Functional neurological disorder is an important aspect with respect to burden and cost of management irrespective of gender as the authors have pointed out very rightly1.
It can be chronic but most of the times present as an emergency therby increasing panic, inpatient admissions. Smooth care, workup and appropriate guidelines for the same may help a lot in such conditions.
There is limited information, awareness, health care utilities, and economic burden of such patients which makes the situation more grim.
So there should be multidisciplinary approach i.e. physiotherapy, occupational therapy, speech and language therapy, and psychological assessment. Functional neurological disorders overlap with refractory neurological conditions i.e. headache, seizure, focal deficit etc., so better these patients be subdivided in these categories. Framing universal guidelines all across the world according to subdivisions with appropriate line of care as is being done in various other disorders may help a lot to smoothen improve management and help reduce the cost of therapy and gender bias.
References-
1. Caoimhe McLoughlin, Ingrid Hoeritzauer, Verónica Cabreira et al. http://dx.doi.org/10.1136/jnnp-2022-330192
2. Christopher D. Stephen, Vicki Fung, Codrin I. Lungu et al Alberto J. Espay Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neur...
Functional neurological disorder is an important aspect with respect to burden and cost of management irrespective of gender as the authors have pointed out very rightly1.
It can be chronic but most of the times present as an emergency therby increasing panic, inpatient admissions. Smooth care, workup and appropriate guidelines for the same may help a lot in such conditions.
There is limited information, awareness, health care utilities, and economic burden of such patients which makes the situation more grim.
So there should be multidisciplinary approach i.e. physiotherapy, occupational therapy, speech and language therapy, and psychological assessment. Functional neurological disorders overlap with refractory neurological conditions i.e. headache, seizure, focal deficit etc., so better these patients be subdivided in these categories. Framing universal guidelines all across the world according to subdivisions with appropriate line of care as is being done in various other disorders may help a lot to smoothen improve management and help reduce the cost of therapy and gender bias.
References-
1. Caoimhe McLoughlin, Ingrid Hoeritzauer, Verónica Cabreira et al. http://dx.doi.org/10.1136/jnnp-2022-330192
2. Christopher D. Stephen, Vicki Fung, Codrin I. Lungu et al Alberto J. Espay Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders. JAMA Neurol. 2021;78(1):88-101. doi:10.1001/jamaneurol.2020.3753
Dear Editor-in-Chief,
We read with great interest the consensus guidelines for diagnosis and management of spontaneous intracranial hypotension (SIH). [1] In the absence of any recommendations, this guideline will help clinicians in formulating their diagnostic and management approaches for SIH. In this letter, we wish to discuss about the epidural blood patch (EBP) in the management of SIH. The role of targeted EBP for management of SIH has not been compared with non-targeted EBP in randomized controlled trials to establish superiority of one over the other. A recent systematic review of studies with 10 or more patients with SIH reported similar success with either technique. [2] However, where expertise is available and when the precise site of cerebrospinal fluid (CSF) leak is identifiable, it is prudent to consider targeted EBP as the first choice. This reduces the volume of autologous blood required, minimizes the need of reliance on gravity for spread of epidurally placed blood to the potential site of leak and decreases the procedure failure rates and need for subsequent EBPs or surgical interventions. In our center, which is a tertiary care neurosciences academic hospital, after an initial conservative management for a week, a targeted EBP is performed as the preferred approach to manage SIH. [3] If the site of leak is not determinable and if the expertise to perform cervical or thoracic EBP is not available, a non-targeted EBP may be the preferred interventi...
Dear Editor-in-Chief,
We read with great interest the consensus guidelines for diagnosis and management of spontaneous intracranial hypotension (SIH). [1] In the absence of any recommendations, this guideline will help clinicians in formulating their diagnostic and management approaches for SIH. In this letter, we wish to discuss about the epidural blood patch (EBP) in the management of SIH. The role of targeted EBP for management of SIH has not been compared with non-targeted EBP in randomized controlled trials to establish superiority of one over the other. A recent systematic review of studies with 10 or more patients with SIH reported similar success with either technique. [2] However, where expertise is available and when the precise site of cerebrospinal fluid (CSF) leak is identifiable, it is prudent to consider targeted EBP as the first choice. This reduces the volume of autologous blood required, minimizes the need of reliance on gravity for spread of epidurally placed blood to the potential site of leak and decreases the procedure failure rates and need for subsequent EBPs or surgical interventions. In our center, which is a tertiary care neurosciences academic hospital, after an initial conservative management for a week, a targeted EBP is performed as the preferred approach to manage SIH. [3] If the site of leak is not determinable and if the expertise to perform cervical or thoracic EBP is not available, a non-targeted EBP may be the preferred intervention. [4]
The second point that remains unclear and poses management dilemma is the treatment approach when a patient is diagnosed with SIH and also manifests with a subdural hematoma (SDH) causing intracranial mass effect. The clinical picture is confusing when the orthostatic nature of headache, classical of SIH, changes to a continuous headache pattern due to SDH. Here, if the SIH is treated first with an EBP, possibility of increase in intracranial pressure adding to that due to a SDH is likely. On the contrary, if SDH is evacuated first, there is possibility of recollection due to ongoing CSF leak. There is need for more clarity on the appropriate approach in such a scenario.
References
1. Cheema S, Anderson J, Angus-Leppan H, et alMultidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotensionJournal of Neurology, Neurosurgery & Psychiatry Published Online First: 05 May 2023. doi: 10.1136/jnnp-2023-331166
2. D'Antona L, Jaime Merchan MA, Vassiliou A, Watkins LD, Davagnanam I, Toma AK, Matharu MS. Clinical Presentation, Investigation Findings, and Treatment Outcomes of Spontaneous Intracranial Hypotension Syndrome: A Systematic Review and Meta-analysis. JAMA Neurol. 2021;78(3):329-337.
3. Sriganesh K, Saini J, Bhadrinarayan V. Targeted cervical epidural blood patch for the management of refractory headache in a patient with spontaneous intracranial hypotension. J Neurosurg Anesthesiol. 2015;27(1):68-9
4. Shukla D, Sadashiva N, Saini J, Kamath S. Spontaneous Intracranial Hypotension - A Dilemma. Neurol India. 2021;69(Supplement):S456-S462.
In “Functional neurological disorder is a feminist issue” by McLoughlin et al.,[1] authors explain that FND patients “suffer subtle and overt forms of discrimination”, suggesting that “FND clinical services and research are chronically underfunded in line with the neglect of disorders disproportionately affecting women”. Ultimately, they insist that feminists should support “parity of esteem” for FND with other neurological conditions.
I suggest that the idea of an alliance between feminism and FND is highly problematic. First, authors minimize the seriousness of human rights violations against women in the name of hysteria. Second, they fail to consider the role that FND plays in healthcare gender bias across specialties. Third, they perpetuate the myth that functional diagnosis rarely errs, further threatening women’s safety in the healthcare system.
First, while authors do acknowledge “objectification and exploitation” of women diagnosed with hysteria, their concern is merely that “some sociologists and scientists have opined that the diagnosis was used as a ‘patriarchal tool’ to silence or ignore complaints of women”. There’s no mention of sexualization of women’s symptoms in the name of hysteria, even as recently as ICD-10, or the range of sexual treatments to which “hysterical” women have been subjected, including genital mutilation. There’s no acknowledgment that these treatments, like sectioning based on the wishes of husbands, fathers, or sons, are...
In “Functional neurological disorder is a feminist issue” by McLoughlin et al.,[1] authors explain that FND patients “suffer subtle and overt forms of discrimination”, suggesting that “FND clinical services and research are chronically underfunded in line with the neglect of disorders disproportionately affecting women”. Ultimately, they insist that feminists should support “parity of esteem” for FND with other neurological conditions.
I suggest that the idea of an alliance between feminism and FND is highly problematic. First, authors minimize the seriousness of human rights violations against women in the name of hysteria. Second, they fail to consider the role that FND plays in healthcare gender bias across specialties. Third, they perpetuate the myth that functional diagnosis rarely errs, further threatening women’s safety in the healthcare system.
First, while authors do acknowledge “objectification and exploitation” of women diagnosed with hysteria, their concern is merely that “some sociologists and scientists have opined that the diagnosis was used as a ‘patriarchal tool’ to silence or ignore complaints of women”. There’s no mention of sexualization of women’s symptoms in the name of hysteria, even as recently as ICD-10, or the range of sexual treatments to which “hysterical” women have been subjected, including genital mutilation. There’s no acknowledgment that these treatments, like sectioning based on the wishes of husbands, fathers, or sons, are violations of human rights perpetrated into the 1960s.
Most importantly, there’s not a word about the many millions of women with disease mistakenly attributed to hysteria, their suffering, or their deaths, without medical care or support. Women with lupus, endometriosis, heart disease, multiple sclerosis, myasthenia gravis, women who resist sex with husbands, gay women, sex workers, and women resistant to housework and caring for children – all of these were gathered under the rubric of hysteria and forced into “moral treatment” based on the wisdom of their male doctors. Authors of this article do their best to obfuscate the firm lineage from hysteria to FND, and the explicit insistence of current FND researchers that “the disappearance of hysteria is an illusion”.[2] These omissions, all on their own, should lead to serious concern for feminists.
Second, authors fail to consider the role that FND plays in the problem of healthcare gender bias. Without hesitation they state that 70% of those with FND are women, a figure outstripped only by somatic symptom disorder, with an astonishing 10:1 recommended female-to-male ratio.[3] Unfortunately, there exists no research that attempts to evaluate gender imbalance in these diagnoses in a way that’s free of bias. Instead, research unanimously evaluates what doctors in fact do when it comes to diagnosis of FND in women vs men. Findings of this kind tell us only that doctors do what they’ve been trained to do for centuries, diagnosing psychosomatic conditions predominantly in women. No substantial research has attempted to determine whether it’s actually wise to see FND in this gendered way.
There is abundant evidence that gender imbalance in diagnosis of functional disorders and SSD is unsupported, because it’s clear now that women struggle to access the tests, treatments, and referrals that men readily receive in the same circumstances. Findings of this kind are well known. Women with symptoms of heart disease are far more likely to be diagnosed with a mental health condition. We receive less hyperperfusion therapy for stroke, and we wait longer for it. We’re more likely to receive sedatives when we need pain medication, and women’s diseases, like endometriosis and lupus, have appallingly long diagnostic delays. Clearly clinicians take it for granted that psychosomatic conditions are an everyday problem for women. As a new label for hysteria, one that in no way rejects the original construct, FND contributes substantially to that impression. Indeed, most clinicians are aware that new hysteria labels have been devised, at least in part, to mislead women into compliance with treatment.[4]
Third, authors affirm the idea that misdiagnosis of FND is rare, citing the well-known finding that “the proportion of misdiagnosis was less than 4%”.[5] What they don’t say is that central studies on misdiagnosis of conversion/FND do not determine error rate. They determine the rate at which doctors are willing to imagine that the diagnosis has erred, confirming the error with findings, and noting results for the record. Slater’s studies on misdiagnosis of hysteria in the 1960s took a more scientific approach, with direct effort to uncover unrecognized disease in a large group of patients diagnosed with hysteria. These methods are not comparable. Low revision rates are not cause for celebration. They’re cause for concern that while error in psychosomatic diagnosis is very common – as evidenced by women’s routine difficulty accessing the healthcare they need – once the diagnosis is made, doctors are dangerously unwilling to imagine that it might be mistaken.
From a feminist perspective, “parity of esteem with neurological conditions of equivalent epidemiological and economic importance” is not warranted for FND. When FND research disclaims hysteria for violations of women’s human rights, when researchers are actively engaged in reversing healthcare gender injustice, and when studies on error seriously commit to reducing mistaken denial of healthcare to women, then it will be time to give FND more attention. Until then, no one should mistake funding for FND with an investment in gender health equity. It is hard to imagine a construct more directly opposed to the aims of feminism.
[1] McLoughlin C, Hoeritzauer I, Cabreira V, et al. Functional neurological disorder is a feminist issue [published online ahead of print, 2023 Mar 28]. J Neurol Neurosurg Psychiatry. 2023;jnnp-2022-330192.
[2] Stone J, Hewett R, Carson A, Warlow C, Sharpe M. The 'disappearance' of hysteria: historical mystery or illusion? J R Soc Med. 2008;101(1):12-8.
[4] Sharpe M, Carson A. "Unexplained" somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med. 2001;134(9 Pt 2):926-930.
[5] Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and hysteria. BMJ 2005;331:989.
We are writing to respectfully offer some additional comments on the recent publication of Hannaway et al. in JNNP titled “Visual dysfunction is a better predictor than retinal thickness for dementia in Parkinson’s disease”.
While the authors provided interesting insights on the predictive value of higher order visual functions for dementia, we noticed that the authors did not find significant associations between parafoveal GCIPL (pfGCIPL) and cognition in their work, whereas our research did. As they mentioned, the range of cognitive impairment was higher in our sample, and possibly this might have driven our findings. However, we would like to add that the relationship between the retina and cognition is not linear, according to our data. As such, we calculated relative risks by categorizing continuous variables, which allowed us to identify non-linear relationships between pfGCIPL and cognitive impairment. Furthermore, we speculate that these variables do not exhibit a synchronous pattern of change over time, suggesting that the temporal trends are not closely linked, which might justify the lack of association in the current work.
We do agree with the authors in that visual function is a good predictor of cognitive deterioration. Our previous work also demonstrated this fact, but we would like to highlight the benefits of retinal OCT imaging in this context, if its utility is validated. Retinal OCT imaging is a faster and easier-to-measure technique com...
We are writing to respectfully offer some additional comments on the recent publication of Hannaway et al. in JNNP titled “Visual dysfunction is a better predictor than retinal thickness for dementia in Parkinson’s disease”.
While the authors provided interesting insights on the predictive value of higher order visual functions for dementia, we noticed that the authors did not find significant associations between parafoveal GCIPL (pfGCIPL) and cognition in their work, whereas our research did. As they mentioned, the range of cognitive impairment was higher in our sample, and possibly this might have driven our findings. However, we would like to add that the relationship between the retina and cognition is not linear, according to our data. As such, we calculated relative risks by categorizing continuous variables, which allowed us to identify non-linear relationships between pfGCIPL and cognitive impairment. Furthermore, we speculate that these variables do not exhibit a synchronous pattern of change over time, suggesting that the temporal trends are not closely linked, which might justify the lack of association in the current work.
We do agree with the authors in that visual function is a good predictor of cognitive deterioration. Our previous work also demonstrated this fact, but we would like to highlight the benefits of retinal OCT imaging in this context, if its utility is validated. Retinal OCT imaging is a faster and easier-to-measure technique compared to measuring visual functions. Moreover, OCTs are widely available in most ophthalmology departments, and this accessibility makes it a practical tool for assessing cognitive impairment and predicting dementia risk, particularly in primary care settings where time and resources are often limited. Furthermore, OCT might be also useful to be incorporated in clinical trials of disease-modifying therapies, as it allows objective, reliable and quantitative measurements of retinal parameters. All these advantages make it imperative to explore and better understand the temporal relationship between the retina and cognition.
We would like to address some final points that were discussed in the paper to provide further clarification. In our work, we included carriers with E46K mutation in the SNCA gene, not GBA gene. Also, the authors state that it is not clear whether model that tested the association between baseline pfGCIPL thickness and the risk of cognitive decline in idiopathic PD was adjusted for age. In fact, the model was adjusted for age, but also for disease duration, sex and levodopa equivalent daily dose.
To conclude, we are grateful for the valuable insights provided by the authors about the usefulness of the retina for cognitive monitoring. Moving forward, we remain committed to further exploring and elucidating this fascinating area of research, and we share the authors' enthusiasm for advancing our knowledge on the temporal dynamics of the retinal structure and its relationship with cognitive processes.
Ayton et al. reported the association between ferritin, apolipoprotein E (APOE) and dementia-related biomarkers such as amyloid β42/total-tau and phosphorylated tau181 (p-tau181) in cerebrospinal fluid (CSF) (1). CSF ferritin and APOE were positively associated with p-tau181, which was most predominant in subjects without increase in amyloid β42/total-tau. I present information about the study.
Pan et al. investigated the associations of CSF ferritin and CSF biomarkers of Alzheimer's disease (AD) (2). They found that CSF ferritin increased in subjects with more advanced categories of CSF biomarkers such as amyloid β42 and p-pau, although there were stronger relationships of CSF ferritin with p-tau and t-tau, rather than amyloid β42. This means that biological action of ferritin in the brain for AD may be more closely related to tau protein.
Baringer et al. described brain iron homeostasis in Alzheimer's disease, Parkinson's disease, and other neurodegenerative diseases (3). They emphasized that endothelial cells of the blood-brain barrier were the site of iron transport regulation, and iron uptake, transcytosis, and release were mainly conducted. By controlling the excess of brain iron, neurodegenerative disorders may be improved. The mechanism that tau protein spreads through functionally connected neurons in Alzheimer's disease have been precisely reported (4), and it may be related to the excess of brain iron storage.
Ayton et al. reported the association between ferritin, apolipoprotein E (APOE) and dementia-related biomarkers such as amyloid β42/total-tau and phosphorylated tau181 (p-tau181) in cerebrospinal fluid (CSF) (1). CSF ferritin and APOE were positively associated with p-tau181, which was most predominant in subjects without increase in amyloid β42/total-tau. I present information about the study.
Pan et al. investigated the associations of CSF ferritin and CSF biomarkers of Alzheimer's disease (AD) (2). They found that CSF ferritin increased in subjects with more advanced categories of CSF biomarkers such as amyloid β42 and p-pau, although there were stronger relationships of CSF ferritin with p-tau and t-tau, rather than amyloid β42. This means that biological action of ferritin in the brain for AD may be more closely related to tau protein.
Baringer et al. described brain iron homeostasis in Alzheimer's disease, Parkinson's disease, and other neurodegenerative diseases (3). They emphasized that endothelial cells of the blood-brain barrier were the site of iron transport regulation, and iron uptake, transcytosis, and release were mainly conducted. By controlling the excess of brain iron, neurodegenerative disorders may be improved. The mechanism that tau protein spreads through functionally connected neurons in Alzheimer's disease have been precisely reported (4), and it may be related to the excess of brain iron storage.
References
1. Ayton S, Janelidze S, Kalinowski P, et al. CSF ferritin in the clinicopathological progression of Alzheimer's disease and associations with APOE and inflammation biomarkers. J Neurol Neurosurg Psychiatry 2023;94(3):211-219.
2. Pan R, Luo S, Huang Q, et al. The associations of cerebrospinal fluid ferritin with neurodegeneration and neuroinflammation along the Alzheimer's Disease Continuum. J Alzheimers Dis 2022;88(3):1115-1125.
3. Baringer SL, Simpson IA, Connor JR. Brain iron acquisition: An overview of homeostatic regulation and disease dysregulation. J Neurochem 2023;165(5):625-642.
4. Schoonhoven DN, Coomans EM, Millán AP, et al. Tau protein spreads through functionally connected neurons in Alzheimer's disease: a combined MEG/PET study. Brain 2023. doi: 10.1093/brain/awad189
Åkerstedt et al. conducted a case-control study with 2075 cases and 3164 controls to investigate the association between sleep and risk of multiple sclerosis (MS) (1). Sleep duration, circadian disruption and sleep quality during adolescence were used for sleep variables. The authors calculated the adjusted OR with 95% CIs using logistic regression models, and short sleep (<7 hours/night) and low sleep quality were significantly associated with increased risk of developing MS. I have a question regarding the ways of multivariate analysis.
The ratio in the number of cases and controls is about 1.5 in this study. If the authors selected unconditional logistic regression analysis, OR might become conservative. If the authors selected conditional logistic regression analysis, the increased number of controls is preferable to make stable estimation. Instead of selecting a case-control study with a matching procedure, using all pooled data without a matching procedure can be selected for the analysis (2).
Anyway, a recall method has a possibility of including bias and risk assessment of MS with subjective sleep variables should be paid with caution.
References
1. Åkerstedt T, Olsson T, Alfredsson L, et al. Insufficient sleep during adolescence and risk of multiple sclerosis: results from a Swedish case-control study. J Neurol Neurosurg Psychiatry 2023;94(5):331-6.
2. Hamajima N, Hirose K, Inoue M, et al. Case-control studies: matched controls...
Åkerstedt et al. conducted a case-control study with 2075 cases and 3164 controls to investigate the association between sleep and risk of multiple sclerosis (MS) (1). Sleep duration, circadian disruption and sleep quality during adolescence were used for sleep variables. The authors calculated the adjusted OR with 95% CIs using logistic regression models, and short sleep (<7 hours/night) and low sleep quality were significantly associated with increased risk of developing MS. I have a question regarding the ways of multivariate analysis.
The ratio in the number of cases and controls is about 1.5 in this study. If the authors selected unconditional logistic regression analysis, OR might become conservative. If the authors selected conditional logistic regression analysis, the increased number of controls is preferable to make stable estimation. Instead of selecting a case-control study with a matching procedure, using all pooled data without a matching procedure can be selected for the analysis (2).
Anyway, a recall method has a possibility of including bias and risk assessment of MS with subjective sleep variables should be paid with caution.
References
1. Åkerstedt T, Olsson T, Alfredsson L, et al. Insufficient sleep during adolescence and risk of multiple sclerosis: results from a Swedish case-control study. J Neurol Neurosurg Psychiatry 2023;94(5):331-6.
2. Hamajima N, Hirose K, Inoue M, et al. Case-control studies: matched controls or all available controls? J Clin Epidemiol 1994;47(9):971-5.
We appreciate the author for exploring the independent factors associated with the achievement of the treatment target (MM and MM5mg) in generalized myasthenia gravis (MG) patients, including early fast-acting treatment (EFT) [1]. This study attempted to include patients treated with EFT or non-EFT by propensity score (PS) matching to obtain a balance in baseline characters between the two groups, and to determine whether EFT was an independent factor of achieving MM5mg the treatment target by adjusting the confounding factors. The primary endpoint of this study was to reach MM5mg, and Cox regression analysis was used to explore the independent factors. Some concerns are raised here for discussion with the authors.
1. Is the starting point of the study from the beginning of immunotherapy? If so, pre-treatment factors such as gender, onset age, pre-treatment disease duration, pre-treatment worst severity, subtype, and severity at the start of treatment, need to be included. Ongoing treatment factors should include at least the dose range and duration of oral prednisone, Calcineurin inhibitors usage and intervals between their initiation time and the beginning of immunotherapy, and the number of cycles of fast-acting therapies administered 6 months after initiation of immunotherapy. All of these factors may affect the prognosis. We also wish to know whether the thymectomy was performed before or after the initiation of immunotherapy in each patient, and the interva...
We appreciate the author for exploring the independent factors associated with the achievement of the treatment target (MM and MM5mg) in generalized myasthenia gravis (MG) patients, including early fast-acting treatment (EFT) [1]. This study attempted to include patients treated with EFT or non-EFT by propensity score (PS) matching to obtain a balance in baseline characters between the two groups, and to determine whether EFT was an independent factor of achieving MM5mg the treatment target by adjusting the confounding factors. The primary endpoint of this study was to reach MM5mg, and Cox regression analysis was used to explore the independent factors. Some concerns are raised here for discussion with the authors.
1. Is the starting point of the study from the beginning of immunotherapy? If so, pre-treatment factors such as gender, onset age, pre-treatment disease duration, pre-treatment worst severity, subtype, and severity at the start of treatment, need to be included. Ongoing treatment factors should include at least the dose range and duration of oral prednisone, Calcineurin inhibitors usage and intervals between their initiation time and the beginning of immunotherapy, and the number of cycles of fast-acting therapies administered 6 months after initiation of immunotherapy. All of these factors may affect the prognosis. We also wish to know whether the thymectomy was performed before or after the initiation of immunotherapy in each patient, and the interval between the thymectomy and the first achievement of the treatment target.
2. In order to obtain a balance in clinical characters between EFT and non-EFT groups, PS matching was adopted in this study. The PS matching should be based not only on the factors that determined the choice of comparative treatments but also on the pre-treatment factors that might influence prognosis. The disease duration and severity at the start of treatment were not considered in the background factors provided in this study. More importantly, is the determination of EFT usage dependent on the factors acquired by the post hoc analysis of MM5mg achievement? Since the concept of EFT to achieve an early improvement and good prognosis gradually spread in Japan in the last decade, and EFT usage was determined individually depending on the physicians who specialized in MG among the 13 participating centers, this unmeasured confounder is advisable to be explored with a questionnaire about the factors that the physician mainly relies on to determine EFT usage. Otherwise, this unmeasured confounder can be obtained with instrumental variable analysis [2] or sensitivity analysis with an E-Value [3] to account for the unmeasured confounders.
Reference：
1.Uzawa A, Suzuki S, Kuwabara S, et al. Effectiveness of early cycles of fast-acting treatment in generalised myasthenia gravis. J Neurol Neurosurg Psychiatry. 2023 Jan 24; jnnp-2022-330519. doi: 10.1136/jnnp-2022-330519.
2.Maciejewski ML, Dowd BE, Norton EC. Instrumental Variables and Heterogeneous Treatment Effects. JAMA. 2022;327(12):1177-1178.
3.Haneuse S, VanderWeele TJ, Arterburn D. Using the E-Value to Assess the Potential Effect of Unmeasured Confounding in Observational Studies. JAMA. 2019;321(6):602-603.
Professor Sinclair and her team1 in Birmingham highlight an urgent issue affecting patients with IIH during the COVID19 pandemic. Their paper elegantly shows that weight gain worsens the severity of papilloedema and puts patients at risk of blindness. They also highlight the risk of worsening papilloedema not picked up with reduced access to hospital appointments.
Here, we report the audit results from our service and share practical actions that have been effective for our service, with wider applicability.
From May – Dec 2020, 58/102 (57%) IIH patients seen for follow up had gained weight compared to weight measured prior to pandemic by median 5.35 (range 0.6,27.3; SD 4.42)kg; with overall weight change of median 1.65 (range -24, 27.3; SD 6.81)kg for the group. 3/58 (5%) patients who gained weight, developed worsening papilloedema.
We agree with the importance of optic disc examination as highlighted by Sinclair and colleagues1, and the need for PPE precautions in the COVID19 pandemic setting. An option we found helpful is fundus photography of the optic disc in the community which the patient then emails their clinician. Fundus photography is now widely available at high-street optometrists. Benefits of doing this include: circumventing patients’ fears of attending hospitals during the pandemic; a patient-held record for future comparison; and the option for clinicians to obtain a colleague’s second opinion on the optic disc photograph.
Professor Sinclair and her team1 in Birmingham highlight an urgent issue affecting patients with IIH during the COVID19 pandemic. Their paper elegantly shows that weight gain worsens the severity of papilloedema and puts patients at risk of blindness. They also highlight the risk of worsening papilloedema not picked up with reduced access to hospital appointments.
Here, we report the audit results from our service and share practical actions that have been effective for our service, with wider applicability.
From May – Dec 2020, 58/102 (57%) IIH patients seen for follow up had gained weight compared to weight measured prior to pandemic by median 5.35 (range 0.6,27.3; SD 4.42)kg; with overall weight change of median 1.65 (range -24, 27.3; SD 6.81)kg for the group. 3/58 (5%) patients who gained weight, developed worsening papilloedema.
We agree with the importance of optic disc examination as highlighted by Sinclair and colleagues1, and the need for PPE precautions in the COVID19 pandemic setting. An option we found helpful is fundus photography of the optic disc in the community which the patient then emails their clinician. Fundus photography is now widely available at high-street optometrists. Benefits of doing this include: circumventing patients’ fears of attending hospitals during the pandemic; a patient-held record for future comparison; and the option for clinicians to obtain a colleague’s second opinion on the optic disc photograph.
In response to the pandemic, we set up technician-led IIH follow-up clinics for vision assessment, optic disc photography and optical coherence tomography (OCT). Patients were sent text message links to symptom questionnaires. Patients were then offered review in a group consultation (GC) setting by video. Those who opted out were offered one-to-one telephone review. The patient feedback for the GC have been overwhelming positive; details of this set up is further described elsewhere2.
A key part of our work with IIH patients is creating community and facilitating peer support, to tackle the sense of isolation from having the diagnosis, exacerbated by the COVID19 pandemic 3. In 2017 we started the IIH weight-loss and wellness (IIH-WoW) workshops on sustainable lifestyle measures for weight loss and wellbeing. Since May 2020 in response to the pandemic, these IIH-WoW workshops have been delivered via video calls. Topics covered included healthy habits and routines, nutrition, physical activity, emotional eating, stress management, goal setting and maintaining motivation. Feedback showed a median rating of 9/10 for ‘how much did you enjoy the workshop” and 8/10 for “how much benefit did you gain from the workshop”. The following patient responses to the question ‘What did you gain from the IIH-WoW workshop?’, illustrate the practical benefits gained from the sense of community, hope, and empowerment:
- “I think one of the challenges I've been experiencing has been - not just sharing my goals but being able to share it with someone who understands my motivation as we'd all ideally like to me free of IIH. That's not really something people in my friend circle can relate to and it's just really nice having that sense of community.”
- “Hearing others struggles. Being able to compare, share compassion, give and receive advice.”
- “Focus not just goals but actioning them and knowing others are doing the same and supporting each other.”
- “I gained two very significant things from this session. The first and most important is seeing and knowing that I'm not alone. I was diagnosed with IIH seven years ago and this event was the first opportunity I've had to meet others with the same condition. In the course of an hour, I went from being terribly isolated, to being part of a sisterhood of diverse, strong, and courageous women... I cannot overstate what a transformative experience that was. The second thing I gained is the sense of possibility. I've had numerous doctors tell me all the things I can't do... Dr Wong has shifted the focus back to what we can do, with small steps, targeted, realistic goals and with the wellbeing of our whole person in mind. In short, I've gained a new initiative.”
Patients valued the sense of peer support from these IIH-WoW and GC sessions, feeling less isolated particularly as IIH is a rare condition and they may feel stigmatised. We facilitate these group sessions using principles from Health Coaching 4 and Motivational Interviewing5, where patients are empowered to act and come up with their solutions.
In summary, we echo the concerns raised by Professor Sinclair and colleagues and highlight additional measures that could further support IIH patients during this pandemic.
Acknowledgements
This work was done at Guys & St Thomas’ (GSTT) NHSFT with the GSTT IIH Team. The IIH-WoW work was shortlisted in 2019 for the King’s Health Partners Education Academy Awards (Mind and Body category) and is only possible with the support from the GSTT IIH Team; the Eye Dept; Deborah Gibson; Dr Denise Ratcliffe; dietetics and physiotherapy teams. The Group Consultation work was awarded top abstract for the British Society of Lifestyle Medicine 2020 conference and shortlisted for the HSJ Acute Sector Innovation Award (2021); supported by Group Consultations Ltd.
Conflicts of interest
None to declare
Funders
None
References
1. Thaller M, Tsermoulas G, Sun R, Mollan SP, Sinclair AJ. Negative impact of COVID-19 lockdown on papilloedema and idiopathic intracranial hypertension. J Neurol Neurosurg Psychiatry. 2020 Dec 24:jnnp-2020-325519. doi: 10.1136/jnnp-2020-325519. Epub ahead of print. PMID: 33361411.
2. Wong SH, Barrow N, Hall K, Gandesha P, Manson A. The Effective Management of Idiopathic Intracranial Hypertension Delivered by In-person and Virtual Group Consultations: Results and Reflections from a Phase One Service Delivery. Neuroophthalmology. 2021 May 10;45(4):246-252. doi: 10.1080/01658107.2021.1887287. PMID: 34366512; PMCID: PMC8312588.
3. Miller ED. Loneliness in the Era of COVID-19. Front Psychol. 2020 Sep 18;11:2219. doi: 10.3389/fpsyg.2020.02219. PMID: 33071848; PMCID: PMC7530332.
4. Conn S, Curtain S. Health coaching as a lifestyle medicine process in primary care. Aust J Gen Pract. 2019 Oct;48(10):677-680. doi: 10.31128/AJGP-07-19-4984. PMID: 31569315.
5. Rollnick, S., & Miller, W. What is Motivational Interviewing? Behavioural and Cognitive Psychotherapy 1995, 23(4), 325-334. doi:10.1017/S135246580001643X
I recently read the article titled "Somatic symptom disorder in patients with post-COVID-19 neurological symptoms: a preliminary report from the somatic study (Somatic Symptom Disorder Triggered by COVID-19)" published in the Journal of Neurology, Neurosurgery, and Psychiatry. As a psychiatrist in Taiwan, I found the findings of the study intriguing and relevant to the mental health challenges faced by our population during the COVID-19 pandemic.
In Taiwan, we have observed similar situations where the pandemic has had a significant impact on mental health. Our recent study, "Mental health impact of the COVID-19 pandemic in Taiwan,"1 published in the Journal of Formosan Medical Association, explored the prevalence of psychiatric distress, suicidal ideation, and levels of worry during the pandemic among a representative sample of 1,087 Taiwanese. The results showed that approximately 12% of respondents experienced psychiatric distress, and about 10% expressed concerns over financial troubles, employment, and mental health conditions.
While the prevalence of psychiatric distress in Taiwan is lower compared to other countries, the study highlights the undeniable effect the pandemic has had on mental health. It is important to acknowledge that the COVID-19 crisis goes beyond health and mental health issues, as its socio-economic impact could have long-lasting consequences if not adequately addressed.
I recently read the article titled "Somatic symptom disorder in patients with post-COVID-19 neurological symptoms: a preliminary report from the somatic study (Somatic Symptom Disorder Triggered by COVID-19)" published in the Journal of Neurology, Neurosurgery, and Psychiatry. As a psychiatrist in Taiwan, I found the findings of the study intriguing and relevant to the mental health challenges faced by our population during the COVID-19 pandemic.
In Taiwan, we have observed similar situations where the pandemic has had a significant impact on mental health. Our recent study, "Mental health impact of the COVID-19 pandemic in Taiwan,"1 published in the Journal of Formosan Medical Association, explored the prevalence of psychiatric distress, suicidal ideation, and levels of worry during the pandemic among a representative sample of 1,087 Taiwanese. The results showed that approximately 12% of respondents experienced psychiatric distress, and about 10% expressed concerns over financial troubles, employment, and mental health conditions.
While the prevalence of psychiatric distress in Taiwan is lower compared to other countries, the study highlights the undeniable effect the pandemic has had on mental health. It is important to acknowledge that the COVID-19 crisis goes beyond health and mental health issues, as its socio-economic impact could have long-lasting consequences if not adequately addressed.
In light of the findings of the somatic study and our own research, I believe it is essential for healthcare professionals worldwide to collaborate and share knowledge to better understand and manage the mental health consequences of COVID-19. Expanding efforts to improve economic security and achieve a rapid governmental socio-economic response are crucial to mitigate the future impact of the pandemic on mental health.
I would like to express my appreciation for your publication of the somatic study, which contributes valuable insights to the understanding of the mental health challenges associated with COVID-19. I hope that our collective efforts will lead to better mental health care for our patients during these trying times.
Sincerely,
Dr. Lien-Chung Wei
Psychiatrist
Taiwan
1. Chen YY, Wu KC, Gau SS. Mental health impact of the COVID-19 pandemic in Taiwan. Journal of the Formosan Medical Association = Taiwan yi zhi 2021;120(7):1421-23. doi: 10.1016/j.jfma.2020.12.002 [published Online First: 2020/12/29]
Dr Smith and his colleagues have recently written an article entitled “Spasticity treatment patterns among people with multiple sclerosis: a Swedish cohort study” which was published in Journal of Neurology, Neurosurgery and Psychiatry in December 23, 2022 (1). The authors conducted a population-based cohort study containing details of 5345 patients with multiple sclerosis (MS) with a follow-up duration of about ten years to assess the prevalence and pattern of medications used by these patients for spasticity and factors associated with them. The study showed that near to 10 percents of patients with incident MS and 19 percents of those with prevalent MS received baclofen. The use of baclofen was higher among patients with higher Expanded Disability Severity Scores and younger individuals. Besides, the study showed that the rate of discontinuation of baclofen as high. The study provides strong evidence on the pattern of treatment in these patients with a proper population size and long follow-up duration; there are, however, concern that I would like to mention.
First, the authors did not consider all treatment types for spasticity. The medications included in the study were baclofen, diazepam, clonazepam, gabapentin and cannaboids. In a nationwide study of individuals who received pharmacologic treatment for spasticity in Sweden, the same country as the current study on MS patients was conducted in, the mean proportion of use of botulinum toxin was 9.2% with percen...
Dr Smith and his colleagues have recently written an article entitled “Spasticity treatment patterns among people with multiple sclerosis: a Swedish cohort study” which was published in Journal of Neurology, Neurosurgery and Psychiatry in December 23, 2022 (1). The authors conducted a population-based cohort study containing details of 5345 patients with multiple sclerosis (MS) with a follow-up duration of about ten years to assess the prevalence and pattern of medications used by these patients for spasticity and factors associated with them. The study showed that near to 10 percents of patients with incident MS and 19 percents of those with prevalent MS received baclofen. The use of baclofen was higher among patients with higher Expanded Disability Severity Scores and younger individuals. Besides, the study showed that the rate of discontinuation of baclofen as high. The study provides strong evidence on the pattern of treatment in these patients with a proper population size and long follow-up duration; there are, however, concern that I would like to mention.
First, the authors did not consider all treatment types for spasticity. The medications included in the study were baclofen, diazepam, clonazepam, gabapentin and cannaboids. In a nationwide study of individuals who received pharmacologic treatment for spasticity in Sweden, the same country as the current study on MS patients was conducted in, the mean proportion of use of botulinum toxin was 9.2% with percentage variation between 5.8% and 13.6% across healthcare regions (2) which indicates that botulinum toxin is among key treatments for spasticity in Swedish population and it would be better if the authors could add the information regarding its use to the work. Second, as the authors aimed to assess the treatment pattern and associated factors with medication use, different factors which were identified previously to be in association with medication use pattern should had been considered in this study and been taken care of in the regression modelling analysis. Besides, as treatment cessation was assessed in this study, consideration of factors that are highly associated with adherence to treatment such as socioeconomic factors would have increased the validity of the findings of the study (3, 4). Furthermore, there seems to be a mismatch between prevalent spasticity and prevalent MS diagnosis. In this study, prevalent MS diagnosis defined when a patient was diagnosed with MS before the start time of the study, 1st of July, 2005; prevalent spasticity was defined as receiving spasticity treatments within the first year of evaluation time from 1 July 2005 to 1 July 2006 and patients with prevalent spasticity were then excluded from the study. This, however, could result in bias when depicting the treatment pattern of patients with prevalent diagnosis of MS. The authors also excluded patients with possible spasticity treatments before MS diagnosis were excluded. Previous studies have shown that there might be weeks, months to years of delay from initial symptoms/signs of MS to the clinical diagnosis by a physician (5-7). The patients with MS could have clinical manifestations long before they’ve been diagnosed with MS and therefore, they probably have sought the medical treatment before the diagnosis; spasticity is among these manifestations (8). Therefore, as the authors assumed that MS is likely the cause that patients without any other registered diseases that could result in spasticity were using spasticity treatment, I believe that it would be better not to exclude “all” the patients with spasticity treatment before MS diagnosis; they could just exclude patients with baclofen use for a long time, for example one year, before the diagnosis of MS and those who were known to have other diseases as a cause for spasticity.
Acknowledgement: None.
Conflict of Interest statement: I declare no conflict of interests.
Funding: None.
References
1. Smith KA, Piehl F, Olsson T, Alfredsson L, Hillert J, Kockum I, et al. Spasticity treatment patterns among people with multiple sclerosis: a Swedish cohort study. Journal of neurology, neurosurgery, and psychiatry. 2022.
2. Forsmark A, Rosengren L, Ertzgaard P. Inequalities in pharmacologic treatment of spasticity in Sweden – health economic consequences of closing the treatment gap. Health Economics Review. 2020;10(1):4.
3. Flemmen HØ, Simonsen CS, Broch L, Brunborg C, Berg-Hansen P, Moen SM, et al. The influence of socioeconomic factors on access to disease modifying treatment in a Norwegian multiple sclerosis cohort. Multiple Sclerosis and Related Disorders. 2022;61:103759.
4. Kołtuniuk A, Chojdak-Łukasiewicz J. Adherence to Therapy in Patients with Multiple Sclerosis—Review. 2022;19(4):2203.
5. Patti F, Chisari CG, Arena S, Toscano S, Finocchiaro C, Fermo SL, et al. Factors driving delayed time to multiple sclerosis diagnosis: Results from a population-based study. Multiple Sclerosis and Related Disorders. 2022;57:103361.
6. Adamec I, Barun B, Gabelić T, Zadro I, Habek M. Delay in the diagnosis of multiple sclerosis in Croatia. Clinical Neurology and Neurosurgery. 2013;115:S70-S2.
7. Kingwell E, Leung AL, Roger E, Duquette P, Rieckmann P, Tremlett H. Factors associated with delay to medical recognition in two Canadian multiple sclerosis cohorts. Journal of the Neurological Sciences. 2010;292(1):57-62.
8. Ford H. Clinical presentation and diagnosis of multiple sclerosis. Clinical medicine (London, England). 2020;20(4):380-3.
Functional neurological disorder is an important aspect with respect to burden and cost of management irrespective of gender as the authors have pointed out very rightly1.
Show MoreIt can be chronic but most of the times present as an emergency therby increasing panic, inpatient admissions. Smooth care, workup and appropriate guidelines for the same may help a lot in such conditions.
There is limited information, awareness, health care utilities, and economic burden of such patients which makes the situation more grim.
So there should be multidisciplinary approach i.e. physiotherapy, occupational therapy, speech and language therapy, and psychological assessment. Functional neurological disorders overlap with refractory neurological conditions i.e. headache, seizure, focal deficit etc., so better these patients be subdivided in these categories. Framing universal guidelines all across the world according to subdivisions with appropriate line of care as is being done in various other disorders may help a lot to smoothen improve management and help reduce the cost of therapy and gender bias.
References-
1. Caoimhe McLoughlin, Ingrid Hoeritzauer, Verónica Cabreira et al. http://dx.doi.org/10.1136/jnnp-2022-330192
2. Christopher D. Stephen, Vicki Fung, Codrin I. Lungu et al Alberto J. Espay Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neur...
Dear Editor-in-Chief,
Show MoreWe read with great interest the consensus guidelines for diagnosis and management of spontaneous intracranial hypotension (SIH). [1] In the absence of any recommendations, this guideline will help clinicians in formulating their diagnostic and management approaches for SIH. In this letter, we wish to discuss about the epidural blood patch (EBP) in the management of SIH. The role of targeted EBP for management of SIH has not been compared with non-targeted EBP in randomized controlled trials to establish superiority of one over the other. A recent systematic review of studies with 10 or more patients with SIH reported similar success with either technique. [2] However, where expertise is available and when the precise site of cerebrospinal fluid (CSF) leak is identifiable, it is prudent to consider targeted EBP as the first choice. This reduces the volume of autologous blood required, minimizes the need of reliance on gravity for spread of epidurally placed blood to the potential site of leak and decreases the procedure failure rates and need for subsequent EBPs or surgical interventions. In our center, which is a tertiary care neurosciences academic hospital, after an initial conservative management for a week, a targeted EBP is performed as the preferred approach to manage SIH. [3] If the site of leak is not determinable and if the expertise to perform cervical or thoracic EBP is not available, a non-targeted EBP may be the preferred interventi...
In “Functional neurological disorder is a feminist issue” by McLoughlin et al.,[1] authors explain that FND patients “suffer subtle and overt forms of discrimination”, suggesting that “FND clinical services and research are chronically underfunded in line with the neglect of disorders disproportionately affecting women”. Ultimately, they insist that feminists should support “parity of esteem” for FND with other neurological conditions.
I suggest that the idea of an alliance between feminism and FND is highly problematic. First, authors minimize the seriousness of human rights violations against women in the name of hysteria. Second, they fail to consider the role that FND plays in healthcare gender bias across specialties. Third, they perpetuate the myth that functional diagnosis rarely errs, further threatening women’s safety in the healthcare system.
First, while authors do acknowledge “objectification and exploitation” of women diagnosed with hysteria, their concern is merely that “some sociologists and scientists have opined that the diagnosis was used as a ‘patriarchal tool’ to silence or ignore complaints of women”. There’s no mention of sexualization of women’s symptoms in the name of hysteria, even as recently as ICD-10, or the range of sexual treatments to which “hysterical” women have been subjected, including genital mutilation. There’s no acknowledgment that these treatments, like sectioning based on the wishes of husbands, fathers, or sons, are...
Show MoreWe are writing to respectfully offer some additional comments on the recent publication of Hannaway et al. in JNNP titled “Visual dysfunction is a better predictor than retinal thickness for dementia in Parkinson’s disease”.
While the authors provided interesting insights on the predictive value of higher order visual functions for dementia, we noticed that the authors did not find significant associations between parafoveal GCIPL (pfGCIPL) and cognition in their work, whereas our research did. As they mentioned, the range of cognitive impairment was higher in our sample, and possibly this might have driven our findings. However, we would like to add that the relationship between the retina and cognition is not linear, according to our data. As such, we calculated relative risks by categorizing continuous variables, which allowed us to identify non-linear relationships between pfGCIPL and cognitive impairment. Furthermore, we speculate that these variables do not exhibit a synchronous pattern of change over time, suggesting that the temporal trends are not closely linked, which might justify the lack of association in the current work.
We do agree with the authors in that visual function is a good predictor of cognitive deterioration. Our previous work also demonstrated this fact, but we would like to highlight the benefits of retinal OCT imaging in this context, if its utility is validated. Retinal OCT imaging is a faster and easier-to-measure technique com...
Show MoreAyton et al. reported the association between ferritin, apolipoprotein E (APOE) and dementia-related biomarkers such as amyloid β42/total-tau and phosphorylated tau181 (p-tau181) in cerebrospinal fluid (CSF) (1). CSF ferritin and APOE were positively associated with p-tau181, which was most predominant in subjects without increase in amyloid β42/total-tau. I present information about the study.
Pan et al. investigated the associations of CSF ferritin and CSF biomarkers of Alzheimer's disease (AD) (2). They found that CSF ferritin increased in subjects with more advanced categories of CSF biomarkers such as amyloid β42 and p-pau, although there were stronger relationships of CSF ferritin with p-tau and t-tau, rather than amyloid β42. This means that biological action of ferritin in the brain for AD may be more closely related to tau protein.
Baringer et al. described brain iron homeostasis in Alzheimer's disease, Parkinson's disease, and other neurodegenerative diseases (3). They emphasized that endothelial cells of the blood-brain barrier were the site of iron transport regulation, and iron uptake, transcytosis, and release were mainly conducted. By controlling the excess of brain iron, neurodegenerative disorders may be improved. The mechanism that tau protein spreads through functionally connected neurons in Alzheimer's disease have been precisely reported (4), and it may be related to the excess of brain iron storage.
References...
Show MoreÅkerstedt et al. conducted a case-control study with 2075 cases and 3164 controls to investigate the association between sleep and risk of multiple sclerosis (MS) (1). Sleep duration, circadian disruption and sleep quality during adolescence were used for sleep variables. The authors calculated the adjusted OR with 95% CIs using logistic regression models, and short sleep (<7 hours/night) and low sleep quality were significantly associated with increased risk of developing MS. I have a question regarding the ways of multivariate analysis.
The ratio in the number of cases and controls is about 1.5 in this study. If the authors selected unconditional logistic regression analysis, OR might become conservative. If the authors selected conditional logistic regression analysis, the increased number of controls is preferable to make stable estimation. Instead of selecting a case-control study with a matching procedure, using all pooled data without a matching procedure can be selected for the analysis (2).
Anyway, a recall method has a possibility of including bias and risk assessment of MS with subjective sleep variables should be paid with caution.
References
Show More1. Åkerstedt T, Olsson T, Alfredsson L, et al. Insufficient sleep during adolescence and risk of multiple sclerosis: results from a Swedish case-control study. J Neurol Neurosurg Psychiatry 2023;94(5):331-6.
2. Hamajima N, Hirose K, Inoue M, et al. Case-control studies: matched controls...
We appreciate the author for exploring the independent factors associated with the achievement of the treatment target (MM and MM5mg) in generalized myasthenia gravis (MG) patients, including early fast-acting treatment (EFT) [1]. This study attempted to include patients treated with EFT or non-EFT by propensity score (PS) matching to obtain a balance in baseline characters between the two groups, and to determine whether EFT was an independent factor of achieving MM5mg the treatment target by adjusting the confounding factors. The primary endpoint of this study was to reach MM5mg, and Cox regression analysis was used to explore the independent factors. Some concerns are raised here for discussion with the authors.
Show More1. Is the starting point of the study from the beginning of immunotherapy? If so, pre-treatment factors such as gender, onset age, pre-treatment disease duration, pre-treatment worst severity, subtype, and severity at the start of treatment, need to be included. Ongoing treatment factors should include at least the dose range and duration of oral prednisone, Calcineurin inhibitors usage and intervals between their initiation time and the beginning of immunotherapy, and the number of cycles of fast-acting therapies administered 6 months after initiation of immunotherapy. All of these factors may affect the prognosis. We also wish to know whether the thymectomy was performed before or after the initiation of immunotherapy in each patient, and the interva...
Professor Sinclair and her team1 in Birmingham highlight an urgent issue affecting patients with IIH during the COVID19 pandemic. Their paper elegantly shows that weight gain worsens the severity of papilloedema and puts patients at risk of blindness. They also highlight the risk of worsening papilloedema not picked up with reduced access to hospital appointments.
Here, we report the audit results from our service and share practical actions that have been effective for our service, with wider applicability.
From May – Dec 2020, 58/102 (57%) IIH patients seen for follow up had gained weight compared to weight measured prior to pandemic by median 5.35 (range 0.6,27.3; SD 4.42)kg; with overall weight change of median 1.65 (range -24, 27.3; SD 6.81)kg for the group. 3/58 (5%) patients who gained weight, developed worsening papilloedema.
We agree with the importance of optic disc examination as highlighted by Sinclair and colleagues1, and the need for PPE precautions in the COVID19 pandemic setting. An option we found helpful is fundus photography of the optic disc in the community which the patient then emails their clinician. Fundus photography is now widely available at high-street optometrists. Benefits of doing this include: circumventing patients’ fears of attending hospitals during the pandemic; a patient-held record for future comparison; and the option for clinicians to obtain a colleague’s second opinion on the optic disc photograph.
I...
Show MoreDear Editor,
I recently read the article titled "Somatic symptom disorder in patients with post-COVID-19 neurological symptoms: a preliminary report from the somatic study (Somatic Symptom Disorder Triggered by COVID-19)" published in the Journal of Neurology, Neurosurgery, and Psychiatry. As a psychiatrist in Taiwan, I found the findings of the study intriguing and relevant to the mental health challenges faced by our population during the COVID-19 pandemic.
In Taiwan, we have observed similar situations where the pandemic has had a significant impact on mental health. Our recent study, "Mental health impact of the COVID-19 pandemic in Taiwan,"1 published in the Journal of Formosan Medical Association, explored the prevalence of psychiatric distress, suicidal ideation, and levels of worry during the pandemic among a representative sample of 1,087 Taiwanese. The results showed that approximately 12% of respondents experienced psychiatric distress, and about 10% expressed concerns over financial troubles, employment, and mental health conditions.
While the prevalence of psychiatric distress in Taiwan is lower compared to other countries, the study highlights the undeniable effect the pandemic has had on mental health. It is important to acknowledge that the COVID-19 crisis goes beyond health and mental health issues, as its socio-economic impact could have long-lasting consequences if not adequately addressed.
In light of the...
Show MoreDr Smith and his colleagues have recently written an article entitled “Spasticity treatment patterns among people with multiple sclerosis: a Swedish cohort study” which was published in Journal of Neurology, Neurosurgery and Psychiatry in December 23, 2022 (1). The authors conducted a population-based cohort study containing details of 5345 patients with multiple sclerosis (MS) with a follow-up duration of about ten years to assess the prevalence and pattern of medications used by these patients for spasticity and factors associated with them. The study showed that near to 10 percents of patients with incident MS and 19 percents of those with prevalent MS received baclofen. The use of baclofen was higher among patients with higher Expanded Disability Severity Scores and younger individuals. Besides, the study showed that the rate of discontinuation of baclofen as high. The study provides strong evidence on the pattern of treatment in these patients with a proper population size and long follow-up duration; there are, however, concern that I would like to mention.
Show MoreFirst, the authors did not consider all treatment types for spasticity. The medications included in the study were baclofen, diazepam, clonazepam, gabapentin and cannaboids. In a nationwide study of individuals who received pharmacologic treatment for spasticity in Sweden, the same country as the current study on MS patients was conducted in, the mean proportion of use of botulinum toxin was 9.2% with percen...
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