bluuebunny/crossref_metadata_2025_split huggingface dataset:
DISEASE MODIFYING TREATMENTS IN MS: INDUCTION OR ESCALATION?
Authors: Williams Owain H , Harding Katharine E , Willis Mark , Pickersgill Trevor , Wardle Mark , Robertson Neil P 
Published: October 2015

BackgroundIt is currently unclear whether aggressive induction or stepwise escalation of DMTs provides optimum long term outcomes for patients with MS.ObjectiveCompare clinical outcomes in clinical practice amongst unmatched patient groups receiving either initial monoclonal induction, injectable DMT only or escalation from injectable DMT.MethodsA subset of a population-based cohort identified 268 patients, with a median follow up post treatment of 5.4 years. Time to disability end points (EDSS) were examined using survival analysis.ResultsMonoclonals (25%) pre and post treatment annual relapse rate reduced from 2.28 (±1.92) to 0.28 (±0.42) 88% reduction; injectables (62%) from 1.08 (±0.97) to 0.4 (±1.03), 63% reduction; escalation (13%) had elevated rates of 1.72 (±2.04) to 0.64 (±0.54), only 63% reduction. Time to EDSS4 was shorter for monoclonal against injectable and escalation strategies: 5.7 vs 12 vs 6.8 years, p=0.0002. Time to EDSS6 was similar for the treatment strategies respectively: 14.6 vs 16.4 vs 13.3 years, p=0.13.ConclusionsPatients requiring escalation had relatively worse outcomes, and could be identified as having higher disease activity on treatment initiation. This data suggest that initial selection of DMT class does not significantly affect long term outcome to EDSS6, or conversely, aggressive induction slows the rate of disability progression to EDSS6.
DESIGNING AN INFORMATION RESOURCE TO EXPLAIN DIAGNOSTIC LUMBAR PUNCTURE AND PROMOTE BEST PRACTICE
Authors: Thomson Alison , Davis Angharad , Paterson Adam , Giovannoni Gavin , Schmierer Klaus 
Published: October 2015

IntroductionThe lumbar puncture (LP) procedure is an important test in neurological practice. Appropriate information is key to both preparing patients for this invasive procedure and facilitating use of atraumatic LP needles to minimize adverse effects such as local pain and post-LP headache.MethodsA cross-disciplinary team (designers, clinicians and people with multiple sclerosis (pwMS)) developed a website to explain the LP procedure at The Royal London Hospital (Barts Health NHS Trust, UK). User testing was carried out to review both the visual design and functionality of the resource for people with visual and cognitive limitations.ResultsAfter successful testing www.clinicspeak.com/LumbarPuncture is being used in the informed consent process for clinical trials involving pwMS at our institution and is being piloted in our day unit and A&E departments. The website includes what to expect, how to deal with adverse effects, why cerebrospinal fluid is examined and information on the atraumatic needle.ConclusionThe resource provides an appropriate way of communicating sensitive, yet important information to patients. It also demonstrates an innovative way of spreading best practice and encourages the widespread adoption of atraumatic needles for LP in both clinical and research settings. The resource will be demonstrated at the meeting.
DEEP BRAIN STIMULATION IN INTRACTABLE SHORT-LASTING UNILATERAL NEURALGIFORM HEADACHE ATTACKS: A MULTICASE SERIES
Authors: Miller Sarah , Zrinzo Ludvic , Matharu Manjit 
Published: October 2015

IntroductionSUNCT and SUNA are primary headache conditions characterized by short lasting attacks of unilateral pain accompanied by autonomic features. Neuroimaging studies have suggested a role of the posterior hypothalamus in its pathogenesis.AimPrevious case reports on deep brain stimulation (DBS) of the midbrain tegmentum (just posterior to the hypothalamus) for SUNCT/SUNA are limited to a total of three patients. We present clinical data on eight new patients treated with DBS.MethodEight patients underwent midbrain tegmentum DBS with an MRI-guided and verified approach. The target lay between the mammillothalamic tract and the anteromedial quadrant of the red nucleus. Headache diaries were used to monitor response.ResultsThe median follow up period was 20 months. Median improvement in attack frequency was 70%. Seven patients obtained a 30% or more reduction in attack frequency at final follow up. At final follow up, one patient had the stimulator off. Seven out of eight patients would opt to have the stimulator again and all would recommend to others.ConclusionMidbrain tegmentum DBS may be a useful treatment in intractable SUNCT. It should be reserved only for patients failing all other medical and surgical treatment options.
TABES DORSALIS IN THE POST ANTIBIOTIC ERA: NEVER SAY NEVER
Authors: Osman Chinar , Clark Tristan , Ghosh Boyd , Halfpenny Christopher 
Published: October 2015

BackgroundTabes dorsalis is a neurological form of tertiary syphilis and is considered to be rare in the post antibiotic era. It results from damage to nerve cells in the dorsal column and roots of the spinal cord. It is characterised by sensory ataxia, lightening pains and urinary incontinence. If left untreated it can progress to paralysis and dementia.Case summaryWe present the case of an HIV positive 47 year old male with a CD4 count of 400 and an undetectable viral load on HAART. He presented with an 8 month history of progressively severe lightening pains, gait disturbance, tinnitus, hearing loss, and urinary incontinence. He had a positive plasma VDRL with a titre of 1:32, and his CSF was VDRL positive. Whole spine MRI scan demonstrated high signal in the dorsal cord with associated atrophy. He was treated with intravenous benzylpenicillin 2.4 grams 4 hourly for 14 days. Follow up at 4 and 8 months demonstrated marked clinical improvement with a falling serum VRDL titre. Repeat LP at 6 month post treatment demonstrated VDRL negativity.DiscussionTabes Dorsalis may still occur in the post antibiotic era. Early recognition and appropriate treatment can lead to good clinical outcomes.
ONE YEAR RETROSPECTIVE AUDIT OF CNS MALIGNANCY 2 WW REFERRALS
Authors: Ashton Elizabeth , Smeeton Benjamin , Weatherby Stuart 
Published: October 2015

BackgroundSince its introduction in 2000, concerns have been raised about the two week wait (2 WW) referral system for suspected malignancy. Studies have demonstrated poor compliance to guidelines, low detection rates and questioned the time effectiveness of the referral process.MethodAll patients referred under the 2 WW system for suspected CNS malignancy to Derriford Hospital, Plymouth Hospitals NHS trust, over a one-year period were retrospectively audited. Data was gained from clinic letters and radiological imaging. The aims were to determine the number of referrals, their appropriateness and subsequent time taken to outpatient appointment, imaging and final diagnosis.Results103 referrals were made between September 2013 and September 2014 with just 48.5% fulfilling NICE referral guidelines for suspected CNS malignancy. Just three tumours were diagnosed with guidelines identifying all of these. Only 28% of 2 WW referrals received diagnostic imaging and an outpatient appointment within two weeks.ConclusionsUnnecessary referrals are placing strain on the 2 WW system. We suggest that a potential solution is for general practitioners to refer patients for imaging at the same time as they make their neurological 2 WW referral in order to cut down waiting times.
ARE FEMALE ACADEMIC NEUROLOGISTS GETTING THEIR VOICES HEARD?
Authors: Lynch Emma 
Published: October 2015

ObjectivesNeurology as a specialty is becoming increasingly feminised. Generally, women are under-represented in academic medicine, particularly at more senior levels. The aim of this study was to assess the gender balance of presenters at the 2014 ABN meeting.MethodsData on gender mix of the specialty was obtained from the 2012 Federation of the Royal College of Physicians Census. Oral presenters and first authors from posters were identified using the Meeting Programme and Abstract Book and the GMC register was used to ascertain individuals' gender.Results29.5% of neurology trainees and consultants are female. There were 38 platform presentations, and 188 poster presentations. It was possible to identify the gender of 99.6% of presenters and first authors. 48.9% of first authors on posters were female; women conducted 18.4% of platform presentations. Oral presenters were significantly more likely to be male (p<0.01).ConclusionCompared to the specialty as a whole, women were well represented at the meeting. However, females were significantly less likely to undertake more prestigious oral presentations. Further work is planned to identify whether the reason behind this imbalance is explicit or implicit bias, and to help identify barriers to increasing female participation in academic neurology.
DEMENTIA AND THE ‘COCKTAIL PARTY’ PROBLEM
Authors: Kamourieh Salwa , Wise Richard 
Published: October 2015

BackgroundListening to one speaker in the presence of others (the ‘cocktail party’ problem) increases demands on attention and cognitive control. This study investigated the function of fronto-parietal systems and auditory regions in patients with progressive memory impairment.MethodsTwenty-five healthy volunteers (controls) and 32 patients were studied with functional MRI. The task involved attending to a female speaker, either in the absence or the presence of a masking male speaker.ResultsA behavioural measure designed to assess success at attending to the female speaker demonstrated a significant impairment in the patient group compared to the controls. This was associated with reduced activity in the dorsal anterior cingulate cortex (dACC), involved in attention and cognitive control, and in the left planum temporale (lPT), an auditory region central to solving the ‘cocktail party’ problem. However, treatment with galantamine in 18 patients resulted in no behavioural improvement and no increase in dACC or lPT activity.ConclusionsAn inability to register verbal information when listening in the presence of distracting background speech will contribute to complaints of ‘impaired memory’ and social isolation. We did not find evidence that central cholinesterase inhibition can improve this function in patients complaining of progressive memory decline.
A SYSTEMATIC REVIEW & META-ANALYSIS OF F-18-LABELLED AMYLOID IMAGING IN ALZHEIMER'S DISEASE
Authors: Yeo Jing Ming , Waddell Briony , Khan Zubair , Pal Suvankar 
Published: October 2015

IntroductionThere has been recent interest in the use of fluorine-18-labelled (18F) tracers in amyloid imaging as they have longer half-lives compared to 11C-labelled Pittsburgh compound-B (11C-PIB). This systematic review and meta-analysis aims to assess the sensitivity and specificity of 18F tracers florbetapir, florbetaben and flutemetamol in diagnosing Alzheimer's disease (AD).MethodsWe systematically searched MEDLINE and EMBASE for relevant studies published from January 1980 to March 2014. We pooled the studies comparing imaging findings in AD and normal controls (NC) in a meta-analysis, calculating the pooled weighted sensitivity, specificity and diagnostic odds ratio (OR) using DerSimonian-Laird random effects model.ResultsA total of nineteen studies investigating 682 patients with AD, met the inclusion criteria; florbetapir (n=10), florbetaben (n=6), flutemetamol (n=3). Our meta-analysis for florbetapir revealed a pooled weighted sensitivity of 89.6%, specificity of 87.2% and diagnostic OR of 91.7 in differentiating AD from NC; and for florbetaben a pooled weighted sensitivity of 89.3%, specificity of 87.6% and diagnostic OR of 69.9.ConclusionThis meta-analysis demonstrated favourable sensitivity and specificity for 18F tracers in diagnosing AD. Further and larger prospective studies are required to establish an optimal imaging analysis methodology for these tracers for consistency and comparability
DISCUSSING SUDDEN UNEXPECTED DEATH IN EPILEPSY: ARE WE EMPOWERING OUR PATIENTS?
Authors: Keddie Stephen , Angus-Leppan Heather , Parker Thomas , Toescu Sebastian , Nash Adina , Adewunmi Lola , Liu Rebecca 
Published: October 2015

Disparity exists between clinical practice and guidelines on discussion of Sudden death in epilepsy (SUDEP) with patients. This study examined how patients were informed about SUDEP; the impact of such discussion, and their views on the discussion.MethodsA quantitative/qualitative questionnaire was given to 50 consenting patients attending epilepsy clinics. Exclusions were patients with intellectual disability, and/or those deemed at risk of negative consequences on completing the study.Results98% of patients were aware of the importance of medication adherence, 78% of driving regulations in epilepsy, and 84% of factors influencing seizure frequency. Only 50% of patients were aware of SUDEP and 38% of status epilepticus.42% of patients preferred SUDEP information at diagnosis and 36% only after three clinic appointments.Negative emotional responses (in 38%), and not behavioural changes, resulted from SUDEP discussions.ConclusionsIn this small in-depth study, only half the patients recalled information about SUDEP. More than one-third of patients reported adverse consequences. There was no improvement in self-management.We suggest a paradigm shift: embedding SUDEP discussion with all potential complications of epilepsy; and emphasising optimal healthcare and self-management. This model has been successfully applied in other areas to empower patients and improve outcome.
BARRIERS IN CLINIC TO DISCUSSING SEXUAL DYSFUNCTION DUE TO MULTIPLE SCLEROSIS
Authors: Tudor Katarina Ivana , Eames Stefani , Haslam Collette , Panicker Jalesh 
Published: October 2015

BackgroundSexual dysfunction is underdiagnosed in patients with multiple sclerosis (pwMS). Little is known about barriers faced by patients and health care professionals (HCPs) in discussing sexual problems.Patients and methods74 PwMS (20 male, 54 female (mean age 45,877±8,823 years)) and 99 HCPs (8 male, 91 female; 82 (83%) nurses) completed questionnaires evaluating barriers to discussing sexual problems in clinic and sexual dysfunction (MSISQ-15 and ASEX), specifically developed for this study.ResultsSymptoms that interfere most with sexual activity are: Takes too long to orgasm (69.11%), bladder symptoms (66.17%), less intense orgasm (66.17%), lack of sexual interest (60.29%), genital numbness (50%). Most common barriers cited by patients include the prominence of other MS symptoms (43.5%), presence of family/friends in consultation room (41.8%), not being asked (37.3%). HCPs identified presence of family/friends in consultation room (57.6% agree), faced lack of knowledge (48.4% agree), patient not ready (44.3% agree), lack of time (42.2%).ConclusionsSexual dysfunction is common in both men and women following multiple sclerosis. However both patients and HCPs face barriers to addressing the problem. Providing time and privacy during the consultation to discuss sexual dysfunction, and training to HCPs will help to address these barriers.
WHAT IS THE NIN, AND WHAT CAN IT DO FOR YOU?
Authors: Morrish Paul 
Published: October 2015

The Neurology Information Network (NIN) is jointly sponsored by Public Health England and NHS England, and identifies, collates and interprets nationally available indicators on all adult neurological conditions. Its priorities are to:
▸ address health inequalities in England
▸ collect and make publicly available national neurology data, in one place
▸ identify gaps in the data and promote research to address these deficits
▸ improve the quality of commissioning by providing relevant data and evidence
▸ promote research to improve the quality of neurological care throughout EnglandResources Available Now: 1. Neurology profiles: http://fingertips.phe.org.uk/profile-group/mental-health/profile/neurology/data. Download and compare figures for: 18 different measures of epilepsy care in 4 Clinical Commissioning Regions and 211 Clinical Commissioning Areas in England. 21 different measures concerning emergency admission to hospital with a neurological condition in 4 Clinical Commissioning Regions and 211 Clinical Commissioning Regions. 2. Compendium of neurology data England 2012–13: The Compendium of Neurological Data, England 2012–3 http://www.hscic.gov.uk/catalogue/PUB13776. Download and compare hundreds more tables concerning neurological care in hospitals and in the community.And in the future? The NIN hopes to offer information on every neurological condition where reliable data can be collected. It will involve clinicians, commissioners, clinical networks, providers, charity groups and other stakeholders in discussions about its future work.
HEADACHE IN MILLER-FISHER SYNDROME
Authors: Amin Reem , Hughes Tom 
Published: October 2015

A 22-year-old female presented with a three day history of headache, unsteadiness and double vision. The headache was described as being occipital, constant, radiated to the front of the head, and was exacerbated by lying down. On direct questioning, it appeared that she had an acute diarrheal illness two weeks previously. Neurological examination was remarkable for a complete external ophthalmoplegia, areflexia and ataxia. A plain CT scan of the head was normal. A lumbar puncture revealed clear cerebrospinal fluid with an opening pressure of 29 cm H2O, a protein content of 0.42g/l, WCC of 0 and RBC of 82. Nerve conduction studies were normal. She was treated with a 5-day course of intravenous immunoglobulins and over the course of four weeks made a complete recovery but for the first week was greatly troubled by headache. The headache was not abolished by the lumbar puncture and became a considerable source of concern for the patient and family. The subsequent Anti GQ1b Antibodies were highly positive.
Headache can be one of the presenting features of MFS but the aetiology is not clear. However it is important that clinicians are aware of headache as a possible feature of the condition, and that it appears to be self limiting.
FLUNARIZINE IN PRIMARY HEADACHE DISORDERS
Authors: Karsan Nazia , Palethorpe David , Bhola Ria , Goadsby Juana Marin, Peter 
Published: October 2015

BackgroundFlunarizine is a widely used migraine preventive not licensed in the UK. In September 2014, the National Institute for Clinical Excellence (NICE) published supportive guidelines for flunarizine use in migraine based on available randomised controlled evidence.AimTo collect data for an audit of flunarizine use from our tertiary headache practice in the UK over twenty years, to try to establish indications for its use, typical doses, short and long term side effects, and treatment outcomes, including changes in acute treatment use and change in frequency and intensity of headache on treatment.ResultsFor the first 30 patients audited the most common indication for flunarizine was chronic migraine, followed by migraine with aura, sporadic hemiplegic migraine and familial hemiplegic migraine and then new persistent daily headache of a migrainous type. Doses up to 15mg were generally well tolerated, with only five patients stopping treatment due to adverse effects. Flunarizine is generally effective; with only three patients reporting no clinical effect: two had hemiplegic migraine and one chronic migraine. The commonest dose used was 10mg and a significant proportion of patients continued treatment for more than one year.ConclusionFlunarizine is an effective, well tolerated migraine preventive that can be used for extended periods in a range of migraine sub-types.
OCCIPITAL NERVE BLOCK: AUDIT OF A DEVELOPING SERVICE
Authors: Wojtowicz Alex , Flower Michael , Hadjikoutis Savvas 
Published: October 2015

BackgroundOccipital nerve block (ONB) is an injection of local anaesthetic, often with corticosteroid, given around the greater occipital nerve in primary and secondary headache disorders. Growing local demand and sparse national guidance prompted this audit to aid service design.AimEstablish local demand and efficacy of ONB. We will then consider changes to the service and re- audit.StandardsNo national guidelines available; standards determined through literature review.MethodsRetrospective review of local ONBs for January–August 2014. Data reported by patients (n=17) through standardised questions, asking about each ONB administered (n=23).ResultsPatients experienced a mean 23 days headache freedom, 42% reduction in headache severity, and 38% reduction in headache days per week. Mean duration of effect was 44 days. Analgesia use fell after 70%, but 9% increased. Mild complications included injection site pain (65%); no moderate or severe complications.DiscussionThese data support the use of ONB to treat headache. Sample is insufficient to determine efficacy by headache type. The following targets are identified for improving the service; audit will be repeated following implementation:1. Improve staffing and facilities for this increasingly popular service.2. Formalise follow-up arrangements.3. Consider routine scheduling of repeat procedures for appropriate patients.
TREATMENT OF NEUROLOGICAL MANIFESTATIONS OF SJOGREN'S SYNDROME
Authors: Dodd Katherine , Pegg Emily , Brown Rachael , Shaunak Sandip 
Published: October 2015

Neurological manifestations of primary Sjogren's syndrome appear to be wide ranging. Treatment is recommended for those with progressive neurological impairment: usually immunosuppressive treatments including cyclophosphamide, steroids, azathioprine, and anti-TNF agents.We present three cases that didn't respond to initial steroid treatment but subsequently improved with regular infusions of intravenous immunoglobulins. In all three cases, the initial anti–Ro test was negative, but became positive after 4–11 years, an important feature to recognise in clinical practice.Case one presented with painful dystonic spasms of the arm and leg, hemi-facial spasm, vertigo, diplopia with skew deviation, and trigeminal neuropathy. Several years later she developed features of systemic mixed connective tissue disease. Case two presented as a facial palsy, sensory trigeminal neuropathy, and spastic quadraparesis. GAD antibody was positive but she did not clinically fit with stiff man syndrome. Case three has had relapsing inflammatory optic neuropathy since the age of 19, with no clear cause initially identified.These cases highlight the diversity in the neurological manifestations of Sjogren's syndrome, the importance of not relying on initial antibody testing, and the potential for improvement with intravenous immunoglobulins, a treatment that has less adverse effects than potentially toxic immunosuppressants.
AUTOIMMUNE RETINOPATHY – IMPORTANCE OF RECOVERIN B ANTIBODIES
Authors: Sturrock Aaron , Karim Abid , Denniston Alastair , Jacob Saiju 
Published: October 2015

Progressive visual failure can be secondary to autoimmune retinopathy (AIR). Presentation include progressive nyctalopia and peripheral field constriction. We present two patients with autoimmune retinopathy and their clinical progression.A 70-year-old lady was referred to the neuroimmunology clinic with progressive nyctalopia and periorbital pain to exclude the possibility of an immune-mediated retinopathy. Visual acuity was 6/18 bilaterally with peripheral visual constriction. OCT showed disruption of the photoreceptor layers. A retinal antibody screen showed positive anti-Recoverin B antibodies. In view of the paraneoplastic association of this antibody, a thorough search for an underlying tumour was performed (CT, PET) and endobronchial ultrasound guided biopsy showed high grade neuro-endocrine small cell lung cancer. Oncological treatment coupled with IVIg therapy stabilised visual function for over 18 months at last follow-up.A 47-year-old gentleman was referred with a three month history of bilateral visual decline and slightly altered personality. Retinal antibody screen showed cytoplasmic staining of inner nuclear layer. Extensive screening for an underlying neoplasia has been negative.AIR can be cancer-associated (CAR), melanoma-associated (MAR) or non-paraneoplastic (nPAIR). Presence of Recoverin B antibodies should prompt thorough screening for underlying neoplasia. Treatment of cancer coupled with immunomodulatory therapy may help in halting progressive visual loss.