Ambivalence among neurologists and neurosurgeons on the treatment of chronic subdural hematoma: a national survey

No class I evidence exists about the optimal treatment of chronic subdural hematoma (CSDH). The aim of this study was to evaluate current practice of CSDH patients with different neurological grades, and probable ambivalence towards various treatment paradigms, especially primary treatment with high-dose corticosteroids, among vascular neurologists and neurosurgeons. A questionnaire survey containing 4 questions, 1 consisting of cases, was sent to every vascular neurologist (n = 83) and neurosurgical centre (n = 15) in the Netherlands. The various treatment options were related to the treating physician, geographical distribution, both in general and for individual case. Sixty-two percent of surveys were returned. The proportion of patients primarily treated with corticosteroids was 17.5 % in 2009 and 20.5 % in 2010. Surgery by either burr holes or craniotomy was favoured by 61.1 % as primary treatment, and conservative treatment with corticosteroids by 22.4 %. Case studies revealed that surgery was preferred in case of severe neurological symptoms, whereas wait-and-see policy was preferred in case of mild symptoms without midline shift, of which 28 % would administer corticosteroids. Variety in answers was obtained in less pronounced cases. In the Netherlands, neurologists and neurosurgeons appear to favour surgery in CSDH patients as primary treatment, especially in severe cases. An ambivalent approach towards treatment protocols was shown, especially in patients with mild symptoms, regardless of hematoma size. A regimen of high-dose corticosteroids only, is preferred by about a quarter and predominantly in milder cases, and might depend on geographical distribution. These results suggest the need for a well-designed randomized trial.     

Public opinion about Alzheimer disease among blacks, hispanics, and whites: results from a national survey

Recent research has documented notable differences in knowledge, awareness, and cultural beliefs about Alzheimer disease (AD) among groups defined by race and ethnicity. The present study was conducted to assess racial differences in knowledge and attitudes about AD among a national sample of adults. Data from 1,176 adults aged 35 years and over (48.6% White, 25.7% Black, and 25.8% Hispanic) obtained via telephone interview were used in this study. Although some notable group differences defined by race/ethnicity were observed, more similarities in patterns of response were discovered than expected. Black and Hispanic respondents were significantly more likely to believe that AD is a normal part of aging, but were more optimistic about future advances in research than White participants. Compared with White and Black respondents, Hispanics were more likely to report feeling well-prepared for handling a diagnosis of AD in a family member. Overall, the results suggest that misconceptions about AD remain among large segments of the population, that AD remains a source of significant concern, and that continued efforts are needed to educate the public about this disease.     

How do neurologists discuss functional symptoms with their patients: a conversation analytic study

Objective

Consultations with patients with functional symptoms can be challenging. This study describes some of the interactional and linguistic resources doctors use when they deliver the diagnosis of a functional disorder and recommend psychological treatment to patients presenting with medically unexplained neurological symptoms.

Methods

Twenty out-patient consultations between three experienced neurologists and patients with non-epileptic seizures (NES, N = 17) or other functional neurological symptoms (FNS, n = 3) were recorded and analysed using Conversation Analysis (CA). Encounters were split into activity sequences (1: history-taking; 2: discussion of examination and test results; 3: diagnosis; 4: aetiology; 5: treatment recommendations). The doctors' formulation effort (FE) in each activity sequence was graded (1: little, 2: some, 3: marked FE).

Results

The doctors' communication behaviour was characterised by FE and accounting activities. FE increased during the course of the encounters and was most marked when doctors discussed the aetiology of symptoms and made psychological treatment recommendations. However, FE was evident even at the beginning of the encounters, and when patients fully aligned with the doctor.

Conclusion

This study provides interactional evidence why doctors may experience these consultations as challenging. While FE and accounting activities were sometimes linked to objective interactional problems (patients' resistance), doctors also seemed to engage in these practices for no clear interactional reasons, suggesting a degree of defensiveness or prior concern about the consultation. The extent of FE and accounting activities may display doctors' interactional distress but may also reflect a degree of delicacy when doctors explain the diagnoses of NES or FNS.     

Delivering the diagnosis of MS--results of a survey among patients and neurologists

OBJECTIVES: The need for an early disclosure of the diagnosis of multiple sclerosis (MS) has become more pressing with the publication of two recent randomized trials which have indicated that very early treatment may favourably alter the disease course. We assessed the current status of diagnostic and therapeutic information on MS from the point of view of patients and neurologists. METHODS: A standardized questionnaire was sent out through the patients' self-help organization in Hamburg, Germany and to all neurologists. RESULTS: A total of 434 of 1300 patients and 80 of 250 neurologists replied. Neurologists gave 90% of the diagnoses but only 50% of patients reported them as the major aid helping to understand the disease. Fifty per cent of patients were not informed about any form of therapy at the time of diagnosis regardless of whether their MS diagnosis was disclosed within the last 5 years or earlier. In contrast to physicians, patients voted for information about a possible MS even if the diagnosis may not yet be clear. CONCLUSION: From the patients' perspective, information about the diagnosis of MS should be more straightforward, and more information about therapies should be provided.     

Ethical issues in Alzheimer disease: the experience of a national Alzheimer society task force.

There has been increasing recognition of the ethical dilemmas that arise in the delivery of health care services and in planning and executing scientific research. Alzheimer disease (AD) and related dementias pose a particular challenge for families, care providers, and researchers because of the nature of the illness. Naturally, those at potential risk of developing the disease are eager for scientists to develop valid predictive tests for the disease. Alzheimer organizations have developed worldwide in response to the growing awareness and knowledge of the effects of dementia on individuals and their families. These organizations have played a role in advocating for research, increasing general awareness of the nature of the disease, and lobbying for more services for persons with dementia and their families. These organizations have also realized the increasing concern about the many ethical issues that arise in caring for those with AD and researching causes and cures. This paper describes a unique process one national Alzheimer society used to develop an Ethics Task Force to provide guidelines on ethical issues.     

Driving and patients with brain tumours: a postal survey of neurosurgeons, neurologists and radiation oncologists.

This study was aimed at evaluating the consistency of driving advice given by treating clinicians to patients diagnosed with brain tumours. Secondary aims include assessing the awareness of current driving guidelines and whether or not there was a need for more specific guidelines in this group of patients. This was undertaken utilizing a scenario-based postal survey. The results show an overall poor consistency in the answers provided for each case scenario. 73.1% respondents were not aware of any current driving guidelines. Of those who were aware of driving guidelines, 67.7% wanted more specific guidelines to be developed. Possible explanations for this are a lack of awareness of the existence of any driving guidelines and a lack of objective criteria in the current driving guidelines. The authors recommend that the current driving guidelines be comprehensively distributed to clinicians who treat patients with brain tumours, as well as forming a multi-disciplinary working party to develop more specific and objective driving guidelines.     

Abulia: a delphi survey of British neurologists and psychiatrists.

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

Early-onset Alzheimer disease in families with late-onset Alzheimer disease: a potential important subtype of familial Alzheimer disease

BACKGROUND: Genetic influences on the development of late-onset Alzheimer disease (LOAD) are heterogeneous and ill defined. OBJECTIVE: To determine the genetic risk factors for LOAD. DESIGN: We asked the following questions: (1) Does early-onset Alzheimer disease (EOAD) occur in families with predominantly LOAD? and (2) Does the apolipoprotein E (APOE) genotype explain the wide differences in onset age in LOAD families? SETTING: University of Washington Alzheimer Disease Research Center, Seattle. PARTICIPANTS: A total of 136 kindreds and a separate group of 29 affected parent-child pairs. MAIN OUTCOME MEASURES: We evaluated the kindreds with familial LOAD for the occurrence of EOAD and the affected parent-child pairs with a 20-year or more difference in the age at onset. RESULTS: In the 136 kindreds with LOAD, 104 had only late-onset cases (men, 36%), whereas 32 families (24%) had a combination of LOAD and EOAD cases. The 44 EOAD cases in these families accounted for 20% of cases of AD in the 32 families and 6% in all 136 families. The early-onset cases had a mean +/- SD onset age of 56.1 +/- 3.2 years (range, 45-59 years; men, 50%). Seven (28%) of 25 individuals with EOAD sampled did not have an APOE epsilon4 allele, and 2 of the earliest-onset cases were epsilon3/epsilon3. In 29 parent-child pairs with a 20-year or more difference in age at onset, 7 (35%) of the 20 children sampled did not have an APOE epsilon4 allele. CONCLUSIONS: Many LOAD families (approximately 25%) have at least 1 individual with EOAD, and in these individuals, the ratio of men to women is nearly 50%, suggesting a possible subtype of familial AD. The APOE genotype plays an important role in these early-onset cases, but at least one fourth of the risk must represent the influence of other genetic and/or environmental factors. These LOAD families with early-onset cases represent an important resource for investigation of these factors.     

Epilepsy and pregnancy: What should the neurologists do?

Epilepsy is one of the most common chronic disorders affecting women of childbearing age. Unfortunately, many women with epilepsy (WWE) still report not receiving key information about pregnancy. They obviously need information about epilepsy and pregnancy prior to conception with a particular emphasis on effective birth control (i.e. contraception), necessity to plan pregnancy, antiepileptic drugs optimization, and folate supplementation. The risks associated with use of antiepileptic drugs during pregnancy have to be balanced against fetal and maternal risks associated with uncontrolled seizures. This report reviews evidence-based counseling and management strategies concerning maternal and fetal risks associated with seizures, teratogenic risks associated with antiepileptic drug exposure with a special emphasis on developmental and behavioural outcomes of children exposed to intra utero antiepileptic drugs.     

How do neurologists discuss functional symptoms with their patients: A conversation analytic study

ObjectiveConsultations with patients with functional symptoms can be challenging. This study describes some of the interactional and linguistic resources doctors use when they deliver the diagnosis of a functional disorder and recommend psychological treatment to patients presenting with medically unexplained neurological symptoms.MethodsTwenty out-patient consultations between three experienced neurologists and patients with non-epileptic seizures (NES, N = 17) or other functional neurological symptoms (FNS, n = 3) were recorded and analysed using Conversation Analysis (CA). Encounters were split into activity sequences (1: history-taking; 2: discussion of examination and test results; 3: diagnosis; 4: aetiology; 5: treatment recommendations). The doctors' formulation effort (FE) in each activity sequence was graded (1: little, 2: some, 3: marked FE).ResultsThe doctors' communication behaviour was characterised by FE and accounting activities. FE increased during the course of the encounters and was most marked when doctors discussed the aetiology of symptoms and made psychological treatment recommendations. However, FE was evident even at the beginning of the encounters, and when patients fully aligned with the doctor.ConclusionThis study provides interactional evidence why doctors may experience these consultations as challenging. While FE and accounting activities were sometimes linked to objective interactional problems (patients' resistance), doctors also seemed to engage in these practices for no clear interactional reasons, suggesting a degree of defensiveness or prior concern about the consultation. The extent of FE and accounting activities may display doctors' interactional distress but may also reflect a degree of delicacy when doctors explain the diagnoses of NES or FNS.     

Psychiatric residents' sexual contact with educators and patients: results of a national survey

In a national survey of PGY-4 psychiatric residents, 4.9% of the 548 respondents indicated that they had been sexually involved with psychiatric educators and 0.9% reported that they had been sexually involved with patients. Most residents reported no or minimal instruction in their residency programs about educator-resident and resident-patient sexual contact. The authors compare these results with those from previous surveys of psychologists. They discuss the need for expanding training curricula to include specific education on sexual exploitation.     

Grief support for informal caregivers of patients with ALS: a national survey

Providing emotional support to caregivers is integral to comprehensive ALS care. The authors surveyed ALS Association centers and clinics and Muscular Dystrophy Association/ALS centers. Respondents thought that grief and bereavement support was integral to ALS care but thought that the support provided by their centers was often inadequate.     

Rehabilitation programs for myocardial infarction patients: a national survey

Considering the evidence in support of the importance of psychologic and social factors in the recovery of myocardial infarction (MI) patients, the authors studied the nationwide prevalence of psychosocial rehabilitation programs for MI patients. Findings from a survey of U. S. hospitals with coronary care units (n = 1628) included widespread involvement of patients and families in inpatient programs, approximately half as many continuing in outpatient programs, limited use of group counseling, and multidisciplinary staffing but counseling by nurses and social workers primarily. The clinical and economic benefits of group-oriented psychosocial rehabilitation programs are discussed. The authors encourage more psychologically informed intervention in the various parts of the patient's life-space and more use of groups.     

Depression in patients with moderate Alzheimer disease: a prospective observational cohort study

Syndromes of depression are frequently concomitant with Alzheimer disease (AD), although often inaccurately diagnosed and/or treated. This prospective, multicenter, observational, cohort study assessed baseline data and 6-month disease changes in moderate AD patients (n=1249) from Spain. Baseline Cornell Scale for Depression in Dementia (CSDD) scores defined 2 cohorts (depressive ≥8 or nondepressive <8). Fewer patients had baseline Diagnostic and Statistical Manual for Mental disorders-IV depression diagnosis (38.9%) than CSDD ≥8 (55.6%). Analysis of diagnostic accuracy of the CSDD versus the Diagnostic and Statistical Manual for Mental disorders-IV criteria showed an optimal cutoff score of ≥12. However, the predefined CSDD cutoff score showed subsyndromal depressive symptomatology associated with lower functionality, worse neuropsychiatric symptomatology, increased caregiver distress, and greater 6-month functional and clinical impairments. Cognition (baseline and 6-month progression) was not significantly associated with depressive symptomatology. Depressive patients received more antidepressive and/or antipsychotic treatments, showing CSDD and Neuropsychiatric Inventory Questionnaire (severity and caregiver distress) 6-month improvements but maintaining doubled scores than nondepressive patients. In conclusion, CSDD ≥8 identified depressive symptomatology in moderate AD patients, significantly associated with excessive neuropsychiatric symptoms and functional, but not cognitive, 6-month deterioration. The health effects over patients and caregivers, alongside the finding that most patients remained depressive after 6 months, demand accurate diagnostic tools and effective treatments for depression in AD.