionalism and those without, along with healthy controls, on grey matter volume, resting-state functional connec- tivity and activity.

Results

Pathological emotionalism was reported by 50% of the patients. It was not associated with depres- sion, impulsiveness, or memory impairment. However, it correlated with abnormalities in specific emotional brain networks: volume reduction in the anterior hippocampus, fusiform gyrus and cerebellum, abnormal hippocampal resting-state functional connectivity with the posteromedial cortex and middle frontal gyrus, and abnormal hemodynamic activity in the fusiform gyrus, inferior parietal lobule, and ventral pons.

Conclusions

Pathological emotionalism is common following a-LE, is not a manifestation of other neu- ropsychiatric disorders, and reflects abnormalities in networks of emotion regulation including, but not limited to the acute hippocampal focus. This condition provides novel insights into the neural basis of emotion regulation and its dysfunction in disease.

christopher.butler@imperial.ac.uk
161  Two-centre audit of cannabidiol use in adults with Dravet syndrome
Authors: Silvennoinen Katri , Mantoan Laura , Nashef Lina , Sisodiya Sanjay M , Sidhu Meneka K
Published: May 2022

Background

Cannabidiol is a newly-available treatment option for seizures in Dravet syndrome (DS).

Methods

Adults in a cannabidiol early access programme at two epilepsy centres were included. Can- nabidiol was titrated up to 20mg/kg, as tolerated. The primary outcome measure was >30% reduction in convulsive seizures assessed at three months of treatment. Secondary outcome measures included later reduction in seizures and incidence of adverse drug reactions (ADRs).

Results

Eighteen individuals (seven female; median age 27.5 years) with SCN1A mutation-positive DS took part. Median follow-up was 166 days; nine individuals continued on maintenance treatment. Median maximum dose was 18.6mg/kg/day. Four individuals (22.2%) had a >30% reduction in convulsive seizures by three months; in two, this became evident after three months. ADRs occurred in 14 (77.8%). Commonest ADRs were somnolence and derangement of LFTs (all 18 took concomitant valproate), occurring in eight and seven individuals, respectively. ADRs led to discontinuation in three, including a seizure-free individual. Twelve people (66.7%) required dosage changes to other antiepileptic drugs.

Conclusion

Cannabidiol was effective in a fifth of patients. Two additional patients showed later reduction in seizure frequency, suggesting longer follow-up is warranted. Treatment was complicated by ADRs. Dose adjustments of other antiepileptic drugs may be needed.

k.silvennoinen@ucl.ac.uk
162  Cracking the NORSE code
Authors: Midgley Laura , Poole Olivia , Broad Rebecca , Delaj Laura , Flores Lorena , Harikrishnan Sreedharan
Published: May 2022

This 32 year old Irish traveller presented initially with tremor in his left hand. Blood tests and imaging at the time were unremarkable and he was treated with Botox and Gabapentin to some benefit. Three months later this gentleman presented with status epilepticus requiring intubation and ventilation. Despite escalat- ing anti-epileptic agents in addition to anaesthetic agents he remained in non-convulsive status with an EEG focus in the right temporal-occipital region. MRI showed left posterior parietal, right parietal-occipital and bilateral thalamic signal hyper-intensity. Routine investigations including autoimmune antibodies were unremarkable except for a raised CSF protein and CSF lactate. Crucially, the family later disclosed an extensive family history of epilepsy, including the patient’s niece and nephew, who were both POLG-1 mutation A467T homozygotes. Following initial genetic screening we found our patient to be a POLG-1 mutation A467T heterozygote, which interestingly should not be pathological. Further detailed genetic screening later revealed he was also a POLG-1 W748S heterozygote. As a compound heterozygote this can lead to destabilisation of the linker region of the POLG-1 gene and result in disease, typically causing death in infancy. This gentleman unfortunately remained in non-convulsive status epilepticus despite maximum drug and adjuvant treatments and was subsequently palliated.

Laura.midgley1@nhs.net
165  A creepy diagnosis
Authors: Talaei Maryam , MacIver Claire , Pearson Owen R , Pickrell William O
Published: May 2022

A 44-year-old-female presented with 3 weeks history of sacral anaesthesia, painful left leg paraesthesia and urinary retention requiring intermittent self-catheterisation. A week prior, she had headache, flu-like symptoms and dysuria and received oral antibiotics for E-Coli urinary infection with a negative vaginal swab.

She was systemically well. On examination, there was mild left ankle dorsiflexion and plantar flexion weakness, brisk lower limb reflexes and altered sensation in left L5 and bilateral S1 dermatomes.

MRI of her whole spine showed subtle signal change in the conus medullaris. CSF revealed 113 white blood cells (80% lymphocytes) with normal protein and glucose and negative oligoclonal bands. Her CT chest,abdomen and pelvis was unremarkable as were: autoimmune and vasculitis screening, serum ACE, vitamin B12, LDH, copper, HIV, syphilis, Lyme, HTLV1&6, Hepatitis B&C, MOG and Aquaporin 4 antibodies.

CSF Herpes simplex virus 2 (HSV2) polymerase chain reaction was positive, confirming a diagnosis of HSV2 myeloradiculitis (Elsberg’s syndrome). She was treated with intravenous acyclovir for three weeks with significant clinical response and she was discharged on long-term daily oral acyclovir.

Elsberg syndrome is presumed infective (HSV2) acute or subacute bilateral lumbosacral radiculomy- elitis and should be considered in patients with CSF pleocytosis, urologic dysfunction and lumbosacral radiculomyeliitis.

maryam.talaei@wales.nhs.uk
167  A case of rapidly progressive meningoencephalitis caused by amoebae in the UK
Authors: Surendranathan Ajenthan , Qazi Hamood , Kumar Atul , Mattoscio Miriam , Chaudhuri Abhijit , Sinha Devesh
Published: May 2022

Background

Cases of Amoebic encephalitis have been reported in countries with tropical climates. Here we describe a rare adult case in the UK with a rapidly progressive history, which was confirmed at autopsy.

Case Presentation

A 77 year old lady, independent and still in employment, with a past medical history of Sjogren’s syndrome, presented with sudden onset of slurred speech, left facial twitching and facial droop. MRI showed a right frontal enhancing lesion with surrounding vasogenic oedema. Dexametha- sone was started for suspected high grade neoplasm. Nine days later she had a temperature of 37.7°C, with no apparent source of systemic infection. Despite empirical treatment with antibiotics, she became progressively unresponsive over the next 72 hours, developing dense left hemiplegia. Repeat MRI head showed large widespread multifocal T2/FLAIR signal changes. A lesional biopsy was planned but she deteriorated rapidly and died. Post mortem revealed disseminated collections of amoebae throughout the cerebral hemispheres, brain stem and cerebellum.

Discussion andConclusions

Amoebic encephalitis, despite its rarity, should be a differential diagnosis in a rapidly progressive infective meningoencephalitis unresponsive to empirical therapy. Mortality is high, however early treatment based on clinical suspicion may improve survival rates.

ajenthans@doctors.org.uk
170  Did the atraumatic lumbar puncture needle campaign have any effect?
Authors: Adegboyega Gideon , Lobo Rhannon , Alsousa Ines , Salman Reem , Lobo Sean , Uppal Encarl , Ali Shair , Schmierer Klaus , Giovannoni Gavin
Published: May 2022

Objectives

To assess the impact of a national atraumatic lumbar puncture needle campaign on lumbar puncture needle usage across the United Kingdom. The campaign commenced in 2015, to increase usage of atraumatic needles to reduce complications associated with traumatic needles.

Design

Retrospective cross-sectional audit

Methods

We requested procurement orders from all regional neuroscience centres in the United Kingdom, through freedom of information (FOI) requests to identify their lumbar puncture needle purchases over a four-year period (2015–2018). Of all sites, 20 centres provided usable datasets. Product codes were cross correlated to identify the type of lumbar puncture needle used. The procurement orders were used as a surrogate marker for lumbar puncture needle usage and to calculate a ratio of atraumatic: traumatic needles.

Results

In total we analysed 739,209 procurement orders over the four-year period. The Atraumatic/Traumatic needle ratio was 0.244 ± 0.039 in 2015 and increased to 0.276 ± 0.046 in 2016 (p=0.05), with

a subsequent decrease in 2017 to 0.252 ±0.042 (p=0.37) and 2018 to 0.256 ± 0.037 (p=0.93).

Conclusions

Despite the increase between 2015 and 2016, the impact of the atraumatic lumbar puncture needle campaign has been marginal. Further efforts will be needed to effect a change in the ‘needle culture’ across neuroscience centres. Aside from the campaigning to highlight reduced complications and the cost-effectiveness of atraumatic needles, further initiatives such as a Delphi process should be considered.

gideon

adegboyega@gmail.com

117
173  Does a post discharge phone follow up reduce readmission rates in patients with neurological conditions?
Authors: Shanmuganathan Sarah , Nitkunan Arani
Published: May 2022

Early readmissions is an issue that not only drains NHS resources but also indicates failures of effective care of patients. Specifically, to neurological admissions, 6.5–11% of admissions are re-admitted within 30 days. We aimed to investigate whether post-discharge telephone calls prevented early readmissions in patients who had inpatient neurological reviews at a district general hospital. 235 inpatients seen by the neurology team at a district general hospital over a period of 2 months were reviewed. 76 were offered a follow up appointment. A significant proportion (45%) of patients were not contactable. When only the patients who were successfully contacted were assessed, there was a non-significant reduction in early readmission (38%). The introduction of post-discharge telephone intervention could be a cost effective method to reduce readmissions. This needs to be reassessed with a more robust method of contacting patients with clarity on when the appropriate time e.g. those at risk of re-admission, contact within 2 weeks and those not, contact at a clinically appropriate time.

2236892s@student.gla.ac.uk
174  A career in neurology: How can we encourage medical students to think about it?
Authors: Gupta Dhruv , Poole Grace , Melamed Naomi
Published: May 2022

Introduction

Interest in neurology is declining, reflected by reduced ST3 applications between 2016–2018. ‘Neurophobia’ and perceived lack of knowledge are possible explanations. Therefore, our aims were to identify factors that attract or deter students from neurology, and the impact of an extra-curricular careers event.

Methods

20 medical students attended a careers event organised by St George’s Clinical Neuroscience Society. A consultant neurologist discussed his experiences, recent neurological developments, and relevant training pathways. Attending students completed a questionnaire before and after the event, consisting of: motivating factors, deterrents, and utility of the event.

Results

45% of students were initially attracted to neurology due to the pathologies presenting in patients. After the talk, this significantly increased to 80% (p<0.05). 75% of students were initially deterred from neurology due to perceived lack of time with a future family. Following the event, this significantly decreased to 55% (p<0.01). 75% of students strongly agreed that similar events should be integrated into the curriculum.

Discussion

Following a careers event, perceived insufficient time with family as a deterrent to entering neurology was attenuated. Such events are valuable in addressing misconceptions of students, and support an informed choice about the realities of a career in neurology.

melamednaomi8@gmail.com
178  Atraumatic lumbar puncture campaign – effect on complications
Authors: Sousa Ines , Salman Reem , Lobo Rhannon , Adegboyega Gideon , Lobo Sean , Uppal Encarl , Ali Shair , Schmierer Klaus , Giovannoni Gavin
Published: May 2022

Aims

To assess the impact of the usage of atraumatic lumbar puncture needles on lumbar puncture complications across the United Kingdom, following the national atraumatic lumbar puncture needle campaign which commenced in 2015

Design

A retrospective cross-sectional audit of regional datasets was employed.

Subjects

All patients undergoing a lumbar puncture for both therapeutic and diagnostic purposes at regional neuroscience centres.

Methods

We requested hospital episode statistics (HES) from all regional neuroscience centres in the United Kingdom (32 sites). Through freedom of information (FOI) requests we asked the centres to provide the number of epidural blood patches procedures, post-lumbar puncture headaches and lumbar puncture needle procurement orders over a four-year period (2015–2018). A surrogate complication rate was cal- culated by the sum of the complications divided by the total procurement orders.

Results

Of all sites 32 sites, 16 centres provided usable datasets. Between the period of 2015–2018 there was a non-significant decrease in complication rates when using atraumatic lumbar puncture needles (p=0.14).

Conclusions

The study did not show a statistically significant decrease in the complication rates over the specified period, supported by previous work suggesting poor adherence to atraumatic needle usage.

ines-alsousa@hotmail.com
181  Peer-to-peer teaching as a learning tool for SHOs working in a highly specialist centre
Authors: Fiorini Francesco , Cox Caitriona , Carr Aisling , Sayal Parag
Published: May 2022

Introduction

Neurology can be challenging for SHOs working at highly specialist centres. Clinical exposure might be limited by firm-based systems and teaching, which is often targeted to more senior trainees, covers rare conditions. This is reflected in GMC survey data from IMT/CMT trainees, which has been poor at NHNN in recent years.

Methods

We developed a novel peer-teaching programme, which was open to SHOs and physician associates. It consisted of weekly sessions led by an SHO with a supervising SpR present. Data on the provision of teaching for SHOs, on learning about topics covered within and outside individual firms, and on teaching opportunities, was collected prior to the programme. We repeated data collection after a 3-month trial of the teaching programme.

Results

We demonstrated significant improvements in trainee perception of overall SHO teaching provision (p=0.014) and in opportunities to develop their own teaching (p=0.01), as well as learning about neuro- logical conditions/topics outside of their own firms (p=0.011). Teaching was consistently well attended and received positive free text responses in the questionnaires.

Conclusion

Neurology SHO peer-teaching creates an effective learning environment to facilitate learning about neurological topics appropriate to training level, where trainees can also improve their own teaching skills.

clc70@doctors.org.uk
182  Mental capacity assessment: a descriptive, cross-sectional study of what doctors think, know and do
Authors: Penn Dexter , Nicholls Jacqueline , Lanceley Anne , Petrie Aviva
Published: May 2022

Background

The Mental Capacity Act (MCA) (2005) was enacted in 2007 in England and Wales, but the assessment of mental capacity still remains an area of professional concern. Doctors’ compliance with legal and professional standards is inconsistent, but the reasons for poor compliance are not well understood. This preliminary study investigates doctors’ experiences of and attitudes toward mental capacity assessment (MCAx).

Methods

This is a descriptive, cross-sectional study where a two-domain, study-specific structured questionnaire was developed, piloted and digitally disseminated to doctors at differing career stages employed in a large, multi-site National Health Service Trust in London over 4 months in 2018. Descriptive statistics and frequency tables adjusted for missing data were generated and secondary analysis was conducted.

Results

Participants (n=92) were predominantly UK trained (82%), female (58%) and between the ages of 30 and 44 years (45%). Less than half (45%) of the participants reported receiving formal MCAx training. Only one-third (32%) of the participants self-rated themselves as very competent (29%) or extremely competent (4%). Self-reported MCA confidence was significantly affected by career stage with Consultants with over 10 years of experience reporting lowest confidence (p=0.001).

Conclusions

This study describes significant variation in practice by doctors and low self-confidence in the practice of MCAx. These results raise concerns that MCAx continues to be inconsistently performed by doctors despite appropriate awareness of the law and professional guidance on best practice.

dexter.penn.14@ucl.ac.uk
183  Safe neurological services: how should we best measure safety in neurology practice in the UK?
Authors: Kipps Christopher , Kinton Lucy , McCarron Mark , Nitkunan Arani , Petheram Kate , Ross-Russell Amy , Tripp Anand , Warner Graham , Zarkali Angelika
Published: May 2022

Patient safety has been recognised as a top global priority. Safe neurological practice is crucial. Yet, how do we adequately measure safety in our services? A range of standpoints need to be considered including safety at clinician level, safety within a service and the organisational safety culture in which clinicians practice.

The ABN is interested in understanding how best to benchmark safety in neurology practice across the UK. It aims to identify the range and extent of quality assurance and safety practice, and assess ways of presenting this data to inform efforts to maintain and improve safe practice at all levels.

A series of questions have been formulated to address this issue, and will be circulated to ABN advisory groups for review. From this a comprehensive safety survey will be constructed and further refined. This will then be used to audit safety practice and attitudes at individual, service and organisational levels across the UK. We will present the results of the advisory group consultation and the intended question- naire to be used in the national survey. Presentation of this work will help raise awareness of the issue to ABN members, and further refine the national audit.

ckipps@nhs.net
186  Published discussion of palliative care for patients with long term neurological conditions
Authors: Rees Richard , Alderman Bryony , Pigott Jen , Schrag Anette
Published: May 2022

Introduction

There is a growing recognition of the need for palliative care services for people with long-term neurological conditions (LTNC). However, in order to provide optimal treatment, there is a need for discussion and teaching within the relevant specialties, and research needs to provide evidence to inform provision of best medical practice.

Methods

We use number of abstracts from neurological, geriatric and palliative care conferences as a marker of the level of discourse at a clinical and academic levels. We searched ABN, BGS (British Geriatric Society), and APM (Association for Palliative Medicine) conference abstracts from 2014–2019 for neuro- logical and palliative search terms as appropriate.

Results

We searched 3,750 abstracts over 21 conferences using the pre-specified search terms. Overall, only 2.19% out of these abstracts related to palliative issues in LTNC (ABN 21/1612 (1.3%), BGS 12/1017 (1.1%), APM 48/1121 (4.4%)) α2 p=3.2x10–8. ‘Dementia’ and ‘Parkinson’s’ were the most commonly identified LNTCs in BGS abstracts (each 4/12), with MND (14/48) and ‘dementia’ (10/48) dominating the APM abstracts.

Discussion

There is a dearth of published research and discussion at academic meetings related to the palliative needs of patients with LTNC. We believe these are necessary to inform best medical practice, and to establish policies and guidelines to serve this vulnerable group, or to inform the ongoing national debate.

richard.n.rees@ucl.ac.uk
191  The neurology grand(ish) round
Authors: Adan Guleed , Kalam Sabrina
Published: May 2022

Anecdotally the neurology grand round (NGR) is perceived as a beneficial learning opportunity but it is also an event that many trainees do not enjoy for a myriad of reasons. This project sought to explore these perceptions and uncover the beliefs that underpin them.

All neurology trainees in a neuroscience centre were invited to take part in a semi-structured focus group. An inductive thematic analysis approach was used given the relative naivety of the phenomenon being studied.

Eight participants consented to take part; two focus groups were conducted with four participants in each group. The data was analysed and divided into appropriately derived codes, themes and sub- themes. Main themes generated included; ‘learning environment’, ‘role of the consultant’, ‘questioning style, ‘learning format’, ‘future employment’ and ‘role of seniority’.

Positive perceptions were based on the ability of the NGR to bring to life and contextualise theoretical prin- ciples in clinical neurology. Barriers to effective learning in the grand round included the anxiety inducing nature of the learning environment and the targeting of individual trainees for public questioning. Future NGRs should be designed to take these perceived barriers into account and improve the educational experience for all neurology trainees, regardless of level of experience.

guleed.adan@liverpool.ac.uk
194  Improving the experience of core medical trainees and trust doctors at NHNN
Authors: Ceronie Bryan , Adams-Carr Kerala , Gration Betty , Yasar Binnaz , Mackay Katherine , Carr Aisling , Khaleeli Zhaleh
Published: May 2022

Introduction

Feedback from core medical trainees and trust-grade doctors at the National Hospital for Neurology and Neurosurgery highlighted areas for improvement including induction, curriculum coverage and educational governance. A rolling programme of improvements since August 2017, facilitated by a consultant-appointed CMT Lead, was implemented in response to feedback.

Methods

Specific improvements included a paired colleague system to facilitate leave, dedicated firm timetables with clinic and acute neurology allowances, a new junior doctor handbook, overhaul of the induction programme, the appointment of clinical support workers and physician associates, daily safety huddles, regular team-building events and a case presentation competition.

Results

We evaluated doctor satisfaction on a 6-monthly basis using an internal survey, from August 2017 to December 2019. Measures that demonstrated clear improvement included the proportion of doctors rating induction as good (14% to 83%), feeling valued as a team member (34 to 75%), deeming the job valuable for training (67% to 100%), attending teaching (39% to 50%), and those that were able to present to a consultant (41% to 58%).

Discussion

Through rolling improvements and regular feedback, job satisfaction has improved. More work remains to be done, in particular to improve attendance at protected teaching and facilitate contact with consultants.

bryan.ceronie@gmail.com
198  Digital information for patients requiring inter-hospital transfers: benefits of co-production
Authors: Wu Kit , King Rachel , Ellis Cathy , Larcombe Karen , Dilley Michael
Published: May 2022

Introduction

Patients admitted with neurological conditions often require transfer to a regional neuroscience centre for further investigations and management. For healthcare teams, inter-hos- pital transfer (IHT) is a complex process to coordinate. For patients and their families, it is a daunting experience with uncertain outcomes [Bosk et al, 2011]. Yet, there is no available digital information on the process of IHT for patients on the internet.

Aim

To produce publicly available digital patient information [leaflet] on the process of IHT in collaboration with patients.

Method andResults

We collaborated with patient representatives from key stakeholder organisa- tions and charities [South London Neuroscience Operational Delivery Network (ODN), King’s Health Partners (KHP), Neurological Alliance and the Brain and Spine Foundation] through co-production meetings set up jointly by ODN and KHP. Together, we defined the target service users and an outline of the content. Building on the digital capabilities of the charities, we defined the host site, its sustainability and maintenance. Thirdly, we defined how healthcare networks will facilitate the dissemination of information in reciprocity.

Conclusion

To our knowledge, this is the first co-produced information leaflet for neurological patients on IHT available in a digital format. Providing written information is an important part of patient care which can reduce anxiety, manage expectations and improve patient satisfaction. Through collaboration, we, as healthcare organisations, can enable changes that benefit both the patients and the healthcare providers.

kitwu@doctors.org.uk
199  Improving training in systems leadership management: a ‘Mini-Darzi’ approach
Authors: Wu Kit , Tahir Mehreen , Adams Sarah , Ellis Cathy , Larcombe Karen , King Rachel , Dilley Michael , Malby Rebecca
Published: May 2022

Introduction

Leadership and management development is mandated by General Medical Council as core skills for all doctors [GMC, 2012]. Yet, the myriad of leadership courses for trainees are delivered by external organisations without opportunities for concrete applications in the NHS setting.

Aims

To develop a short applied leadership and management course appropriate for doctors in training using peer-learning approach, and to review its impact through objective feedback from participants’ implementation of projects.

Method andResults

A management and leadership course was developed using a peer-learning approach by three Darzi fellows participating in leadership development programme and project-based attachments to NHS organisations [Malby, 2018]. The course follows a three-stage approach: a one-day workshop to impart knowledge and skills in systems change; a quality improvement project in the par- ticipants’ workplace; finishing with a workshop for participants to showcase their project and feedback.

Results and Summary

The course educates participants in clinical leadership in the NHS and equip them with the tools to manage new challenges. The application of knowledge in the participants’ workplace through implementation of a systems change project allows for greater understanding of quality improve- ment within NHS healthcare. In turn, it will encourage participants to seek further opportunities to develop their skills and lead change projects in their future careers.

kitwu@doctors.org.uk