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General Clinical News
Using a mostly Caribbean Hispanic cohort of stroke-free individuals aged 40-and-over, researchers have found significant cross-sectional associations between greater depression, brain ageing and episodic memory . Following up at five years, the study found no significant evidence for a depression-linked change in cognition over this time period. The data comes from the Northern Manhattan Study (NOMAS), a community-based research study of stroke and risk factors.
Prenatal APAP associated with language delay in children at 30 months
Language delay may be linked to prenatal acetaminophen (paracetamol) use
The effect of prenatal exposure to acetaminophen (APAP)/paracetamol on child development has become a common topic of debate, and this study suggests that language development may be negatively affected . A Swedish cohort of 754 pregnant women were tested for urinary concentration of APAP and asked how many tablets they took between conception and week eight of their pregnancy. Based on data at 30 months, girls who were prenatally exposed to APAP were more likely to show delayed language development.
As well as being linked to heart disease, stroke and cancer, researchers now believe that obstructive sleep apnoea (OSA) could also be responsible for a reduction in cortical thickness in the left and right temporal lobes of the brain, areas known to be affected by dementia .
Researchers at the University of Mississippi have found that continuous positive airway pressure (CPAP) therapy on veterans
with comorbid PTSD and OSA reduced PTSD symptoms .
The low oxygen levels that can result from obstructive sleep apnoea (OSA) during sleep has been studied recently as an antecedent to cognitive decline and other neurological disorders . As a result, researchers in Spain have been looking at integrated care models involving GPs to help with effective management of OSA. By combining GPs’ recommendations with an algorithm to treat OSA, the study found that primary care management showed a clear economic advantage.
Recurrent ischaemic stroke risk associated with sleep apnoea Identifying a lack of data about the links between sleep apnoea and recurrent ischemic stroke, researchers at the University of Michigan have found that there is an association between sleep apnoea and a combined endpoint of recurrent ischemic stroke and mortality .
A practical approach to the diagnosis of spinal cord lesions With a growing range of diagnostic tools available, this paper aims to provide clinicians with an improved approach to diagnosis of adult non-compressive, non-traumatic spinal cord disorders .
In the first study to look at associations between muscular and cognitive function in people with major depression and bipolar disorder, findings indicated that handgrip strength is a biomarker for cognition among people with these mental health conditions . Data from handgrip dynamometry tests to measure handgrip strength was taken from 110,067 patients recorded in the UK Biobank, 22,699 of whom had major depression and 1,475 who had bipolar disorder. Further research is needed to investigate causality.
New exercise framework for people with Parkinson’s
Exercise for people with Parkinson’s: a practical approach
People with Parkinson’s are less physically active than the general population. Parkinson’s UK produced an exercise framework in collaboration with physiotherapists, people with Parkinson’s and exercise professionals. Here, three physiotherapy professionals associated with the project further elaborate on the role of exercise in helping offset the symptoms of Parkinson’s and provide advice for medical professionals working with people with Parkinson’s to establish an exercise regime . Aerobic exercise is more effective than goal=based exercise for the treatment of cognition in Parkinson’s disease. Meanwhile, Canadian researchers have been studying whether the type of exercise could alter its effectiveness as a treatment of cognition in PD . In a 12-week study, 76 people with Parkinson’s undertook aerobic and goal-based exercises with the aim of finding out which of the two brings about the greater improvement in cognition. Aerobic exercise was found to improve inhibitory control in people with Parkinson’s.
Treadmill exercise safe for patients with Parkinson’s disease – High-intensity treadmill exercise has also been deemed safe and feasible for people with Parkinson’s disease . However, this paper stops short of providing advice about efficacy, saying that further studies are required.
Neurologist survey highlights misreported symptoms, driving safety in Parkinson’s
Neurologists give insights on how to improve communication and quality of life for families of Parkinson’s disease patients
Caregivers and families of those with Parkinson’s often struggle to cope with the complex needs of the patient. The themes highlighted in this survey of 16 neurologists in San Francisco are likely to resonate closer to home, with respondents reporting discrepancies between patient and caregiver reporting of symptoms, difficult conversations over driving safety and a gender imbalance between the roles that caregivers take on .
A guide to effective management of psychiatric disorders in Parkinson’s
Psychiatric disorders in Parkinson’s disease
Properly diagnosing and managing psychiatric disturbances in patients with Parkinson’s disease can be difficult, as the physical and motor aspects of the disease tend to receive greater attention. Accurate diagnosis of comorbid psychiatric disorders in Parkinson’s disease can help to reduce the anxiety of caregivers who, the author writes, are often affected more by symptoms of the psychiatric conditions associated with Parkinson’s than they are by the physical symptoms of the disease .
Link between mental health disorders and pseudobulbar affect in Parkinsonian syndromes
Pseudobulbar affect linked to mood symptoms in Parkinsonian syndromes
Pseudobulbar affect (PBA) is a condition that involves involuntary
or disproportionate emotional displays, mainly crying or laughing. Most often linked to neurologic injuries like stroke and TBI, the study of PBA is now focusing on neurologic diseases including Parkinson’s. This paper aims to shed light on the little-understood links between mental health disorders, Parkinson’s and PBA, finding evidence for an association based on a lower mental health status .
Overactive bladder occurrence more frequent in idiopathic Parkinson’s disease Idiopathic Parkinson’s disease may increase risk for overactive bladder
Overactive bladder (OAB) is common among people diagnosed with Idiopathic Parkinson’s disease (IPD), the most commonly diagnosed form of Parkinson’s. Focusing on data from the year 2000, this retrospective cohort study used a cohort of 4,571 IPD patients’ data and 18,255 patients without IPD for control . The data came from the National Health Insurance Research Database in Taiwan. This study showed that occurrence of OAB was far more frequent in the cohort with IPD than in the control group. The authors recommend further studies to understand the nature of the link between IPD and OAB.
Tremor prevalence in Parkinson’s decreases over time
Resting tremor most common in early Parkinson’s disease
This study looks at the prevalence of different types of tremor in
people with early-stage Parkinson’s disease . Findings show that 79% of the cohort of 378 patients presented with resting tremor, most of which occurred in the upper limbs. Following up at 2 years, 68% of the cohort had resting tremor, in line with a general reduction in prevalence of tremors. The authors write that this general decrease in tremor prevalence could be due to worsening rigidity, residual effect from medications or daily
variability in tremor prevalence.
Ropinirole, bromocriptine and piribedil for Parkinson’s have highest adverse effect rates
Parkinson’s drugs with highest adverse effect rates
Using data from 24 randomised controlled trials taken from PubMed, EMBASE and Cochrane Library, this systematic review has found the three Parkinson’s drugs with the highest rate of adverse effects . Ropinirole, bromocriptine and piribedil caused the highest rate of symptoms of nausea, dyskinesia, hallucination, dizziness, constipation and somnolence in Parkinson’s patients. As a result, the authors recommend against their use for treatment of Parkinson’s.
Regulations updated for valproate prescription in women of childbearing potential
Valproate and childbearing potential – new regulations
Sodium valproate hit the headlines last year after patient surveys found that the well-evidenced risks associated with taking the drug during pregnancy had not been effectively communicated to women taking valproate . As a response, new regulations have been drawn up preventing the prescription of valproate to pregnant women in most cases, and restricting prescription to women of childbearing potential unless they adhere to a strict pregnancy prevention programme. However, valproate is still
effective for treatment of epilepsy, and may be prescribed where no other option is available.
Managing patients with comorbid epilepsy and psychosis
Epilepsy and Psychosis: a practical approach
There are multiple conflicting factors in the treatment of patients with epilepsy and psychosis, including considerations of diagnosis and medication – antipsychotics may worsen seizures. The authors present a practical approach to managing people with epilepsy and psychosis .
Supporting bereaved families in cases of Sudden Unexpected Death in Epilepsy
SUDEP, the aftermath: Supporting the bereaved
Approximately half of all epilepsy deaths in the UK can be accounted for by Sudden Unexpected Death in Epilepsy (SUDEP). The authors of this paper argue that doctors currently have too little contact with bereaved families and that misunderstandings surrounding the cause of death need to be addressed more clearly .
Systematic review finds epileptic seizure reduction with adjunctive cannabinoids
Cannabinoids may be effective as adjunctive treatment for refractory epilepsy
A systematic review of the use of cannabinoids to treat epilepsy has found that nearly half of patients in studies that reported seizure frequency achieved a 50% or greater reduction in seizures after taking cannabinoids . Around 30% of epilepsy patients have a drug-resistant form of the condition, which means that new adjunctive and alternative therapies are closely watched.
Stress management therapies may reduce seizures in treatment-refractory epilepsy
Seizure frequency may lessen with stress reduction
A study comparing two different stress-reduction techniques as adjunctive therapies for medication-resistant epilepsy has found that both progressive muscle relaxation (PMR) and focused attention activity reduce seizure frequency by around a quarter . Researchers found no evidence that one treatment was superior for seizure reduction, but their research has implications for the study of stress in epilepsy nevertheless. Their results will need repetition with a larger sample size, as this study was
under powered due to a loss of funding.
Despite more AEDs, one in three new epilepsy diagnoses still medication-resistant
More than one-third of new cases of epilepsy are treatment-refractory
This paper aimed to establish whether the assertion, made in an 18-year-old study, that one-third of adults with epilepsy were unable to control seizures with antiepileptic drugs (AEDs) still held true . Their findings are stark: Irrespective of the number of new AEDs available to epilepsy patients, one third of their cohort still experienced treatment-refractory seizures.
Meta-analysis shows higher probability of major depression in women with epilepsy
Women with epilepsy more likely to have major depressive disorder
The prevalence of major depressive disorder (MDD) as a comorbidity of epilepsy has been underestimated and is more common in women than men, surmise the authors of this metaanalysis of 35 studies . The researchers argue that more should be done to tackle MDD in people with epilepsy, and especially women, to improve their quality of life.
Vitamin D supplements for epilepsy and multiple sclerosis: advice for neurologists
Vitamin D Supplementation
Interest in vitamin D levels as a possible cause of increased risk of multiple sclerosis and epilepsy has recently grown among neurologists. This paper advises neurologists  on how to advise anxious patients about what they can do to mitigate the effects of low vitamin D levels, which is a modifiable factor in people with epilepsy, who have a higher risk of fracture. Similarly, patients with vitamin D deficiency are likely to face worsened MS prognosis.
Supplementary vitamin D linked to lower rate of MS relapse
Vitamin D: The only dietary supplement showing significant benefit for MS
Supplementary vitamin D is currently being trialed in people with MS , and is linked to a lower rate of relapse. Currently, no other dietary supplements show a significant impact on MS progression.
Updated McDonald criteria makes greater use of MRI in MS diagnosis
New MS diagnostic criteria in practice
In 2017 a revised set of diagnostic criteria were introduced to aid accurate and early diagnosis of multiple sclerosis . The McDonald criteria make wider use of MRI to identify CNS damage disseminated in time and space and oligoclonal bands in the spinal fluid, the latter of which can predict a second clinical attack following clinically isolated syndrome in patients displaying dissemination. The criteria recommend caution when
treating patients from less at-risk demographic groups to avoid misdiagnosis.
Higher score on MS disease severity scale linked to increased neuropathic pain risk
Severe MS associated with increased neuropathic pain risk
This study shows that a more severe MS disease course can be linked to a higher incidence of neuropathic pain . The study involved 1249 participants with a mean disease duration of eight years, and used the Expanded Disability Status Scale (EDSS) to quantify disease severity. A higher score on the EDSS was clearly linked to an increased incidence of neuropathic pain, while age, gender and disease severity were linked to pain in general.
Mood, anxiety disorders linked to greater MS disease progression in women
Psychiatric comorbidities increase neurologic disability in multiple sclerosis
A study has found that the presence of a psychiatric comorbidity in people with multiple sclerosis is associated with greater disease severity . A cohort of 2,312 people with MS was used, 35.8% of whom met the criteria for a mood or anxiety disorder. At ten-year follow up, those with psychiatric comorbidities showed greater disease progression, averaging three points higher on the EDSS. The findings were statistically significant in women, but not men.
MS patients experience range of clinical disturbances in the 10 years prior to diagnosis
Various clinical disturbances precede MS diagnosis
Patients with multiple sclerosis were significantly more likely to present with a range of clinical disturbances in the ten-year period before first MS record, a nested case-control study has shown . Using data from the United Kingdom Clinical Practice Research Datalink, 10,204 MS patients were identified and matched to 39,448 controls. In the ten years before their
MS diagnosis, patients showed a significantly higher incidence of diagnosis with gastric, intestinal, urinary or anorectal disturbances, as well as anxiety, depression, insomnia, fatigue, headache and pain.
People with MS comorbidities more likely to face delay in diagnosis, higher mortality rate
Comorbidities in multiple sclerosis associated with diagnostic delays, mortality risk
A Danish study has shown that the presence of comorbidity in multiple sclerosis is responsible for increased delays in diagnosing MS and a higher mortality rate . Cardiovascular and lung comorbidities increased the odds of a MS diagnostic delay of 5-10 years referenced with a delay of 0-5 years, with statistically significant odds for later delays found in those
with cerebrovascular, lung, diabetes and cancer comorbidity. A higher risk of mortality was found in MS patients with cancer, cardiovascular, cerebrovascular, diabetes, lung, Parkinson’s disease and psychiatric comorbidity, but not autoimmune comorbidity.
MOTOR NEURONE DISEASE
Riluzole most beneficial to survival during stage 4 of ALS
Riluzole prolongs survival in late-stage amyotrophic lateral sclerosis
Riluzole is known to reduce mortality in amyotrophic lateral sclerosis (ALS), but little data exists to show at what point during the disease this benefit occurs. This retrospective analysis of data from 1992-1994 taken from the original dose-ranging trial of riluzole shows a significant prolonging of survival in stage 4, the last stage of ALS . In order to back up their findings, the authors hope that further prospective studies of riluzole will be completed in light of their research.
Slow vital capacity decline linked to higher incidence of clinically meaningful events in ALS
Predicting ALS disease progression with respiratory function decline
The most common cause of death in ALS is respiratory failure as a result of decline in respiratory skeletal muscle function. The authors of this paper find that a decline in slow vital capacity (SVC) can be used to provide a prognosis, based on the finding that an increased rate of decline in SVC is associated with an increased incidence of clinically meaningful events .
Phase I study: Treg infusions slow rate of ALS progression
Immunotherapy promising for slowing progression of ALS
ALS disease progression can be slowed by autologous infusions of expanded regulatory T-lymphocytes (Tregs), a phase I trial indicates . Three patients were infused with Tregs with concomitant subcutaneous Interleukin-2 injections eight times – four at two week intervals and four at four week intervals. Treg infusions remained safe and well-tolerated in early and late stages of ALS, and Treg suppressive function correlated with a slower rate of clinical progression. Future research should focus on optimisation
of Treg doses with the aim of prolonging slowed disease progression.
DEMENTIA AND GENERAL COGNITION
Rheumatic diseases linked to heightened dementia risk
Increased dementia risk seen in rheumatic diseases
Using data from patients entered in the Taiwan National HealthInsurance Research Database (NHIRD) between 2000 and 2010, this paper shows a statistically significant link between dementia and rheumatoid arthritis . Sjögren’s syndrome (SS), systemic lupus erythematosus (SLE) and osteoarthritis (OA) were linked to dementia in females, and SS, psoriatic arthritis (PsA) and OA were linked to dementia in males. The authors offer inflammation and medications as two possible explanations for this link.
Study finds higher leafy vegetable consumption knocks years off cognitive age
Increasing leafy vegetable intake may boost cognition
This study involving 960 participants from the Rush Memory and Ageing Project (MAP) with an average age of 81 years old found that those who ate 1-2 servings of green leafy vegetables per day equated to being 11 years younger than those who rarely/never consumed green leafy vegetables . This may be due to the neuroprotective actions of the lutein, folate, beta-carotene and phylloquinone contained in such foods. Limitations of the study are that it may not be generalised to younger adults or non-white
people – further studies are required to elucidate the effect in these populations.
Hypertension independent risk factor for dementia in 50-year-olds
Higher blood pressure at mid-life increases dementia risk
Hypertension at age 50 – but not at age 70 – is associated with an increased risk of dementia, a study has shown . Systolic blood pressure (SBP) of ≥130 mmHg was used to define hypertension, a lower threshold than is standard in the UK. Among those with hypertension, dementia risk was independent of cardiovascular disease (CVD). Blood pressure data was used from the Whitehall II cohort study of 8,639 people.
Diabetes linked to decline in memory, psychomotor speed, executive function
Long-term type 1 diabetes associated with cognitive decline
Type 1 and type 2 diabetes can be responsible for cognitive deficits compared to the general population, according to new research . A cohort of people who had been diagnosed with type 1 diabetes for at least 50 years were compared to an age-matched cohort of people with type 2 diabetes and an age-matched control group. Those with diabetes of either type performed worse than control in terms of memory, psychomotor speed and executive function.
Use of hearing aids could help to slow cognitive decline in over 50s
Hearing aids may mitigate cognitive decline, memory loss
A study of people over the age of 50 shows that the use of hearing aids is positively associated with a slower decline in episodic memory . Episodic memory score data was used, with scores based on the sum of immediate and delayed recall of ten words. The data on the 2,040 patients included in the study were taken from the Health and Retirement Study (HRS).
TBI in 3-to-7-year-olds linked to higher risk of secondary ADHD
Risk of secondary ADHD higher after childhood TBI
Early childhood traumatic brain injury (TBI) has been linked to a higher incidence of secondary attention deficit/hyperactivity disorder (SADHD) in children 5-10 years post-trauma . The paper, conducted on a concurrent cohort/prospective study of children hospitalised for TBI or orthopaedic injury who were aged between 3 and 7 years old, found that patients should be monitored for attention deficits/problems post-injury.
History of TBI, sexual abuse linked to psychogenic non-epileptic seizures
Objective score identifies non-epileptic psychogenic seizures linked to abuse, TBI
Psychogenic non-epileptic seizures (PNES) are classified as medication-resistant or atypical seizures which are usually caused by painful mental or emotional processes, and encompass a wide range of conditions, most commonly dissociative seizures and panic attacks. This paper finds that a history of stressful events (sexual abuse in particular) was linked to an increased incidence of PNES . The finding of an increased frequency of PNES in women of childbearing potential was significant.
Retrospective study shows mild TBI linked to Parkinson’s in veterans
Traumatic brain injury linked to increased Parkinson’s disease risk in veterans
This retrospective cohort study, which was conducted across all patients in the Veterans Health Administration database who were diagnosed with TBI between October 2002 and September 2014, showed that mild TBI is linked with an increased risk of Parkinson’s disease in military veterans . The authors hope to foster greater understanding of the modifiable risk factors involved in post-TBI Parkinson’s.
Swedish study shows long-lasting increase in dementia risk after TBI
Traumatic brain injury associated with increased dementia risk
A study has shown a time and dose-dependent link between traumatic brain injury (TBI) and subsequent dementia diagnosis . The findings of the cohort study, using data from Swedish 50-and-overs, provide evidence for a high risk of dementia after TBI that decreases over time, but is still identifiable over 30 years after injury. The authors also suggest that, based on their data, the severity of the trauma and the incidence of multiple TBIs may correlate with a higher risk of dementia.
Lower respiratory diseases increase subsequent rates of MI, stroke
Rate of MI, Stroke higher after respiratory infection:
Lower respiratory tract infection was responsible for 4.8% of
all deaths in 2013.
In this paper from the European Respiratory Journal, researchers have found an association between lower respiratory diseases, including S.pneumoniae, and increased rates of first myocardial infarction (MI) and stroke using data from the Scottish Morbidity Report, which includes data of day cases from acute specialities in hospitals in Scotland . 1,227 individuals with first MI and 762 with first stroke were analysed. The authors claim that their findings should be generalised to similar Northern European populations.
Social isolation increases incidence of AMI and stroke, and subsequent mortality
Social isolation, loneliness may increase AMI, Stroke risk
Social isolation and loneliness may be linked with a greater incidence of acute myocardial infarction (AMI) or stroke, say the authors of this study in Heart journal . Analysis of a sample of 479,054 participants from the UK Biobank between 2007 and 2010 with complete data on social isolation/loneliness, AMI and stroke, found that over a follow-up period of over seven years (avg. 7.1 years), people reporting social isolation and loneliness displayed a 1.4-1.5-fold risk of incident AMI or stroke. Social
isolation (but not loneliness) was an independent risk factor for mortality following AMI or stroke.
Seizure hospitalisation more common among stroke survivors than in general population
Stroke survivors have higher risk for subsequent seizures than general population
Using a US-based cohort of patients hospitalised for acute stroke without a history of seizures, this study found that annual incidence of seizures was eleven times higher after stroke than among the general population (1.68% and 0.15% respectively) . The cumulative rate of hospitalisation for seizure after eight years was 9.27% after stroke compared to 1.21% among the general population. Additional risk factors for seizures included being 65 or older, and incidence of intracerebral haemorrhage and subarachnoid haemorrhage. and Retirement Study (HRS).
Further evidence of migraine-CVD link provided in Danish population study
Clarifying cardiovascular risk in migraine:
Migraineurs face a higher risk of cardiovascular events that
increases with age, and is under-recognised in women. The link
between CVD and migraine is well-documented, but guidance
on the topic is lacking and some migraine treatments which raise
the risk of CVD further are still prescribed to patients. This BMJ
editorial  provides up-to-date information on the issue based
on Danish population-based study data published in January .
Headache occurrence, severity associated with reduction in basic needs satisfaction
Headaches linked to reduced psychological need satisfaction
A preliminary study of 116 young adults has found that the occurrence of headaches led to reduced basic needs satisfaction . Participants completed a daily diary of headache activity and needs satisfaction over a period of three weeks, with the results showing a further decrease in needs satisfaction for those with severe headaches.
Study of 2011 Norwegian terror attack survivors shows increased prevalence of migraine
Migraine, tension-type headache likely after exposure to violence
Exposure to violence and terror attacks increases the risk of persistent migraine and tension-type headaches in adolescents, a study comprising of survivors of the 2011 Norway terrorist attack on Utøya Island has shown . Each of the 213 survivors of the Utøya mass shooting, with a mean age of 17.7 years old, were matched with 8 controls from the general population-based Young-HUNT3 study. The authors conclude that violence may affect central sensitisation and pain modulation/perception, thereby becoming pathogenic in triggering the onset of frequent headaches.
Could psychological therapies for pain in older adults help solve the US opioid epidemic?
Opioids are commonly prescribed for chronic pain, but with a
growing focus on a US-wide opioid epidemic this year, alternative
treatments are being studied in detail . This meta-analysis looks
at possible psychological treatments for chronic pain, finding that
there was a small benefit to pain mitigation and catastrophisation
in older adults, and also improved their ability to self-manage pain.
Further research is needed before more robust psychological
treatments for chronic pain can be developed.
Migraine with aura responsible for 18% of all improper thrombolytic treatments
The most commonly-used emergency thrombolytic treament for stroke is IV tissue plasminogen activator (IV-tPA). Around 7% of all IV-tPA adminstered as a thrombolytic treatment for stroke is unnecessary due to misdiagnosis of a stroke-mimicking condition. An estimated 18% of these unnecessary treatments are given to patients suffering from the symptoms of migraine with aura (MA) .
Two-part fibromyalgia exam lets GPs diagnose with reduced rheumatologist involvement
There is an increasing expectation that primary care providers should be able to recognise and treat fibromyalgia (FM) with limited involvement from rheumatologists. With this in mind, a simple bipartite screening test for fibromyalgia has been devised to aid GPs in making a probable diagnosis of FM before sending the patient for a follow-up . Patients were asked to report pain on pinching the Achilles tendon, and asked whether they would agree that they ‘have a persistent deep aching over most of [their] body’.
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Thanks to Chris Jutting (freelance journalist) for the collection of news items.
Posted January 2019