Megan Alcauskas

Right Brain: Reading, writing, and reflecting Making a case for narrative medicine in neurology

A narrative, at its simplest, is a story. Doctors listen to and tell stories every day. At morning report, on rounds, at case conferences, while taking a patient’s history in clinic and when signing out in the evenings, stories are told, revised, and retold. These narratives are the foundations of clinical practice and the currency of patient–physician and physician–physician relationships. Neurologists are the custodians of speech and language within the medical community. We study, examine, and characterize speech and language and can diagnose pathology based on their aberrations. Not only do details and subtle nuances frequently make the diagnosis, but how the patient tells a story, including word choice, sentence structure, and prosody, takes on clinical significance. Neurology is one of the few specialties in which the patient’s history has retained its value despite increasingly sophisticated diagnostic technology. More can be gained from a patient’s story than dry facts placed in a sequential pattern. Absorbing, interpreting, and responding to a patient’s narrative require a special skill set. These skills, called “narrative competence” by narrative scholars, include those that are practical, such as recognizing a story’s structure and appreciating metaphors and illusions, those that are creative, such as envisioning multiple endings, and those that are emotional, such as feeling empathy and recognizing a story’s mood.1 By developing narrative competence, physicians can better understand a patient’s experience and thereby be better equipped to help him or her. Narrative medicine, rather than a specialty, is a framework for clinical practice based on developing and utilizing this skill set. It is a way of approaching the clinical encounter that focuses on appreciating and reflecting on the patient’s experience and the patient–physician relationship in order to improve both by building trust, developing empathy, and fostering a sense of shared responsibility in a patient’s health. …

Emergency Department visits before the diagnosis of MS

IMPORTANCE Prompt diagnosis and early initiation of disease-modifying treatment improves long-term outcomes in MS patients. This study looks at the path to MS diagnosis from the Emergency Department (ED), a frequent point of access for healthcare. OBJECTIVE To evaluate how patients presenting to the Mount Sinai ED with initial manifestations of MS are ultimately diagnosed with demyelinating disease. DESIGN Retrospective, observational analysis of all patients diagnosed with MS from 2005 to 2009. Part of the Resource Utilization in MS (RESUMS) Study. SETTING Urban, tertiary care center Emergency Department PARTICIPANTS Forty-nine patients were diagnosed with MS during the study period and made a total of 98 ED visits prior to that diagnosis. MAIN OUTCOME MEASURES Outcome measures included percentage of ED visits for neurologic symptoms, percentage that were likely initial manifestations of MS, percentage of visits admitted, mean length of hospital stay of those patients admitted, time until MS diagnosis, and time until initiation of disease modifying agent. Demographic and presentation-specific features correlating with time until MS diagnosis were evaluated. RESULTS 69.4% of patients were female. Mean age was 32.9 years (range 16-56). Hispanics comprised 40.8%, African Americans 28.6%, and Caucasians 18.2%. 59.2% of patients had private insurance, 26.5% Medicaid, and 6.1% Medicare. 50% of ED visits (49) were for neurologic symptoms (sensory symptoms 44.9%, vision changes 26.5%, weakness 24.5%, imbalance 16%, diplopia and vertigo 10.2%). 75.5% of the ED visits for neurologic symptoms were admitted; mean length of stay was 5.7 days (range 1-18). MS or demyelinating disease was diagnosed at the time of the ED visit or admission in 30/49 (61.2%) of neurologic presentations, with 73.5% diagnosed within a week. In the remaining 26.6%, MS diagnosis was delayed. 18.4% were diagnosed within a year of their neurologic ED visit and 8.2% remained undiagnosed at 1 year. Disease modifying agents were started in 71.4% of patients, 77.1% within 6 months. CONCLUSIONS AND RELEVANCE ED presentations for acute neurologic symptoms are an important opportunity to diagnose and treat early MS, and while the majority of the patients studied were appropriately triaged, diagnosed and treated in a timely manner, there exists room for improvement.

Editors' note: Teaching Video NeuroImages: Olivary enlargement and pharyngeal nystagmus

In “Teaching Video NeuroImages: Olivary enlargement and pharyngeal nystagmus,” authors Finlay and Yacovino described a 77-year-old woman with a pontine cavernoma and rhythmic contractions of the soft palate and upper larynx on videofluoroscopy. The accompanying MRI showed right inferior olivary nucleus hypertrophy.

Editors' note: Systematic review and statistical analysis of the integrity of 33 randomized controlled trials

In “Systematic review and statistical analysis of the integrity of 33 randomized controlled trials,” pertaining to bone density and osteoporosis studies of neurologic patients, Bolland et al. used statistical techniques to examine the data integrity of the 33 trials. They found, among other points, that the distribution of p values for differences in baseline characteristics did not adhere to the expected uniform distribution, raising questions about the data.

Editors' note: Swallowing-induced displacement of the carotid artery as a risk of stroke: Flip-flop phenomenon

In “Swallowing-induced displacement of the carotid artery as a risk of stroke: Flip-flop phenomenon,” the authors hypothesized that the migration of the internal carotid artery (ICA) with swallowing, in the presence of a moderate ICA plaque, may be a risk factor for stroke in certain cases. Drs. Zaed and Lanzino describe a patient who experienced recurrent strokes exclusively while eating and in whom imaging showed a complicated ICA plaque.

Editors' note: The state of academic neurology departments in the United States, 2016: A national survey

In “Sleep architecture and the risk of incident dementia in the community,” the authors found an association between dementia risk and lower percentage of REM sleep. They hypothesized that changes in REM sleep may be protective against cognitive decline.

Editors' note: Serum neurofilament light is sensitive to active cerebral small vessel disease

In “Serum neurofilament light is sensitive to active cerebral small vessel disease,” the authors highlighted neurofilament light (NfL)s role as a new biomarker for active cerebral small vessel disease (CSVD). Drs. Schreiber et al. report their own data in patients with CSVD and microhemorrhages, which showed significantly higher concentrations of CSF NfL in patients with CSVD than in controls.

Editors' note: Olfaction and risk of dementia in a biracial cohort of older adults

In “Olfaction and risk of dementia in a biracial cohort of older adults,” the authors found an association between worsened olfaction and dementia. Drs. Fuller-Thomson and Jopling suggest the link is cumulative lifetime lead exposure, associated with both deterioration in olfaction and cognitive decline.

Editors' note: Standard operating procedures improve acute neurologic care in a sub-Saharan African setting

In “Olfaction and risk of dementia in a biracial cohort of older adults,” the authors found an association between worsened olfaction and dementia. Drs. Fuller-Thomson and Jopling suggest the link is cumulative lifetime lead exposure, associated with both deterioration in olfaction and cognitive decline.

Editors' note: Smoking cessation and secondary stroke prevention

In response to the editorial “Smoking cessation and secondary stroke prevention” by Boehme, Dr. Munakomi emphasizes that passive smoking, including from secondhand smoke and sidestream smoke, can be risk factors for secondary strokes. Author Boehme agrees that both smoke-free environments and smoking cessation should be promoted in the interest of public health.