Do statins really increase the risk of Parkinson’s disease?

Statins are famous, and their fame lies in their ability to bust cholesterol, the villain in many medical disorders such as heart attack (myocardial infarction) and stroke. Some may add that statins are infamous, and this is partly because of their side effects such as muscle pain. Love them or hate them, we can’t get away from statins…even as the debate rages about their benefits and downsides.

By ChiltepinsterOwn work, CC BY-SA 3.0, Link

It is not surprising therefore that the statin debate will filter into neurology. The sticking point here however has nothing to do with cholesterol busting, but all to do with whether statins increase or reduce the risk of developing Parkinson’s disease (PD). Strange as it may seem, statins and PD have a long history. And a positive one generally, I hasten to add. There is a large body of evidence to suggest a protective effect of statins on PD as reflected in the following studies:

  1. Confounding of the association between statins and Parkinson disease: systematic review and meta-analysis 
  2. Statin therapy prevents the onset of Parkinson disease in patients with diabetes
  3. Statin use and risk of Parkinson’s disease: A meta-analysis 
  4. Statin use and its association with essential tremor and Parkinson’s disease
  5. Statin use and the risk of Parkinson’s disease: an updated meta-analysis
  6. Long-term statin use and the risk of Parkinson’s disease
  7. Discontinuation of statin therapy associated with Parkinson’s disease
Modeling the Molecular Basis of Parkinson’s Disease. Argonne National Laboratory on Flikr https://www.flickr.com/photos/argonne/4192798573

It was therefore with some consternation that a recent study, published in the journal Movement Disorders, really put the cat among the pigeons. The paper is titled:

Statins may facilitate Parkinson’s disease: insight gained from a large, national claims database,

The authors of this paper set out to investigate ‘the controversy surrounding the role of statins in Parkinson’s disease’. In this retrospective analysis of over 2,000 people with PD, and a similar number of control subjects, the authors found that statins significantly increased the risk of developing PD. This is clearly a conclusion looking for a fight!

By Col. Albert S. Evans – internet archives, Public Domain, Link

I must admit I was totally unaware there was any controversy about statins and PD. I was therefore curious to find out what studies are out there fuelling it. Which other trials have bucked the trend and reported an increased risk of PD from statins? And where best to find the answers but in PubMed, the repository of all human knowledge! And I found that there were only a few studies that did not report a protective effect of statins on PD, and these studies concluded, quite reasonably, that they found no relationship between PD and statins. Here are a few of the studies:

  1. Statin adherence and the risk of Parkinson’s disease: A population-based cohort study. 
  2. Use of statins and the risk of Parkinson’s disease: a retrospective case-control study in the UK. 
  3. Statin use and the risk of Parkinson disease: a nested case control study. 

These papers reporting the absence of evidence seem happy to engage in an amicable debate to resolve the question.

By DavidKF1949Own work, CC BY-SA 3.0, Link

One study however stood out like a sore thumb because it positively reported a negative effect of statins on PD (try and work that out!). This 2015 study, also published in Movement Disorders, is titled Statins, plasma cholesterol, and risk of Parkinson’s disease: a prospective study. The paper concludes that “statin use may be associated with a higher PD risk, whereas higher total cholesterol may be associated with lower risk“. Not only are the authors arguing that statins are bad for PD, they are also suggesting that cholesterol is good! This is a paper that was itching for fisticuffs.

By Jan SteenWeb Gallery of Art:   Image  Info about artwork, Public Domain, Link

What is a jobbing neurologist to do? What are the millions of people on statins to do? Whilst awaiting further studies, I will say stay put. Go with the bulk of the evidence! And keep track of The Simvastatin Trial, funded by The Cure Parkinson’s Trust. This trial is looking at the benefit of statins in slowing down PD. And surely, very soon, the science will lead to a resolution of the argument-all you need to do is keep track of everything PD in Neurochecklists.

By Léon Augustin Lhermittehttp://wellcomeimages.org/indexplus/obf_images/fc/7f/643258ab30237374aaea5ac15757.jpgGallery: http://wellcomeimages.org/indexplus/image/L0006244.html, CC BY 4.0, Link

 

Primary angiitis of the CNS: unusual presentations of a rare and dangerous disorder

Primary angiitis of the central nervous system (PACNS) is inflammation of the blood vessels of the central nervous system (stating the obvious you might say). It differs from other forms of angiitis or vasculitis, such as lupus and giant cell arteritis (GCA), which respect no boundaries. PACNS is as dangerous a neurological disorder as they come, and just as rare. It requires aggressive, and paradoxically equally life-threatening, immunosuppressive treatment. Between the devil and deep blue sea-that’s exactly where the neurologist managing a patient with PACNS will be found.

BRAINADE! the Brain Grenade. Emilio Garcia on Flikr. https://www.flickr.com/photos/lapolab/11929014084
BRAINADE! the Brain Grenade. Emilio Garcia on Flikr. https://www.flickr.com/photos/lapolab/11929014084

The clinical features of PACNS are unfortunately very non-specific and include headaches, seizures, stroke, and cognitive changes. This makes PACNS is a challenge to diagnose. Even when suspected, PACNS may evade detection even by the special scan of the blood vessels called angiography. More frequently, the only certain way of confirming this disease in life is with a brain biopsy. Did I say ‘certain’? I take that back. Alas, even brain biopsy is not guaranteed to make the diagnosis of PACNS. A high degree of confidence and teeth-gritting is therefore an absolute requirement in any neurologist unfortunate enough to come face-to-face with this menace.

By The original uploader was Glitzy queen00 at English Wikipedia - Transferred from en.wikipedia to Commons., CC BY-SA 3.0, Link
By The original uploader was Glitzy queen00 at English Wikipedia – Transferred from en.wikipedia to Commons., CC BY-SA 3.0, Link

To make complicated matters even worse for the unwary neurologist, there are now reports suggesting that PACNS presents in even rarer and atypical ways. For the neurological Sherlocks and Poirots, here are 2 unusual presentations of PACNS.

Isolated spinal cord involvement

Spinal Cord 2. Green Flames 09 on Flikr. https://www.flickr.com/photos/greenflames09/116396742
Spinal Cord 2. Green Flames 09 on Flikr. https://www.flickr.com/photos/greenflames09/116396742

This is a case report from the Journal of Neurology of a 44-year old woman who presented with PACNS but with purely spinal cord involvement and completely sparing the brain. The diagnosis in this case was only confirmed with a spinal cord biopsy. The authors reviewed the literature and only found 8 previous reports of PACNS beginning in the spinal cord, and half of these progressed to involve the brain. 

Unilateral cerebral presentation

Keep Left. Howard Lake on Flikr. https://www.flickr.com/photos/howardlake/4440588147
Keep Left. Howard Lake on Flikr. https://www.flickr.com/photos/howardlake/4440588147

Most cases of PACNS evenly involve both sides of the brain. This report, again from Journal of Neurology, bucks this trend with the report of a 55-year old man who had PACNS which only involved the left side of his brain. This unilateral hemispheric PACNS is a reminder that an entity called focal PACNS exists.

https://pixabay.com/en/light-bulb-brain-absorbed-light-1599359/
https://pixabay.com/en/light-bulb-brain-absorbed-light-1599359/

Do you have any sightings of unusual cases of PACNS? Please drop a comment

_________________________________________________________________________


	

7 ominous signs that suggest you need to see a neurologist

Neurologists spend most of their time diagnosing benign conditions which are curable or treatable, or at least people learn to live with. Every now and then we see people with startling symptoms such as coma, convulsions, neck stiffness, or paralysis. These are obviously concerning to patients and their families who have a foreboding of diseases such as meningitis, epilepsy, and stroke. Serious as these disorders are, they at least announce themselves and show their hands. Many other neurological symptoms unfortunately give no hint of the serious diseases that follow in their trail. That is when things get a bit tricky.

Ominous. Ankakay on Flikr. https://www.flickr.com/photos/ankakay/4101391453
Ominous. Ankakay on Flikr. https://www.flickr.com/photos/ankakay/4101391453

What are these seemingly benign symptoms which jolt neurologists out of their blissful complacency? What are these red flag symptoms that pretend they are grey? Here are my 7 deceptively ominous neurological signs everyone should know about.

7. A numb chin

By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 784, Public Domain, https://commons.wikimedia.org/w/index.php?curid=531758
By Henry Vandyke CarterHenry Gray (1918) Anatomy of the Human Body (See “Book” section below)Bartleby.com: Gray’s Anatomy, Plate 784, Public Domain, https://commons.wikimedia.org/w/index.php?curid=531758

This must be the most deceptive sinister symptom in neurology. Not many people will rush to their doctors to complain about a numb chin, but it is a symptom that makes neurologists very nervous. This is because the chin gets its sensory supply from the mandibular branch of the fifth cranial nerve, also called the trigeminal nerve because it has three branches. And neurologists know that, for some bizarre reason, cancers from other parts of the body occasionally send deposits to this nerve. The numb chin syndrome is therefore not to be treated lightly.

6. Muscle twitching

OK, don’t panic yet. We have all experienced this; a flickering of an overused and tired muscle; a twitching of the odd finger; the quivering of the calf muscles in older people. Neurologists call these fasciculations, and they are only a concern if they are persistent, progressive, and widespread. And also usually only if the affected muscles are weak. In such cases neurologists worry that fasciculations are the harbingers of sinister diseases, particularly motor neurone disease (MND), better known in America as amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease. Many people with muscle twitching will however have nothing seriously wrong with them, and many will be shooed out of the consulting room with the label of benign fasciculations syndrome (we love our syndromes, especially when they are benign). There are many other causes of fasciculations, but MND is clearly the most sinister of them all.

5. Transient visual loss

Scott Maxwell on freestockphotos. http://www.freestockphotos.biz/stockphoto/9747
Scott Maxwell on freestockphotos. http://www.freestockphotos.biz/stockphoto/9747

Neurologists often ask people with headache if their vision blurs or disappears for brief periods of time. These visual obscurations are not as dramatic as the visual loss that accompanies minor strokes or transient ischaemic attacks (TIAs). Visual obscurations affect both eyes and last only a few seconds. They are the result of sudden but brief increases in an already elevated pressure in the head. This may occur with relatively benign conditions such as idiopathic intracranial hypertension (IIH), but it may also portend a serious disorder such as a brain tumour.

4. Sudden loss of bowel or bladder control

bubble-1013915_1920

Loss of control down there would surely concern many people, but often not with the urgency it deserves. There are many non-neurological causes of bowel or bladder incontinence, but a sudden onset suggests that it is arising from the nervous system. The worrying diagnoses here are spinal cord compression and spinal cord inflammation (transverse myelitis). These disorders are often associated with other symptoms such as leg stiffness and weakness, but I really wouldn’t wait until these set in before I ask to see a neurologist.

3. Saddle anaesthesia

bicycle-saddle-791704_1920

Whilst we are on the topic of things down there, a related sinister symptom is loss of sensation around the genitals and buttocks, something your doctor will prudently call saddle anaesthesia. This arises when the nerves coming off the lower end of the spinal cord, collectively called the cauda equina, are compressed. The unpalatable condition, cauda equina syndrome (CES), worries neurologists because the compression may be due to a tumour in the spinal canal.

PS: The bicycle saddle is an apt analogy, but if you prefer horse riding, below is an alternative image to soothe your hurt feelings.

 

By BLW - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1956552
By BLW – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1956552

2. A painful droopy eyelid

A droopy eyelid is a deceptively benign symptom which worries neurologists. This symptom, which neurologist prefer to call ptosis, is particularly concerning if it is accompanied by double vision. One worrying disorder which causes ptosis is myasthenia gravis (MG), and this presents with ptosis on both sides. More sinister is ptosis which is present only on one side, particularly if it is painful. This may be caused by brain aneurysms, especially those arising from a weakness of the posterior communicating artery (PCOM) artery. As the aneurysm grows, it presses on the third cranial or oculomotor nerve, one of three nerves that controls the eyeballs and keeps the eyelids open. An aneurysm is literally a time-bomb in the brain as they wield the threat of bursting and causing a catastrophic bleeding around the brain. This makes ptosis an ominous, but also a helpful, neurological symptom.

By Cumulus z niderlandzkiej Wikipedii, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=3167579
By Cumulus z niderlandzkiej Wikipedii, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=3167579

There are many other causes of ptosis including Horner’s syndrome, so don’t panic yet but get that eyelid checked out if it refuses to straighten out.

 

1. Thunderclap headache

By © Marie-Lan Nguyen / Wikimedia Commons, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=24189896
By © Marie-Lan Nguyen / Wikimedia Commons, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=24189896

thunderclap headache is a symptom that means exactly what it says on the label! Neurologists will ask if the onset felt as if one was hit by a cricket bat. Even though most people have never been so assaulted, almost everyone with thunderclap headache readily agree this is what it feels like. It is such a distressing symptom that it doesn’t strike the afflicted person (pun intended) that their doctors are more concerned about investigating them, then they are in curing their headache. They patient is rushed to the CT scanner, and then subjected to a lumbar puncture. The doctors then heave a huge sigh of relief when the spinal fluid shows no blood or blood products, reassured that the patient has not suffered a subarachnoid haemorrhage (SAH) from a ruptured a brain aneurysm. The patient, who now has just another headache, is left to get to grips with their now, suddenly, very uninteresting symptom. There are many other causes of a thunderclap headache, but a ruptured aneurysm is the most sinister. If you develop a thunderclap headache, don’t wait to see a neurologist…just get to the nearest hospital!

PS: Don’t feel aggrieved if you are across the Pacific; it is also a thunderclap headache if it felt like being hit by a baseball bat!

Baseball bat in sun. Peter Chen on Flikr https://www.flickr.com/photos/34858596@N02/3239696542
Baseball bat in sun. Peter Chen on Flikr https://www.flickr.com/photos/34858596@N02/3239696542

 

Want to check out more ominous signs? Check out Smart handles and red flags in neurological diagnosis by the neurologist Chris Hawkes in Hospital Medicine.

 

What are the most iconic neurological disorders?

Neurology is a broad specialty covering a staggering variety of diseases. Some neurological disorders are vanishingly rare, but many are household names, or at least vaguely familiar to most people. These are the diseases which define neurology. Here, in alphabetical order, is my list of the top 60 iconic neurological diseases, with links to previous blog posts where available.

 

1. Alzheimer’s disease

By uncredited - Images from the History of Medicine (NLM) [1], Public Domain, https://commons.wikimedia.org/w/index.php?curid=11648572
By uncredited – Images from the History of Medicine (NLM) [1], Public Domain, https://commons.wikimedia.org/w/index.php?curid=11648572

2. Behcet’s disease

By Republic2011 - Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=17715921
By Republic2011Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=17715921

3. Bell’s palsy

By http://wellcomeimages.org/indexplus/obf_images/69/f2/8d6c4130f4264b4b906960cf1f7e.jpgGallery: http://wellcomeimages.org/indexplus/image/M0011440.html, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36350600
By http://wellcomeimages.org/indexplus/obf_images/69/f2/8d6c4130f4264b4b906960cf1f7e.jpgGallery: http://wellcomeimages.org/indexplus/image/M0011440.html, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36350600

4. Brachial neuritis

5. Brain tumours

6. Carpal tunnel syndrome

7. Cerebral palsy (CP)

8. Cervical dystonia

9. Charcot Marie Tooth disease (CMT)

By http://wellcomeimages.org/indexplus/obf_images/66/09/4dfa424fe11bb8dc56b2058f04ba.jpgGallery: http://wellcomeimages.org/indexplus/image/V0026141.html, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36578490
By http://wellcomeimages.org/indexplus/obf_images/66/09/4dfa424fe11bb8dc56b2058f04ba.jpgGallery: http://wellcomeimages.org/indexplus/image/V0026141.html, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36578490

10. Chronic inflammatory demyelinating polyneuropathy (CIDP)

11. Cluster headache

12. Creutzfeldt-Jakob disease (CJD)

By Unknown - http://www.sammlungen.hu-berlin.de/dokumente/11727/, Public Domain, https://commons.wikimedia.org/w/index.php?curid=4008658
By Unknownhttp://www.sammlungen.hu-berlin.de/dokumente/11727/, Public Domain, https://commons.wikimedia.org/w/index.php?curid=4008658

13. Duchenne muscular dystrophy (DMD)

By G._Duchenne.jpg: unknown/anonymousderivative work: PawełMM (talk) - G._Duchenne.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9701531
By G._Duchenne.jpg: unknown/anonymousderivative work: PawełMM (talk) – G._Duchenne.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9701531

14. Encephalitis

15. Epilepsy

16. Essential tremor

17. Friedreich’s ataxia

By Unknown - http://www.uic.edu/depts/mcne/founders/page0035.html, Public Domain, https://commons.wikimedia.org/w/index.php?curid=3960759
By Unknownhttp://www.uic.edu/depts/mcne/founders/page0035.html, Public Domain, https://commons.wikimedia.org/w/index.php?curid=3960759

18. Frontotemporal dementia (FTD)

19. Guillain-Barre syndrome (GBS)

By Anonymous - Ouvrage : L'informateur des aliénistes et des neurologistes, Paris : Delarue, 1923, Public Domain, https://commons.wikimedia.org/w/index.php?curid=28242077
By Anonymous – Ouvrage : L’informateur des aliénistes et des neurologistes, Paris : Delarue, 1923, Public Domain, https://commons.wikimedia.org/w/index.php?curid=28242077

20. Hashimoto encephalopathy

21. Hemifacial spasm

22. Horner’s syndrome

By Unknown - http://ihm.nlm.nih.gov/images/B15207, Public Domain, https://commons.wikimedia.org/w/index.php?curid=19265414
By Unknownhttp://ihm.nlm.nih.gov/images/B15207, Public Domain, https://commons.wikimedia.org/w/index.php?curid=19265414

23. Huntington’s disease (HD)

https://en.wikipedia.org/wiki/George_Huntington#/media/File:George_Huntington.jpg
https://en.wikipedia.org/wiki/George_Huntington#/media/File:George_Huntington.jpg

24. Idiopathic intracranial hypertension (IIH)

25. Inclusion body myositis (IBM)

26. Kennedy disease

27. Korsakoff’s psychosis

28. Lambert-Eaton myasthenic syndrome (LEMS)

29. Leber’s optic neuropathy (LHON)

30. McArdles disease

31. Meningitis

32. Migraine

33. Miller-Fisher syndrome (MFS)

By J3D3 - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=34315507
By J3D3Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=34315507

34. Motor neurone disease (MND)

35. Multiple sclerosis (MS)

36. Multiple system atrophy (MSA)

37. Myasthenia gravis (MG)

38. Myotonic dystrophy

39. Narcolepsy

40. Neurofibromatosis (NF)

41. Neuromyelitis optica (NMO)

42. Neurosarcoidosis

43. Neurosyphilis

44. Parkinson’s disease (PD)

45. Peripheral neuropathy (PN)

46. Peroneal neuropathy

47. Progressive supranuclear palsy (PSP)

48. Rabies

49. Restless legs syndrome (RLS)

50. Spinal muscular atrophy (SMA)

51. Stiff person syndrome (SPS)

52. Stroke

53. Subarachnoid haemorrhage (SAH)

54. Tension-type headache (TTH)

55. Tetanus

56. Transient global amnesia (TGA)

57. Trigeminal neuralgia

58. Tuberous sclerosis

59. Wernicke’s encephalopathy

By J.F. Lehmann, Muenchen - IHM, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9679254
By J.F. Lehmann, Muenchen – IHM, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9679254

60. Wilson’s disease

By Carl Vandyk (1851–1931) - [No authors listed] (July 1937). "S. A. Kinnier Wilson". Br J Ophthalmol 21 (7): 396–97. PMC: 1142821., Public Domain, https://commons.wikimedia.org/w/index.php?curid=11384670
By Carl Vandyk (1851–1931) – [No authors listed] (July 1937). “S. A. Kinnier Wilson“. Br J Ophthalmol 21 (7): 396–97. PMC: 1142821., Public Domain, https://commons.wikimedia.org/w/index.php?curid=11384670

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The Neurology Lounge has a way to go to address all these diseases, but they are all fully covered in neurochecklists. In a future post, I will look at the rare end of the neurological spectrum and list the 75 strangest and most exotic neurological disorders.

Imagine you have just suffered a devastating stroke!

Imagine you have just had a stroke!

Devastating,  distressing, life changing.

By Bhernandez from miami - stressed and worried, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=11438423
By Bhernandez from miami – stressed and worried, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=11438423

Imagine you are stuck in a wheelchair,

Helpless and speechless.

wheelchair-1230101_1920

Now imagine you are transported back in time,

6 months before your stroke

Antique clock face with hands. Cindy Schultz on Flikr. https://www.flickr.com/photos/29008389@N03/5937058272
Antique clock face with hands. Cindy Schultz on Flikr. https://www.flickr.com/photos/29008389@N03/5937058272

You see your physically able self,

Master of your faculties,

Enjoying all the ‘good things’ of life.

By http://wellcomeimages.org/indexplus/obf_images/4c/82/72258f7d55d449942e63cf26072d.jpgGallery: http://wellcomeimages.org/indexplus/image/V0019565.html, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36528051
By http://wellcomeimages.org/indexplus/obf_images/4c/82/72258f7d55d449942e63cf26072d.jpgGallery: http://wellcomeimages.org/indexplus/image/V0019565.html, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36528051

Now feel the regret,

That you did nothing to prevent the stroke,

The sudden event that stole your dreams and aspirations.

Regret. Neil Moralee on Flikr. https://www.flickr.com/photos/neilmoralee/13747234805
Regret. Neil Moralee on Flikr. https://www.flickr.com/photos/neilmoralee/13747234805

Now you realise this is a second chance,

After such a close shave,

Imagine the relief.

Phew!. Tibor Miklos on Flikr. https://www.flickr.com/photos/tibormade/3267191528
Phew!. Tibor Miklos on Flikr. https://www.flickr.com/photos/tibormade/3267191528

Imagine the pleasure!

smile-476038_1280

Now you have a choice to make.

To resume the pleasures you previously indulged in…

Sumptuous Lunch. Nadir Hashmi on Flikr. https://www.flickr.com/photos/nadircruise/5749352648
Sumptuous Lunch. Nadir Hashmi on Flikr. https://www.flickr.com/photos/nadircruise/5749352648

Or recollect the warnings you ignored before,

Which you turned a deaf ear to,

Which are now more valuable than all the gems in the world.

gems-836763_1920

You wisely decide to turn a new leaf.

Turn page. andy.brandon50 on Flikr. https://www.flickr.com/photos/54027476@N07/4999944659
Turn page. andy.brandon50 on Flikr. https://www.flickr.com/photos/54027476@N07/4999944659

Now make a full list,

Of all the things you should have done,

And could have done,

To prevent the disastrous stroke.

pexels-photo-58457

Now take a hard look at your list,

And start acting on it,

Right now!

JUST DO IT. Paper Fold. the_fafa on Flikr. https://www.flickr.com/photos/32559932@N04/6051955099
JUST DO IT. Paper Fold. the_fafa on Flikr. https://www.flickr.com/photos/32559932@N04/6051955099

_______0_______0_______0_______0_______0_______0_______0____

Get off the couch,

Walk round the block,

Put out that cigarette.

Ashtray. Jocelyn on Flikr. https://www.flickr.com/photos/-jocelyn-/6513335519
Ashtray. Jocelyn on Flikr. https://www.flickr.com/photos/-jocelyn-/6513335519

Switch off the TV

Get on that weighing scale

Check your blood pressure

By www.volganet.ru, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=16363865
By www.volganet.ru, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=16363865

Cut down internet time,

Cut out the fat and carbs,

Get on the treadmill.

Running on a treadmill. E'Lisa Campbell on Flikr. https://www.flickr.com/photos/eccampbellphotography/5447958713
Running on a treadmill. E’Lisa Campbell on Flikr. https://www.flickr.com/photos/eccampbellphotography/5447958713

Say ‘pass’ to that pint 

Top up with the greens

Invest in a good pair of walking shoes

walking-boots-220499_1280

Visit a garden or park this weekend

Mow the lawn

 Give up the stressful job

6/52³: Estrés / Stress. Andrés Nieto Porras on Flikr. https://www.flickr.com/photos/anieto2k/27247021692
6/52³: Estrés / Stress. Andrés Nieto Porras on Flikr. https://www.flickr.com/photos/anieto2k/27247021692

_______0_______0_______0_______0_______0_______0_______0____

And now you have finally done it!

You have prevented a calamitous stroke.

sunset-summer-golden-hour-paul-filitchkin

 

It wasn’t that hard after all,

Now you can relax,

And be proud of yourself!

boy-145743

You may download the powerpoint version of this presentation below:

imagine a stroke

What are the obstacles to creating reliable neurology checklists?

This is a follow up to my previous blog post on the value of checklists in medical practice. That post explored how checklists improve clinical practice and promote patient safety. It also cited Atul Gawande‘s call to Medicine to “seize the opportunity” and produce checklists for all aspects of clinical practice.

Neurology. MV Maverick. https://www.flickr.com/photos/themvmaverick/11396461045
Neurology. MV Maverick. https://www.flickr.com/photos/themvmaverick/11396461045

 

Picking up this gauntlet for neurology comes with peculiar challenges. Here are the 7 hurdles to overcome.

1. The challenge of a diverse specialty

Legume diversity. Global Crop Diversity Trust on Flikr. https://www.flickr.com/photos/croptrust/3594324633
Legume diversity. Global Crop Diversity Trust on Flikr. https://www.flickr.com/photos/croptrust/3594324633

Neurology consists of an astonishing diversity of sub-specialities. Any neurology checklist must exhaustively cover the major neurological categories such as stroke, epilepsy, movement disorders, headache, dementia, neuromuscular diseases, sleep disorders, neuro-inflammation, nervous system tumours, and neurological infections. These topics must be thoroughly covered with emphasis on their clinical features, investigations, and treatments. A useful database must also include rare neurological diseases, of which neurology has quite a few. This is reflected in my previous blog on the most perplexing diseases that excite neurologists.

2. The challenge of multiple associated specialties

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Neurological disorders cut across many diverse allied neurological specialties. Any dependable checklist database must cover these specialised fields which include neurosurgery, neuroradiology, neuroophthalmology, neuropsychiatry, neuropaediatrics, and pain management. It must also include important diseases which straddle neurology and general medicine. These include a long list of cardiovascular, nutritional, endocrine and gastrointestinal disorders. Furthermore, neurologists often have to deal with surgical complications especially in orthopaedics and following transplant surgery. Neurologists are also frequently called upon to attend to neurological problems that are unique to pregnancy. Any practical checklist application must therefore thoroughly address these areas.

Brain Cells Created From Skin Cells in Landmark Study. Day Donaldson on Flikr. https://www.flickr.com/photos/thespeakernews/15656329862
Brain Cells Created From Skin Cells in Landmark Study. Day Donaldson on Flikr. https://www.flickr.com/photos/thespeakernews/15656329862

3. The challenge of reliable content

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It goes without saying that the most important feature of any database is reliable content which alone will engender trust and confidence. A reliable checklist must obtain its material from dependable sources. Neurology is replete with reliable textbooks and reference websites, . Neurology is also bursting at the seams with journals such as Neurology, Brain, the JNNP, and Journal of Neurology, each churning out a bewildering array of neurology guidelines, review articles, ground-breaking studies, and fascinating case reports. The challenge is to keep a regular handle on these sources, sifting through for practical and established material. As important for the user is that any checklist must be fully referenced and hyperlinked to the source material.

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4. The challenge of practical functionality

Any practical checklist database must be available on the move, easily accessible and searchable. In other words, it must be in the form of a mobile application. The app must have a reliable search functionality. More importantly for users is the requirement that the application must serves as a prompt to remember important points across the breadth of neurological practice: history taking, investigations, differential diagnosis, and treatment. For the administrator, the technology must make it easy to update and edit content, keeping the content consistently up-to-date.

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5. The challenge of varied target groups

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In developing any form of medical resource, it is a challenge to define the target audience. The primary aim of a neurology checklist application is to ease the challenges medical professionals face in accessing relevant and practical information about neurology in a timely way. This may be on a busy ward round or clinic, but also when researching a topic or preparing a presentation. The core users of a neurology application will therefore clearly be neurologists and neurology trainees.

By SpinningSpark real life identity: SHA-1 commitment ba62ca25da3fee2f8f36c101994f571c151abee7 - Created with Superliminal's Magic Cube 4D, CC BY-SA 3.0, https://en.wikipedia.org/w/index.php?curid=17492843
By SpinningSpark real life identity: SHA-1 commitment ba62ca25da3fee2f8f36c101994f571c151abee7 – Created with Superliminal’s Magic Cube 4D, CC BY-SA 3.0, https://en.wikipedia.org/w/index.php?curid=17492843

In many places however other cadres of medicine cater for people with neurological diseases. Psychiatrists, neurosurgeons, paediatriciansgeneral physicians, obstetricians, ophthalmologists, specialist and general nurses, would likely access the database. Other health care professionals may also find areas of interest such as speech therapists, physiotherapists and occupational therapistsMedical students and researchers also require vast amounts of neurological information, often within restricted time frames.

A Tangle of Different Colours 001. Christina Quinn on Flikr. https://www.flickr.com/photos/chrisser/7909899736
A Tangle of Different Colours 001. Christina Quinn on Flikr. https://www.flickr.com/photos/chrisser/7909899736

6. The challenge of public access

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Specialised medical application are never aimed at non-medically trained people. The reality however is that the general public are closely involved in their care today, seeking reliable information to address their medical concerns. It is inevitable that patients and their families will access the checklist database. For this reason the language must be simple and clear, avoiding any sort of ambiguity.

7. The challenge of resources and pricing

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A checklist application, to be most beneficial, should ideally be free to use. A Wikipedia model would be a model to adapt. But creating a checklist database, with all the features mentioned above, would surely stretch resources in terms of time and funding. There will also be great demands on resources to maintain and enhance it. A balance must be struck between beneficence and realism. Such a balance should have, as with most applications, a free version with sufficient access of some sort, and a premium version with unlimited access. The developer must also be aware that potential users have limited resources to spread round their conflicting demands. Any premium account should be affordable, perhaps not more than the equivalent cost of a cup of coffee and a cake a month.

Muffin and coffee. Phil Gyford on Flikr. https://www.flickr.com/photos/philgyford/6534958441
Muffin and coffee. Phil Gyford on Flikr. https://www.flickr.com/photos/philgyford/6534958441 

 

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Is there any neurology checklist application that has taken the above challenges into consideration? This will be revealed in my next blog post, How simple checklists unlock excellent neurological practice?

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How to keep your distance from a neurologist

An apple a day will never be enough to avoid neurological diseases. For one, the nervous system is extensive, vulnerable from the top of the head to the tips of the toes. For another, the cells that constitute the nervous system are susceptible to an astonishing variety of insults. This explains the diversity and number of neurological diseases, and why medical students and doctors find neurology daunting.

brain.nervous.system.tumblr_lgnqxgo0bK1qbz7jdo1_500. Beth Scupham on Flikr. https://www.flickr.com/photos/bethscupham/6597797299
brain.nervous.system.tumblr_lgnqxgo0bK1qbz7jdo1_500. Beth Scupham on Flikr. https://www.flickr.com/photos/bethscupham/6597797299

 

There are many neurological diseases that we can do absolutely nothing to guard against. This is the case with genetic neurological diseases, unless we find a way of choosing our parents wisely! Proven ways of improving our defences include exercising regularly, eating healthily, and stopping smoking; these however have their limitations against many neurological disorders.

But don’t despair, there are measures we can take to shield ourselves against some avoidable neurological conditions. Many of these arise because of activities we engage in, often mindless of their consequences. The list is fairly long, but here are my  ‘12 Don’ts of Neurology’ to help avoid a meeting with a neurologist.

1. Don't get angry

Anger is an unpredictable negative emotion which hardly ever serves any useful purpose. If you need a very good reason to keep your cool, know that anger is a recognised trigger of stroke. On balance therefore, it’s not worth blowing a fuse.

2. Don’t stay too long at the hair-dressers sink
Lego hairdresser. RobethK on Flikr. https://www.flickr.com/photos/39066002@N05/3595226638
Lego hairdresser. RobethK on Flikr. https://www.flickr.com/photos/39066002@N05/3595226638

Excessive neck extension, as occurs at the hairdresser’s or the chiropractor, could stretch and tear the inner lining of a neck artery. This painful tear is called a dissection and it allows a blood clot to form. What happens next is the serious part; the clot may dislodge and travel up the blood vessel where it blocks blood flow to the brain. The result, understandably, is called the beauty parlor stroke syndrome.

3. Don’t cross your legs
By William Orpen - 1. Unknown2. National Maritime Museum, London3. Royal Museums Greenwich, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1210625*oil on canvas *96.5 x 91.5 cm *circa 1900 *signed b.r.: Orpen
By William Orpen – 1. Unknown2. National Maritime Museum, London3. Royal Museums Greenwich, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1210625*oil on canvas
*96.5 x 91.5 cm
*circa 1900
*signed b.r.: Orpen

 

We all do it: sit back and hang one leg over the other knee. Habitual crossed-leg sitting however puts your peroneal nerve at risk of compression where it crosses round the knee to innervate the leg and foot muscles. The result is foot drop. Sitting in the yoga lotus position causes a similar damage, as does prolonged squatting (strawberry pickers foot drop).

4. Don’t stay too long on the toilet seat
Monaco-toilet seat. waldopepper on Flikr. https://www.flickr.com/photos/waldopepper/979771632
Monaco-toilet seat. waldopepper on Flikr. https://www.flickr.com/photos/waldopepper/979771632

The sciatic nerve is the largest peripheral nerve in the body, and it traverses the buttock on its way to innervate most of the lower limb muscles. It is vulnerable to prolonged sitting on hard surfaces, and it’s a no-brainer that this is called toilet-seat neuropathy. You could of course have your toilet seat nicely padded! You may also protect your sciatic nerve by not putting thick wallets and coins in your back pocket.

5. Don’t build your muscles to excess
Venice muscle beach. Lin Mei on FLikr. https://www.flickr.com/photos/leomei/2651904068/in/photostream/
Venice muscle beach. Lin Mei on FLikr. https://www.flickr.com/photos/leomei/2651904068/in/photostream/

It is trendy to have a nice six-pack or firm pecs, but this may come at a price. As the muscles get stronger and bulkier, they may compress the nerves which pass through them. Most vulnerable are the thoracodorsal, the suprascapular, and the pectoral nerves. A shrunken pectoral muscle on one side is sure evidence that you have overdone it.

6. Don’t over-do the athletic thing

Athletic sports that involve excessive upper limb movements may stretch and compress the nerves. Particularly vulnerable is the axillary nerve which supplies the muscles you need to lift your arm away from your body. The culprit sports include volleyball, javelin, rock climbing, and rugby.

7. Don’t overload that backpack
Nile ruckpack. Zhao on Flikr. https://www.flickr.com/photos/kodomut/15383406657
Nile ruckpack. Zhao on Flikr. https://www.flickr.com/photos/kodomut/15383406657

It’s so convenient to sling a backpack over the shoulder, but it is not benign if you overload it. This is because the heavy weight of a backpack may damage the brachial plexus, the large network of nerves that innervate the upper limb. The resulting limp upper arm is called…you guessed it, rucksack paralysis.

8. Don’t ever be handcuffed
By No machine-readable author provided. Klaus with K assumed (based on copyright claims). - No machine-readable source provided. Own work assumed (based on copyright claims)., CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=331725
By No machine-readable author provided. Klaus with K assumed (based on copyright claims). – No machine-readable source provided. Own work assumed (based on copyright claims)., CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=331725

 

The wrist is the gateway to three important nerves, all vulnerable to compression. External pressure on the wrist particularly picks on the superficial branch of the radial nerve. The resulting handcuff palsy causes pain and tingling over the back of the hand. A similar effect may result from tight wristwatches and bracelets. A good reason to go bare below the elbows.

9. Don’t hold to tightly to your bicycle handlebars
By http://www.flickr.com/people/liuwencheng/ - http://www.flickr.com/photos/liuwencheng/5231909712/, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=12397523
By http://www.flickr.com/people/liuwencheng/http://www.flickr.com/photos/liuwencheng/5231909712/, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=12397523

 

To avoid the so-called cyclists palsy, you must not only choose your machine carefully, but take care when riding. This is to protect your ulnar nerve which traverses the wrist just where the cycle handlebars would compress it. This causes paralysis of many of the small muscles of the hand, sparing only the thumb.

10. Don’t tighten your belt excessively

The victim nerve this time is a branch of the femoral nerve, the second largest nerve of the lower limb. This nerve migrates from the abdomen into the thigh by squeezing just under the belt line. It is vulnerable to compression here, and the result is meralgia paraesthetica. This is a fairly common condition, easily recognised by a combination of pain, tingling, and numbness over a well-demarcated patch on the outer thigh. Wearing skinny jeans is another recognised cause, as are prolonged sitting and weight gain.

11. Don’t use ill-fitting ski boots
By Amy Johnson, contesstant on EpicSki - http://www.epicski.com/t/109820/ok-time-for-some-flexon-pics, CC BY-SA 2.5, https://commons.wikimedia.org/w/index.php?curid=18307412
By Amy Johnson, contesstant on EpicSki – http://www.epicski.com/t/109820/ok-time-for-some-flexon-pics, CC BY-SA 2.5, https://commons.wikimedia.org/w/index.php?curid=18307412

 

Choosing the wrong ski boots may not just mess up your skiing holiday, it could result in compression of the peroneal nerve around the ankle . This causes tingling over the foot …but this may persist long after you have (angrily?) discarded the offending boots.

12. Don’t fail a hanging attempt
By Chris 73 / Wikimedia Commons, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1554031
By Chris 73 / Wikimedia Commons, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=1554031

 

The nerves vulnerable to the hangman’s noose are the greater auricular nerves. These nerves transmit sensation from the ears; not a major problem if the hanging is successful; if the attempt fails however, be prepared for numb ears in resurrection.

Tree Nervous System. Sam Salt on Flikr. https://www.flickr.com/photos/basilisksam/2305245225
Tree Nervous System. Sam Salt on Flikr. https://www.flickr.com/photos/basilisksam/2305245225

 

To explore this topic in further detail, I recommend the following books:


Localization in Clinical Neurology 

Peripheral Neurology: Case Studies