Traumatic brain injury (TBI) is the leading cause of mortality and
disability in young adults worldwide, especially in developing
countries.[1] TBI has recently been suggested to be an ongoing and perhaps
lifelong process, and it may adversely affect multiple organ systems. For
TBI, prevention is better than the cure. However, the risks of TBI are
unclear. Liao et al. examined a clinical database that included the
medica...
Traumatic brain injury (TBI) is the leading cause of mortality and
disability in young adults worldwide, especially in developing
countries.[1] TBI has recently been suggested to be an ongoing and perhaps
lifelong process, and it may adversely affect multiple organ systems. For
TBI, prevention is better than the cure. However, the risks of TBI are
unclear. Liao et al. examined a clinical database that included the
medical insurance records of one million people in order to address
whether patients with mental disorders have an increased risk of TBI and
its associated increased post-injury mortality.[2] They suggested that
patients with mental disorders, especially those with diagnoses for the
top 3 risk groups (specified nonpsychotic mental disorders due to brain
damage, alcohol- or drug-induced mental disorders, and emotional
disturbances), should be considered for special care for the prevention of
TBI. In addition, they found that, in comparison with patients without
TBI, patients with TBI were more likely to have hypertension, diabetes,
stroke, epilepsy, and require renal dialysis.
An ounce of prevention is worth a pound of cure. Traffic safety laws
and preventive measures have reduced the incidence of TBI from traffic
accidents. However, the age of onset of mental disorders may have an
effect. In the study by Kessler et al., the medians and interquartile
ranges (IQR; 25th-75th percentiles) of the ages of onset of anxiety
disorders, mood disorders, and substance disorders were 25-53 (IQR, 15-
75), 25-45 (IQR, 17-65), and 18-29 (IQR, 16-43), respectively.[3] In
Taiwan, we can get a driver's license at 20 years of age by finishing a
health examination and passing a road driving test, and we can renew our
driver's licenses every 6 years without a health examination. In fact, we
may not be reducing the incidence of TBI that is related to mood disorders
and substance abuse effectively.
Furthermore, elderly people and people with selected comorbidities,
including hypertension, diabetes, stroke, epilepsy and renal dialysis,
have the highest risk of TBI. Because those coexisting medical conditions
are known risk factors for dementia, these findings suggest that head
injuries are not purely random events, but that patients with TBI seem to
have higher cognitive dysfunction, which puts them at increased risk of
suffering a head injury.[4] It is possible that a person will get his
driver's license at a young age and that he will not need a health
examination for driving all of his life, and he might suffer a head injury
and eventually get dementia. However, he still drives. It is a vicious
cycle and will not decrease the incidence of TBI related to dementia.
Good traffic safety laws and preventive measures have reduced the
incidence of TBI. One of the authors of this paper, Wen-Ta Chiu, is the
Minister of the Department of Health in Taiwan. We suggest that the
Taiwanese government should set up health examinations that include
cognitive, behavioral, or psychiatric assessments when driver's licenses
are renewed. The early detection of cognitive dysfunction in patients with
mental disorders may decrease the incidence of TBI.
REFERENCES
1. Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic
brain injury in adults. Lancet Neurol 2008;7:728-741.
2. Liao CC, Chiu WT, Yeh CC, et al. Risk and outcomes for traumatic
brain injury in patients with mental disorders. J Neurol Neurosurg
Psychiatry 2012;83:1186-1192.
3. Wang HK, Lin SH, Sung PS, et al. Population based study on
patients with traumatic brain injury suggests increased risk of dementia.
J Neurol Neurosurg Psychiatry 2012;83:1080-1085.
4. Kessler RC, Amminger GP, Aguilar-Gaxiola S, et al. Age of onset of
mental disorders: a review of recent literature. Curr Opin Psychiatry.
2007;20:359-64.
With interest I read the article by Erro et al. in the January
edition of JNNP (2013;84;14-17). The authors aim to assess nonmotor
symptoms (NMS) in a cohort of newly diagnosed patients with Parkinson's
disease (PD) with a subsequent follow up of two years. Meanwhile,
treatment with (a combination of) levodopa, dopamine agonists or a MAO-
inhibitor was started according to the movement disorder spec...
With interest I read the article by Erro et al. in the January
edition of JNNP (2013;84;14-17). The authors aim to assess nonmotor
symptoms (NMS) in a cohort of newly diagnosed patients with Parkinson's
disease (PD) with a subsequent follow up of two years. Meanwhile,
treatment with (a combination of) levodopa, dopamine agonists or a MAO-
inhibitor was started according to the movement disorder specialist
insight. The conclusion is that NMS are frequent, remain stable and only
few NMS are influenced after two years of dopaminergic treatment.
I agree with the authors that we know little about the effects of
dopaminergic treatment on NMS. Some NMS may be dopa-responsive and in my
opinion several items that appear in different nonmotor scales are in fact
motor symptoms (morning dystonia, tremor on awakening, etc.). Therefore
studies of this kind are needed. However, I find the conclusion of the
current study problematic:
1. The study's design: patients included in the study are assessed
with the NMS-Quest and dopaminergic therapy is started 'ad libitum' (which
indeed reflects clinical practice) and after two years patients are re-
assessed with NMS-Q. It would have been much better when a control group
was included in the study, because now the current manuscript does neither
elucidate the natural course of NMS, nor does it demonstrate the effect of
dopaminergic treatment. The authors report that NMS remain stable but we
know nothing about disease progression. PD is a (sometimes fast)
progressive disorder and it is known that both motor and nonmotor problems
accumulate after only several years. Disease progression (both motor and
nonmotor) may have been 'masked' by dopaminergic treatment but without a
control group we really don't know.
Another possibility would have been that patients were assessed with the
NMSQuest after a much shorter follow up in order to assess treatment
effects instead of disease progression. I believe that the current paper
is a spin off of previous work published in JON which may explain the
current set up of the study.
2. The authors report findings of the UPDRS part three but motor
complications are not presented. How many patients were assessed in the on
state when assesses at follow up with the NMS-Q?
3. Trenkwalder (Movement Disorders 2010) clearly showed that several NMS
(early morning motor function particularly, but also the overall NMS
burden) can be treated with the dopamine agonist rotigotine. This
important study is unfortunately not mentioned in the article by Erro.
Kind regards,
Nico Weerkamp, Dept. of Neurology, Atrium Medical Center Heerlen, the
Netherlands
Henri Dunantstraat 5
6419 PC Heerlen, the Netherlands
nicoweerkamp@hotmail.com
Traumatic brain injury (TBI) is the leading cause of mortality and disability in young adults worldwide, especially in developing countries.[1] TBI has recently been suggested to be an ongoing and perhaps lifelong process, and it may adversely affect multiple organ systems. For TBI, prevention is better than the cure. However, the risks of TBI are unclear. Liao et al. examined a clinical database that included the medica...
Dear editor,
With interest I read the article by Erro et al. in the January edition of JNNP (2013;84;14-17). The authors aim to assess nonmotor symptoms (NMS) in a cohort of newly diagnosed patients with Parkinson's disease (PD) with a subsequent follow up of two years. Meanwhile, treatment with (a combination of) levodopa, dopamine agonists or a MAO- inhibitor was started according to the movement disorder spec...
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