Joseph Kane

Revisiting DLB Diagnosis: A Consideration of Prodromal DLB and of the Diagnostic Overlap With Alzheimer Disease

Efforts to clinically diagnose cases having dementia with Lewy bodies (DLB) identify those with a characteristic clinical syndrome (probable DLB) at the expense of missing an equal, if not greater, number of cases who have atypical presentations thought to be associated with coexisting Alzheimer pathologies. This article argues that further efforts should now be made to characterize this atypical group that constitutes cases previously identified postmortem as the Lewy body variant of Alzheimer disease (AD) or as AD with Lewy bodies. Since such fine distinction is unlikely to be achieved on clinical grounds alone, this new diagnostic category will require robust biomarker validation. Turning to a consideration of early/prodromal diagnosis of both typical and atypical DLB cases, it is suggested that there will be at least 3 prototypical forms—a mild cognitive impairment variant, associated with early visuoperceptual and attentional deficits; a delirium onset DLB with provoked or spontaneous delirium as the presenting features; and a psychiatric disorder DLB with its primary presentation as a late-onset affective disorder or psychosis.

Clinical prevalence of Lewy body dementia

BackgroundThe prevalence of dementia with Lewy bodies (DLB) and dementia in Parkinson’s disease (PDD) in routine clinical practice is unclear. Prevalence rates observed in clinical and population-based cohorts and neuropathological studies vary greatly. Small sample sizes and methodological factors in these studies limit generalisability to clinical practice.MethodsWe investigated prevalence in a case series across nine secondary care services over an 18-month period, to determine how commonly DLB and PDD cases are diagnosed and reviewed within two regions of the UK.ResultsPatients with DLB comprised 4.6% (95% CI 4.0–5.2%) of all dementia cases. DLB was represented in a significantly higher proportion of dementia cases in services in the North East (5.6%) than those in East Anglia (3.3%; χ2 = 13.6, p < 0.01). DLB prevalence in individual services ranged from 2.4 to 5.9%. PDD comprised 9.7% (95% CI 8.3–11.1%) of Parkinson’s disease cases. No significant variation in PDD prevalence was observed between regions or between services.ConclusionsWe found that the frequency of clinical diagnosis of DLB varied between geographical regions in the UK, and that the prevalence of both DLB and PDD was much lower than would be expected in this case series, suggesting considerable under-diagnosis of both disorders. The significant variation in DLB diagnostic rates between these two regions may reflect true differences in disease prevalence, but more likely differences in diagnostic practice. The systematic introduction of more standardised diagnostic practice could improve the rates of diagnosis of both conditions.

Physician-Specific Maximum Acceptable Risk in Personalized Medicine: Implications for Medical Decision Making

Background. In discrete-choice experiments (DCEs), respondents are presented with a series of scenarios and asked to select their preferred choice. In clinical decision making, DCEs allow one to calculate the maximum acceptable risk (MAR) that a respondent is willing to accept for a one-unit increase in treatment efficacy. Most published studies report the average MAR for the whole sample, without conveying any information about heterogeneity. For a sample of psychiatrists prescribing drugs for a series of hypothetical patients with schizophrenia, this article demonstrates how heterogeneity accounted for in the DCE modeling can be incorporated in the derivation of the MAR. Methods. Psychiatrists were given information about a group of patients’ responses to treatment on the Positive and Negative Syndrome Scale (PANSS) and the weight gain associated with the treatment observed in a series of 26 vignettes. We estimated a random parameters logit (RPL) model with treatment choice as the dependent variable. Results. Results from the RPL were used to compute the MAR for the overall sample. This was found to be equal to 4%, implying that, overall, psychiatrists were willing to accept a 4% increase in the risk of an adverse event to obtain a one-unit improvement of symptoms – measured on the PANSS. Heterogeneity was then incorporated in the MAR calculation, finding that MARs ranged between 0.5 and 9.5 across the sample of psychiatrists. Limitations. We provided psychiatrists with hypothetical scenarios, and their MAR may change when making decisions for actual patients. Conclusions. This analysis aimed to show how it is possible to calculate physician-specific MARs and to discuss how MAR heterogeneity could have implications for medical practice.

DELAYS IN DIAGNOSING LEWY BODY DEMENTIA

NY, USA; Emory University, Atlanta, GA, USA; Jefferson University, Philadelphia, PA, USA; University of California San Diego, San Diego, CA, USA; Columbia University, New York, NY, USA; Georgetown University, Washington, D.C. USA; Johns Hopkins University, Baltimore, MD, USA; Georgetown University, Washington, D.C., USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA; Stanford University, Palo Alto, CA, USA; Oregon Health and Science University, Portland, OR, USA; University of Rochester, Rochester, NY, USA; Barrow Neurological Institute, Phoenix, AZ, USA; Ohio State University, Columbus, OH, USA; George Washington School of Medicine and Health Sciences, Washington, D.C., USA; Lewy Body Dementia Association, Lilburn, GA, USA. Contact e-mail: bboeve@mayo.edu

GEOGRAPHICAL VARIATIONS IN DIAGNOSTIC RATES FOR DEMENTIA WITH LEWY BODIES IN CLINICAL SERVICES

S 0.80 0.62 0.70 0.50 0.95 0.85 0.80 0.62 0.98 0.90 1.05 0.98 E 0.61 0.43 0.79 0.63 0.21 0.06 0.79 0.63 0.79 0.94 0.37 0.94 PPV 0.59 0.41 0.79 0.5 0.46 0.31 0.73 0.54 0.73 0.9 0.62 0.91 NPV 0.81 0.64 0.79 0.63 0.86 0.6 0.85 0.71 0.98 0.94 1.12 0.98 PLR 2.04 1.22 3.33 1.52 1.21 0.97 3.73 1.78 3.39 7.02 1.5 7.84 NLR 0.33 0.13 0.38 0.19 0.23 0.03 0.25 0.1 0.83 0.77 1.79 0.62 PPP 0.27 0.37 0.18 0.4 PNP 0.05 0.06 0.04 0.04 SS NO NO NO NA

DIAGNOSIS OF DEMENTIA IN PARKINSON’S DISEASE IN CLINICAL PRACTICE

P2-520 DIAGNOSIS OF DEMENTIA IN PARKINSON’S DISEASE IN CLINICAL PRACTICE Ajenthan Surendranathan, Joseph Kane, Alison Bentley, Sally H. Barker, John-Paul Taylor, Alan Thomas, Ian G. McKeith, David Burn, John T. O’Brien, University of Cambridge, Cambridge, UnitedKingdom; Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom; Newcastle University, Newcastle upon Tyne, United Kingdom. Contact e-mail: as2489@medschl.cam.ac.uk

Clozapine-induced liver injury and pleural effusion.

Clozapine, whilst associated commonly with a transient and benign increase in liver enzymes, has also been associated with varying presentations of hepatitis in existing case reports. This report describes what we believe to be the first documented case of acute liver injury and pleural effusion associated with clozapine, resolving after cessation of the agent. The case supports existing literature in advocating a high index of suspicion, particularly in the 4-5 weeks following clozapine initiation, when considering nonspecific clinical symptoms and signs.

A Life Too Short: The Tragedy of Robert Enke

A Life Too Short: The Tragedy of Robert Enke By Ronald Reng. Yellow Jersey. 2011. £16.99 (hb). 400 pp. ISBN: 9780224091657 In late 2009, Robert Enke was at the peak of his footballing powers, acknowledged as one of the German Bundesliga’s best goalkeepers and expected to represent his country