Geraint Fuller

Neurophilia: a fascination for neurology—a new syndrome

Neurophobia—the pathological fear of neurology—is a well recognised state of mind. This was first described in 19941 as occurring in medical students, and subsequently being demonstrated in junior doctors2 and around the world.3 ,4 While ‘neurophobia’ does not appear in the DSM-IV, the term does carry the implication that this is a disorder. However, as it is so widespread, occurring at all levels of training, across continents and through time, perhaps it should be regarded as the natural state for medical students and doctors. That certainly seems to be the presumption in many of the articles where it is discussed.2–4 In this article, I would like to explore a previously undescribed state, ‘neurophilia’, a love of neurology or more precisely a fascination by neurology. Moreover, I will argue that this is both widespread within medicine and the general population. Neurophilia is probably a precondition to become a neurologist and presumably pretty much all the readers of Practical Neurology are afflicted. How can we assess this in …

Milk, chocolate and Nobel prizes

In a recent paper Dr Messerli1 reported a strong correlation between a nations chocolate consumption with the countrys prowess in winning Nobel prizes per capita (see Carphology, in this issue). Messerli speculated that flavonoids within chocolate may contribute to this link by improving cognitive function—while recognising a correlation does not establish causation. However, chocolate is not usually consumed on its own, often being combined …

Revolutions in neurological training

> “Reform, reform, reform. Aren’t things bad enough already?” > > Duke of Wellington Photo courtesy of RemedyUK Postgraduate medical training in the UK is changing, not through evolution but by revolution. There are three inter-related elements to these changes (box), with changes in the body supervising training (PMETB), the structure of training itself (MMC) and the method of application for training posts (MTAS). The recent marked failings in the last of these, both inherent in the selection tools and in the technology delivering it, have been widely discussed in the press.1 MTAS is now being reviewed and revised in an attempt to salvage credible and fair selection for training posts. However, the most dramatic long-term changes are in the introduction of run-through training and it is this that I will focus on here. #### Changes in medical training in the UK Run-through training refers to a single training grade that takes the trainee from the end of their foundation programme, equivalent to intern elsewhere, through to specialist accreditation. Many readers from outside the UK will immediately be thinking “so what?”, because their system may already have run-through training. However, for UK trainees this is a dramatic change—more so for neurology than other specialties. The changes are meant to alter the structure but not the content of training. The changes are illustrated in the figure. Previously, the first year after qualification was as a “houseman”, followed by 2–4 years in Senior House …

Silent Witnesses in the Diagnosis of Epilepsy

Epilepsy is primarily a clinical diagnosis that depends on the patient’s account and – importantly – an accurate witness description of the attacks in the even to floss of awareness, consciousness or recall of the events. Unfortunately, not all ‘blackouts’ (loss of consciousness) are witnessed. So are there any useful clues – silent witnesses – that can tell us about the nature of a blackout under these circumstances? CONSIDER FOUR PATIENTS Patient A: a 44-year-old man wakes in the morning feeling non-specifically unwell and notices that he has bitten the side of his tongue. Patient B: a 36-year-old woman wakes in the morning feeling groggy and achy with mid-thoracic back pain, having gone to bed completely well the night before. Because of her back pain she attends her family doctor who arranges a plain X-ray, which shows a thoracic vertebral compression fracture (Fig. 1). Patient C: a 64-year-old man wakes in the morning with

WHAT SHOULD I TELL A PATIENT AFTER AN ISOLATED EPISODE OF DEMYELINATION

INTRODUCTION There is nowadays a widespread belief that it is right for patients to be actively involved in decisions about their care (Coulter 1999). Much time is given to informed consent before surgery. The balance of risks and benefits is discussed with the patient before proceeding to an operation. Discussion prior to a surgical intervention is more formalized than for medical intervention, such as drug treatment, because an operation is a unidirectional intervention, once it is done it cannot be undone. What other intervention is unidirectional in the same way as surgery? Giving information shares this property, once you have told a patient something you cannot undo that, you can expand on the information, put it in context, but you cannot retrieve the information. A large part of what we as neurologists do is to give patients information. We make diagnoses, which we explain to patients, we devise investigation and

48, XXYY syndrome associated tremor

48, XXYY syndrome is a form of sex chromosome aneuploidy that affects between 1 in 18 000 to 1 in 40 000 males. It is not inherited and is diagnosed by karyotyping. It has similarities to 47, XXY Klinefelters syndrome, with tall stature, micro-orchidism, hypergonadotropic hypogonadism and infertility in males. However, patients with 48, XXYY syndrome also commonly have dental problems, tremor, attention deficit disorder, learning difficulties, allergies and asthma. The tremor is typically reported as an intention tremor (in 71% of patients XXYY aged >20 years with 48), which becomes more common with age and worsens over time.

Neurologists and the ‘doctors with desks’ fallacy

Not very long ago neurologists made almost exclusively clinical diagnoses untroubled by scans or genetic tests. Diagnoses were proved right or wrong with time and sometimes pathology. This type of neurology was very difficult. Training was long and neurology was the province of the neurologist. Technological advances introduced scanners, genetic tests, improved neurophysiology and more sophisticated neurological diagnoses. These investigations were still scarce and often were only available in neuroscience centres. A significant part of neurological expertise was the optimum use of these scarce resources for patient management. More recently there has been a huge expansion in the provision of these technological aids to diagnosis. Scanners are much more widely available – and much more sophisticated. MR sequences such as diffusion weighting can be used to distinguish between old and new changes to tell you about the time course of events and not simply anatomical changes. The internet has also made access to information on rare and unusual diseases much easier – with journals such as this available online. This democratisation of the provision of …

Practical Neurology reader survey 2016

The essential point of Practical Neurology is that it is practical in the sense of being useful for everyone who sees neurological patients and who wants to keep up to date, and safe, in managing them. In other words this is a journal for jobbing neurologists who plough through the tension headaches and funny turns week in and week out. The success of most academic journals can be captured in a single number, its impact factor. This provides a measure of the importance of the research being published and the degree to which it influences other authors in the field. Practical Neurology , in contrast, defines its impact by other measures: how often it is read; how useful are the articles to clinical neurologists; how often it influences clinicians in the clinic and whether it is interesting, entertaining and thought provoking. In the spring of this year, we undertook a web-based questionnaire to find out how well the journal serves its readers, looking for your comments and …

Metaphors and Analogies In Neurology: From Kerplunk to Dripping Taps

Although we use metaphors and analogies in everyday speech all the time, I for one sometimes forget the definitions. A metaphor is a figure of speech in which a name, descriptive term or phrase is applied to an object or action to which it is imaginatively but not literally applicable. For example: revising for exams at the last minute seems to be ‘sailing very close to the wind’; we ‘get to grips with’ learning neurology; it’s raining ‘cats and dogs’ and so on. An analogy is another figure of speech, which uses correspondence or partial similarity to illustrate an idea, feeling or experience; for example, ‘your face has gone as red as a beetroot’, I feel ‘just like I am on the deck of a boat in a heavy sea’. INTRODUCTION A picture is said to be worth a thousand words (one kiloword!). Metaphors and analogies are pictures painted in

End the cult of cotton wool

Towards the end of a neurological examination, the tyro, usually a medical student about to take finals or a junior doctor taking higher examinations, gets out a piece of cotton wool and starts dabbing. ‘Tell me when you feel this’, they say before they start touching one side then the other in an apparently systematic way. They touch each dermatome, from top to bottom. The patient patiently responds ‘yes’, sometimes attempting to help with ‘I felt that more’, as this continues. This process goes on for some time. As a rule, not much useful clinical information is gleaned from this—beyond establishing that some areas are more sensitive than others (most will have discovered this in childhood). The examination has taken time, patience and an effort of concentration from the patient, to little avail. The medical student (or junior doctor) is doing a dance, taught to them by well-meaning doctors who …