RSS 1.0Neurological Bulletin
The five volumes of the open access journal Neurological Bulletin (ISSN 1942-4043) were published from 2009-2013. The journal, led by editor-in-chief William Schwartz of the University of Massachusetts Medical School, promoted scientific inquiry and reasoning for trainees in neurology and neuroscience, and the academic neurology community at large. It published original investigations, case reports and case series, therapeutic trials, and timely reviews, written by students, residents, or fellows, with faculty as possible co-authors or mentors. Neurological Bulletin has been discontinued; all published articles will continue to be available and preserved in the eScholarship@UMassChan repository.
Recently Published
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Radiologically Isolated Syndrome: An OverviewThe use of brain magnetic resonance imaging (MRI) for evaluation of neurological disorders has increased in the past two decades. This has led to an increased detection of incidental findings on brain MRI. The most common of these asymptomatic abnormalities are white matter lesions that are interpreted as demyelinating based on radiological criteria. However, in the absence of associated clinical symptoms suggestive of multiple sclerosis (MS), a definite diagnosis of MS cannot be made in patients with these incidental white matter lesions. These patients are now diagnosed as radiologically isolated syndrome (RIS). The natural history and clinical approach to patients with RIS are reviewed in this article.
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Traumatic Injuries Among Multiple Sclerosis PatientsBackground Because of the high degree of disability in multiple sclerosis (MS) patients, minimizing injury occurrence is essential for preserving quality of life. Objectives By documenting the incidence of particular injuries, establishing relative risks of particular injuries in different subsets of MS patients and analyzing when the injuries occurred following diagnosis, we aim to provide information to encourage injury prevention recommendations and to provide preliminary data for further clinical research. Methods This study utilized a questionnaire consisting of 40 fill-in-the-blank or multiple choice questions. It was administered to previously diagnosed MS patients at office visits, infusion center visits, hospital stays, MS clinic visits and MS support groups. Results The years following definite MS diagnosis with the highest injury rates (injuries/people years lived) were 25 years or more (.0594 injuries/year, 95% CI [0.0771 - 0.0449]). In addition, people below the age of 40 have nearly a doubled risk of injury compared to people above the age of 40 (p= .033). Primary progressive MS patients had the greatest past incidence of fractures, 55.6% (5/9) (p=0.033). Patients reported that only 17.4% (19/109) of injuries occurred during exercise. Conclusions Overall, risk factors for injury include male gender, living longer with MS, being younger and having the diagnosis of primary progressive MS. Patient education, along with specific treatments and regimented physical activity, can lead to a more robust and injury free lifestyle in this patient population.
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Single Unprovoked Seizure: Wait Time to Full Medical Assessment, Does It Matter?Introduction Single unprovoked seizures occur in about 4% of the population and they have significant psychosocial consequences for the patients and their families. Little information is available on the timeliness and safety of assessment of first unprovoked seizures. In this study, we review the timeliness of the referral and evaluation of patients with first unprovoked seizure in a Canadian neurological provincial referral center. Method Retrospective analysis of 51 patients over a 3.5 year period was performed and data were collected on patient demographics, date of event and time to evaluation by the epileptologist, evaluations completed, treatments initiated and patient outcomes. Results We found that most patients were seen by the epileptologist within 6 months, there was only a 9% discrepancy in final diagnoses between the epileptologist and the referring physician, and there were no fatalities or serious complications in the patients we studied. However, a few patients waited very long periods before imaging and evaluation by the epileptologist, and restrictions on driving privileges were recommended in only 3% of the patients. Conclusions We conclude that the referral process for a first unprovoked seizure is timely. Primary care providers need further education with regards to the consequences of seizures and some areas of the referral region need better access to imaging and epileptologists.
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Warfarin Versus Warfarin and Aspirin in Atrial FibrillationBackground Anticoagulation with warfarin is an important therapy for preventing strokes in patients with atrial fibrillation (AF). Physicians often combine warfarin with aspirin despite evidence for increased bleeding. We investigated the hemorrhagic outcomes related to the differential management of AF with warfarin alone versus combination therapy. Methods and Results This retrospective cohort study of 695 patients enrolled at a university hospital-based anticoagulation clinic includes patients who received anticoagulation with warfarin or warfarin and aspirin between June 1, 2007 and September 30, 2008. All patients were ≥45 years old, had AF as the indication for anticoagulation, and did not have mechanical heart valves. Hemorrhages were classified as major if they caused death, involved critical sites, or required hospitalization with transfusion of ≥2 units of blood. All other bleeds were classified as minor. Of the 695 patients 307(44.2%) received combination therapy. Hemorrhage rates in the warfarin and the combination cohorts were 5.2% and 7.0% per 100-people years (p=0.29), respectively. There were 17 (3.4%) patients with major hemorrhages in the warfarin only group and 9 (2.8%) in the combination group (p=0.62). On average, patients on combination therapy had lower international normalized ratio (INR) values circa presentation (4.27 vs 3.13 p=0.049). In either group, any history of hemorrhage was associated with a 3.8 (95% CI, 1.79-8.13) times higher risk of hemorrhaging compared to patients without such a history. Conclusions This study highlights the high incidence of combination therapy and suggests that patients on combination therapy may bleed at lower INR levels. However, hemorrhagic outcomes did not differ significantly.
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Does Neurological Examination Change With Resolution of PLEDs on EEG in Non-Anoxic Patients: A Prospective Observational StudyWe present a prospective observational study of 18 consecutive non-anoxic patients with Periodic Lateralized Epileptiform Discharges (PLEDS) on their EEG, who were followed acutely till resolution of their PLEDS. We followed their electroencephalographic and clinical courses. 13 of the 18 patients were discharged from the hospital at their baseline mental status, 3 died in the hospital and 2 patients did not show any clinical improvement. All the 13 patients who improved showed complete resolution of PLEDS on their follow-up EEG. The 3 patients who died showed severe diffuse cerebral dysfunction without PLEDS on their follow-up EEGs. Of the 2 patients with no improvement, one showed severe diffuse cerebral dysfunction and the other showed persistent intermittent PLEDS which were state dependent. All patients received anti-epileptic drugs (AEDs). Structural versus non-structural PLEDs etiology made no difference in terms of the discharged patients’ outcome. Our study thus far suggests that a majority of the patients showed neurological improvement with resolution of PLEDS on their EEG. 4 of the 5 patients who did not improve showed severe diffuse cerebral dysfunction on their EEG and 1 showed intermittent PLEDS. All the patients who did poorly had initially presented with multiple convulsive generalized seizures and had multiple medical complications. We would like to see if this trend continues in a larger cohort of patients.
