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1.  In the psychiatrist's chair: how neurologists understand conversion disorder 
Brain  2009;132(10):2889-2896.
Conversion disorder (‘hysteria’) was largely considered to be a neurological problem in the 19th century, but without a neuropathological explanation it was commonly assimilated with malingering. The theories of Janet and Freud transformed hysteria into a psychiatric condition, but as such models decline in popularity and a neurobiology of conversion has yet to be found, today's neurologists once again face a disorder without an accepted model. This article explores how today's neurologists understand conversion through in-depth interviews with 22 neurology consultants. The neurologists endorsed psychological models but did not understand their patients in such terms. Rather, they distinguished conversion from other unexplained conditions clinically by its severity and inconsistency. While many did not see this as clearly distinct from feigning, they did not feel that this was their problem to resolve. They saw themselves as ‘agnostic’ regarding non-neuropathological explanations. However, since neurologists are in some ways more expert in conversion than psychiatrists, their continuing support for the deception model is important, and begs an explanation. One reason for the model's persistence may be that it is employed as a diagnostic device, used to differentiate between those unexplained symptoms that could, in principle, have a medical explanation and those that could not.
doi:10.1093/brain/awp060
PMCID: PMC2759333  PMID: 19321463
conversion disorder; hysteria; malingering; deception; factitious disorder
2.  Limits to truth-telling: Neurologists’ communication in conversion disorder 
Patient Education and Counseling  2009;77(2):296-301.
Objective
Neurologists face a dilemma when communicating with their conversion disorder patients – whether to be frank, and risk losing the patient's trust, or to disclose less, in the hope of building a therapeutic relationship. This study reports how neurologists in the UK described dealing with this dilemma in their practice.
Methods
Practicing consultant neurologists from an NHS region were recruited by snowball sampling. Twenty-two of 35 consultants in the region were interviewed in depth, and the interviews qualitatively analysed.
Results
The neurologists were reluctant to disclose conversion disorder as a differential diagnosis until they were certain. They were guided by the receptivity of their patients as to how psychological to make their eventual explanations, but they did not discuss their suspicions about feigning. They described their communications as much easier now than they had seen in training.
Conclusion
Neurologists adapt their disclosure to their patients, which facilitates communication, but imposes some limits on truth-telling. In particular, it may sometimes result in a changed diagnosis.
Practice implications
An optimum strategy for communicating diagnoses will need to balance ethical considerations with demonstrated therapeutic benefit.
doi:10.1016/j.pec.2009.05.021
PMCID: PMC2773836  PMID: 19560894
Conversion disorder; Factitious disorder; Malingering; Hysteria; Truth-telling; Deception; Neurology
3.  Differential effects of pre and post-payment on neurologists' response rates to a postal survey 
BMC Neurology  2010;10:100.
Background
Monetary incentives are an effective way of increasing response rates to surveys, though they are generally less effective in physicians, and are more effective when the incentive is paid up-front rather than when made conditional on completion.
Methods
In this study we examine the effectiveness of pre- and post-completion incentives on the response rates of all the neurologists in the UK to a survey about conversion disorder, using a cluster randomised controlled design. A postal survey was sent to all practicing consultant neurologists, in two rounds, including either a book token, the promise of a book token, or nothing at all.
Results
Three hundred and fifty-one of 591 eligible neurologists completed the survey, for a response rate of 59%. While the post-completion incentive exerted no discernible influence on response rates, a pre-completion incentive did, with an odds-ratio of 2.1 (95% confidence interval 1.5 - 3.0).
Conclusions
We conclude that neurologists, in the UK at least, may be influenced to respond to a postal survey by a pre-payment incentive but are unaffected by a promised reward.
doi:10.1186/1471-2377-10-100
PMCID: PMC2984383  PMID: 20973984
4.  Sudden unexpected death in epilepsy (SUDEP): don't ask, don't tell? 
Background
The National Institute for Clinical Excellence in the UK has issued guidelines stating all individuals with epilepsy be given information about sudden unexpected death in epilepsy (SUDEP).
Methods
We conducted a survey of current practice among UK neurologists, using a questionnaire sent to all practising neurologists in the UK listed on the Association of British Neurologists database, asking under what circumstances they told patients about SUDEP.
Results
Of the validated respondents, 5% discussed SUDEP with all patients, 26% with a majority, 61% with a few, and 7.5% with none. The commonest reasons for SUDEP to be discussed were the patient asking about it and the neurologist counselling people with known risk factors for SUDEP.
Conclusions
The variation we found, although not necessarily in tune with the guidelines, reflects the variation in patients' need for knowledge about their condition.
doi:10.1136/jnnp.2005.066852
PMCID: PMC2077594  PMID: 16421121
epilepsy; SUDEP
5.  Use of corticosteroids in multiple sclerosis by consultant neurologists in the United Kingdom 
OBJECTIVES—To survey the use of corticosteroids in multiple sclerosis as recommended by United Kingdom consultant neurologists.
METHODS—A postal questionnaire covering the use of corticosteroids for acute multiple sclerosis relapse and chronic progressive multiple sclerosis with regard to frequency of use, type of corticosteroid, and dosage regime was sent to all members of the Association of British Neurologists with a United Kingdom address.
RESULTS—Two hundred and twelve United Kingdom consultant neurologists replied to the survey (74% response rate). Eighty six per cent indicated that they prescribed corticosteroids in more than one quarter of acute multiple sclerosis relapses seen. Intravenous methylprednisolone was recommended at some time by 99% of consultant neurologists, the most popular regime being 1g daily for 3 days (74%; 154/208). Over one half (53%; 109/206) never recommended a subsequent tapering course of oral corticosteroids; of those that did, 25% (24/96) recommended a tapering course lasting more than 1 month. Eighty eight per cent (181/206) of prescribers of intravenous methylprednisolone were able to offer the course as a day case on the ward; 7% (15/206) at an outpatient clinic; and 5% (11/206) at home. Almost three quarters of neurologists recommended oral corticosteroids for some acute relapses, although the most popular response was for occasional use only (48%; 101/212). Forty five per cent (96/211) at least occasionally recommended steroids for patients with chronic multiple sclerosis not experiencing an acute relapse.
CONCLUSIONS—Although the vast majority of consultant neurologists would prescribe intravenous methylprednisolone for acute multiple sclerosis relapse at some time, the use of corticosteroids for multiple sclerosis was otherwise variable. There seemed to be little consensus about the use of oral steroids in acute relapse, the prescribing of a tapering course of oral steroids after intravenous methylprednisolone, or the utility of steroids in chronic multiple sclerosis. Variability of prescribing recommendations probably reflects a lack of clear evidence in the face of a wide range of clinical situations, variable access, and timing of access to neurologists in the acute phase of relapse and pressure on neurologists to treat in an otherwise "hopeless" situation. Large multicentred trials are needed to consider these issues.


PMCID: PMC2170248  PMID: 9728950
6.  Do Neurologists and Primary Care Physicians Agree on the Extent of Specialty Involvement of Patients Referred to Neurologists? 
OBJECTIVE
Understanding the roles and responsibilities of physicians who manage mutual patients is important for assuring good patient care. Among physicians expressing a preference to involve a neurologist in the care of a patient, we evaluated agreement between neurologists and primary care physicians for the extent of specialty involvement in the evaluation and management of the patient, and the factors influencing those preferences.
DESIGN AND SETTING
A self-administered survey containing 3 clinical scenarios was developed with the assistance of a multispecialty advisory board and mailed to a stratified probability sample of physicians.
PARTICIPANTS
Six hundred and eight family physicians, 624 general internists, and 492 neurologists in 9 U.S. states.
INTERVENTIONS
For each scenario, those respondents who preferred involvement of a specialist were asked about the preferred extent of that involvement: one-time consultation with and without test/medication ordering, consultation and limited follow-up, or taking over ongoing care of the specialty problem as long as it persists.
MAIN RESULTS
Survey response rate was 60%. For all 3 scenarios, neurologists preferred a greater extent of specialty involvement compared to primary care physicians (all P <.05). Other physician and practice characteristic factors, including financial incentives, had lesser or no influence on the extent of specialty involvement preferred.
CONCLUSIONS
The disagreement between primary care physicians and specialists regarding the preferred extent of specialist involvement in the care of patients with neurological conditions should raise serious concerns among health care providers, policy makers, and educators about whether mutual patient care is coordinated and appropriate.
doi:10.1111/j.1525-1497.2004.30535.x
PMCID: PMC1492387  PMID: 15209604
referral and consultation; physician's practice patterns
7.  Psychiatric illness in inpatients with neurological disorders: patients' views on discussion of emotional problems with neurologists. 
The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient's physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients.
PMCID: PMC1443098  PMID: 6434026
8.  Inter-Rater Agreement in the Clinical Diagnosis of Essential Tremor: Data from the NEDICES-2 Pilot Study 
Tremor and Other Hyperkinetic Movements  2014;4:tre-04-187-4774-3.
Background
Our aim was to assess the diagnostic agreement among the neurologists in the Neurological Disorders in Central Spain 2 (NEDICES-2) study; these neurologists were assigning diagnoses of essential tremor (ET) vs. no ET.
Methods
Clinical histories and standardized video-taped neurological examinations of 26 individuals (11 ET, seven Parkinson’s disease, three diagnostically unclear, four normal, one with a tremor disorder other than ET) were provided to seven consultant neurologists, six neurology residents, and five neurology research fellows (18 neurologists total). For each of the 26 individuals, neurologists were asked to assign a diagnosis of “ET” or “no ET” using diagnostic criteria proposed by the Movement Disorders Society (MDS). Inter-rater agreement was assessed both with percent concordance and non-weighted κ statistics.
Results
Overall κ was 0.61 (substantial agreement), with no differences between consultant neurologists (κ = 0.60), neurology residents (κ = 0.61), and neurology research fellows (κ = 0.66) in subgroup analyses. Subanalyses of agreement only among those 15 subjects with a previous diagnosis of ET (11 patients) and those with a previous diagnosis of being normal (four individuals) showed an overall κ of 0.51 (moderate agreement).
Discussion
In a population-based epidemiological study, substantial agreement was demonstrated for the diagnosis of ET among neurologists of different levels of expertise. However, agreement was lower than that previously reported using the Washington Heights–Inwood Genetic Study of Essential Tremor criteria, and a head-to-head comparison is needed to assess which is the tool of choice in epidemiological research in ET.
doi:10.7916/D8JD4TQ0
PMCID: PMC3918509  PMID: 24587969
Tremor, essential tremor; clinical diagnosis; inter-rater agreement; reliability
9.  Survey of physician experiences and perceptions about the diagnosis and treatment of fibromyalgia 
Background
Fibromyalgia (FM) is a condition characterized by widespread pain and is estimated to affect 0.5-5% of the general population. Historically, it has been classified as a rheumatologic disorder, but patients consult physicians from a variety of specialties in seeking diagnosis and ultimately treatment. Patients report considerable delay in receiving a diagnosis after initial presentation, suggesting diagnosis and management of FM might be a challenge to physicians.
Methods
A questionnaire survey of 1622 physicians in six European countries, Mexico and South Korea was conducted. Specialties surveyed included primary care physicians (PCPs; n=809) and equal numbers of rheumatologists, neurologists, psychiatrists and pain specialists.
Results
The sample included experienced doctors, with an expected clinical caseload for their specialty. Most (>80%) had seen a patient with FM in the last 2 years. Overall, 53% of physicians reported difficulty with diagnosing FM, 54% reported their training in FM was inadequate, and 32% considered themselves not knowledgeable about FM. Awareness of American College of Rheumatology classification criteria ranged from 32% for psychiatrists to 83% for rheumatologists. Sixty-four percent agreed patients found it difficult to communicate FM symptoms, and 79% said they needed to spend more time to identify FM. Thirty-eight percent were not confident in recognizing the symptoms of FM, and 48% were not confident in differentiating FM from conditions with similar symptoms. Thirty-seven percent were not confident developing an FM treatment plan, and 37% were not confident managing FM patients long-term. In general, rheumatologists reported least difficulties/greatest confidence, and PCPs and psychiatrists reported greatest difficulties/least confidence.
Conclusions
Diagnosis and managing FM is challenging for physicians, especially PCPs and psychiatrists, but other specialties, including rheumatologists, also express difficulties. Improved training in FM and initiatives to improve patient-doctor communication are needed and may help the management of this condition.
doi:10.1186/1472-6963-12-356
PMCID: PMC3502453  PMID: 23051101
10.  The function of ‘functional’: a mixed methods investigation 
Objective
The term ‘functional’ has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean ‘hysterical’. The DSM-V working group proposes to use ‘functional’ as the official diagnostic term for medically unexplained neurological symptoms (currently known as ‘conversion disorder’). This study aimed to explore the current neurological meanings of the term and to understand its resilience.
Design
Mixed methods were used, first interviewing the neurologists in a large UK region and then surveying all neurologists in the UK on their use of the term.
Results
The interviews revealed four dominant uses—‘not organic’, a physical disability, a brain disorder and a psychiatric problem—as well as considerable ambiguity. Although there was much dissatisfaction with the term, the ambiguity was also seen as useful when engaging with patients. The survey confirmed these findings, with a majority adhering to a strict interpretation of ‘functional’ to mean only ‘not organic’, but a minority employing it to mean different things in different contexts - and endorsing the view that ‘functional’ would one day be a neurological construct again.
Conclusions
‘Functional’ embodies real divisions in neurologists' conceptualisation of unexplained symptoms and, perhaps, between those of patients and neurologists: its diversity of meanings allows it to be a common term while meaning different things to different people, or at different times, and thus conceal some of the conflict in a particularly contentious area. This flexibility may help explain the term's longevity.
doi:10.1136/jnnp-2011-300992
PMCID: PMC3277687  PMID: 22250186
11.  Future role of neurologists. 
Western Journal of Medicine  1994;161(3):331-334.
Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.
Images
PMCID: PMC1011420  PMID: 7975577
12.  Functional symptoms in neurology: questions and answers 
Between 10 and 30% of patients seen by neurologists have symptoms for which there is no current pathophysiological explanation. The objective of this review is to answer questions many neurologists have about disorders characterised by unexplained symptoms (functional disorders) by conducting a multidisciplinary review based on published reports and clinical experience. Current concepts explain functional symptoms as resulting from auto-suggestion, innate coping styles, disorders of volition or attention. Predisposing, precipitating, and perpetuating aetiological factors can be identified and contribute to a therapeutic formulation. The sympathetic communication of the diagnosis by the neurologist is important and all patients should be screened for psychiatric or psychological symptoms because up to two thirds have symptomatic psychiatric comorbidity. Treatment programmes are likely to be most successful if there is close collaboration between neurologists, (liaison) psychiatrists, psychologists, and general practitioners. Long term, symptoms persist in over 50% of patients and many patients remain dependent on financial help from the government. Neurologists can acquire the skills needed to engage patients in psychological treatment but would benefit from closer working relationships with liaison psychiatry or psychology.
doi:10.1136/jnnp.2004.048280
PMCID: PMC1739564  PMID: 15716517
13.  Clinical research training of Peruvian neurologists: a baseline assessment 
Neurology International  2010;2(1):e6.
In Peru, despite a strong clinical research infrastructure in Lima, and Masters degree programs in epidemiology at three universities, few neurologists participate in clinical research. It was our objective to identify perceived needs and opportunities for increasing clinical research capacity and training opportunities for Peruvian neurologists. We conducted a descriptive, cross-sectional survey of Peruvian neurologists in Lima and Arequipa, Peru. Forty-eight neurologists completed written surveys and oral interviews. All neurologists reported interest in clinical research, but noted that lack of time and financial resources limited their ability to participate. Although most neurologists had received some training in epidemiology and research design as medical students or residents, the majority felt these topics were not adequately covered. Neurologists in Arequipa noted international funding for clinical research was uncommon outside the capital city of Lima. We concluded that clinical research is important to Peruvian neurologists. The three main barriers to increased participation in clinical research identified by neurologists were insufficient training in clinical research methodology, meager funding opportunities, and lack of dedicated time to participate in clinical research. Distance learning holds promise as a method for providing additional training in clinical research methodology, especially for neurologists who may have difficulty traveling to larger cities for additional training.
doi:10.4081/ni.2010.e6
PMCID: PMC3093214  PMID: 21577342
clinical research; training; neurology; global health; Peru; evidence-based medicine.
14.  The Evaluation of Rapidly Progressive Dementia 
The Neurologist  2011;17(2):67-74.
Background
Rapidly progressive dementia (RPD) is a unique set of disorders resulting in cognitive, behavioral, and motor decline within 2 years. A variety of etiologies may contribute to RPD including neurodegenerative, inflammatory, infectious, and toxic-metabolic conditions. Jakob-Creutzfeldt disease (CJD) is frequently the most concerning diagnosis on the differential. The challenge for the neurologist is distinguishing prion disease from reversible processes that result in dementia.
Review Summary
This review discusses the clinical aspects and the diagnostic work-up of RPD. Particular focus is given to both CJD and the potentially treatable inflammatory conditions that may cause a similar presentation. Furthermore, a standardized step-wise approach is outlined for patients presenting with RPD.
Conclusion
Neurologists should adopt a standardized approach to the rapidly presenting disease processes that may mimic CJD in their clinical and radiological features.
doi:10.1097/NRL.0b013e31820ba5e3
PMCID: PMC3356774  PMID: 21364356
Rapidly progressive dementia; Jakob-Creutzfeldt disease; Immune-mediated dementia; Paraneoplastic syndrome; Hashimoto’s Encephalopathy
15.  Survey of Medication Usage Patterns Among Essential Tremor Patients: Movement Disorder Specialists vs. General Neurologists 
Parkinsonism & related disorders  2010;16(9):604-607.
Background
Although small treatment trials have examined the efficacy of front-line medications in tremor reduction in essential tremor (ET), an overall survey of pharmacological management has not been undertaken in a large sample of ET cases.
Objectives
To conduct a survey of medication usage among several hundred ET patients.
Methods
A computerized database at the Neurological Institute of New York was used to identify 223 ET patients cared for by movement disorder neurologists and 37 cared for by general neurologists. Each had been seen one or more times within past five years. Lifetime treatment data were abstracted from clinical records.
Results
One-hundred-sixty-three (73.1%) of 223 patients cared for by movement disorder neurologists had taken medication for ET during their lifetime; 53/163 (32.5%) had taken ≥4 medications; 31/163 (19.0%) had taken ≥5 medications; and 3 (1.8%), ≥10 medications. Nearly three-quarters (158/223 [70.9%]) had taken primidone or propranolol, yet 89/158 (56.3%) had discontinued both. Among 11 patients who had undergone ET surgery, the mean number of ET medications tried was 6.0±2.8 (range = 3–12). Medication usage by general neurologists was less than by movement disorder specialists (p<0.001). One-third of general neurologists’ patients (14/37 [37.8%]) had taken primidone or propranolol at some point and 6/14 (42.9%) had discontinued both.
Conclusions
In this large survey, a substantial proportion of ET patients failed treatment with both front-line medications. Among patients seeing movement disorder specialists, the number of medications they had had to try was sizable. These data demonstrate the limitations of current pharmacological options for ET.
doi:10.1016/j.parkreldis.2010.07.011
PMCID: PMC2963696  PMID: 20691629
Essential tremor; clinical; epidemiology; treatment; medication
16.  How do patients referred to neurologists for headache differ from those managed in primary care? 
Background
Headache is the neurological symptom most frequently presented to GPs and referred to neurologists, but little is known about how referred patients differ from patients managed by GPs.
Aim
To describe and compare headache patients managed in primary care with those referred to neurologists.
Design of study
Prospective study.
Setting
Eighteen general practices in south-east England.
Method
This study examined 488 eligible patients consulting GPs with primary headache over 7 weeks and 81 patients referred to neurologists over 1 year. Headache disability was measured by the Migraine Disability Assessment Score, headache impact by the Headache Impact Test, emotional distress by the Hospital Anxiety and Depression Scale and illness perception was assessed using the Illness Perception Questionnaire.
Results
Participants were 303 patients who agreed to participate. Both groups reported severe disability and very severe impact on functioning. Referred patients consulted more frequently than those not referred in the 3 months before referral (P = 0.003). There was no significant difference between GP-managed and referred groups in mean headache disability, impact, anxiety, depression, or satisfaction with care. The referred group were more likely to link an increased number of symptoms to their headaches (P = 0.01), to have stronger emotional representations of their headaches (P = 0.006), to worry more (P = 0.001), and were made anxious by their headache symptoms (P = 0.044).
Conclusion
Patients who consult for headache experience severe disability and impact, and up to a third report anxiety and/or depression. Referral is not related to clinical severity of headaches, but is associated with higher consultation frequency and patients' anxiety and concern about their headache symptoms.
PMCID: PMC2047014  PMID: 17504590
headache; migraine disorders; neurology; primary health care; referral and consultation
17.  Treatment selection and experience in multiple sclerosis: survey of neurologists 
Background
Multiple sclerosis (MS) is a complex disease with many therapeutic options. Little is known about how neurologists select particular disease-modifying therapies (DMTs) for their patients.
Objective
To understand how neurologists make decisions regarding the prescription of DMTs for patients with MS, and to explore neurologists’ experiences with individual DMTs.
Methods
From December 2012 to January 2013, members of a nationwide physician market research panel were sent an online study invitation with a link to a survey website. Eligible neurologists were included if they currently practice medicine in the United States, and if they treat ≥20 patients with MS.
Results
A total of 102 neurologists (n=63 general neurologists; n=39 MS specialists; 81.4% male) completed the survey. The mean (standard deviation) number of years in practice since completing medical training was 16.4 (8.6) years. Overall, the most commonly prescribed DMTs were subcutaneous interferon (IFN) β-1a and glatiramer acetate; approximately 5.5% of patients were untreated. The most important attributes of DMT medication selection were (in order of importance) efficacy, safety, tolerability, patient preference, and convenience. The DMT with the highest neurologist-reported percentage of patients who were “Very/Extremely Satisfied” with their therapy was fingolimod (31.0%), followed by glatiramer acetate (13.9%; P=0.017). Compared with fingolimod (94.0%), significantly fewer (P<0.05) neurologists reported that “All/Most” of their patients were adherent to treatment with glatiramer acetate (78.0%), subcutaneous IFN β-1a (84.0%), and IFN β-1b (75.0%); no significant differences were observed with intramuscular IFN β-1a (92.9%; P=0.75). Patients’ calls to neurologists’ offices were most commonly related to side effects for all self-injectable DMTs, whereas calls about fingolimod primarily involved insurance coverage issues.
Conclusion
Our survey results showed that very few patients with MS did not received any DMT. Among the DMTs available at the time of the survey, neurologists reported that patients were most satisfied with, and adherent to, fingolimod, but these patients also faced more problems with insurance coverage when compared with those taking self-injectable DMTs.
doi:10.2147/PPA.S53140
PMCID: PMC3979792
multiple sclerosis; disease-modifying therapy; physician survey; treatment selection; treatment adherence; treatment satisfaction
18.  A survey of American neurologists about brain death: understanding the conceptual basis and diagnostic tests for brain death 
Background
Neurologists often diagnose brain death (BD) and explain BD to families in the intensive care unit. This study was designed to determine whether neurologists agree with the standard concept of death (irreversible loss of integrative unity of the organism) and understand the state of the brain when BD is diagnosed.
Methods
A previously validated survey was mailed to a random sample of 500 board-certified neurologists in the United States. Main outcomes were: responses indicating the concept of death that BD fulfills and the empirical state of the brain that would rule out BD.
Results
After the second mailing, 218 (44%) surveys were returned. Few (n = 52, 27%; 95% confidence interval (CI), 21%, 34%) responded that BD is death because the organism has lost integrative unity. The most common justification was a higher brain concept (n = 93, 48%; 95% CI, 41%, 55%), suggesting that irreversible loss of consciousness is death. Contrary to the recent President's Council on Bioethics, few (n = 22, 12%; 95% CI, 8%, 17%) responded that the irreversible lack of vital work of an organism is a concept of death that the BD criterion may satisfy. Many responded that certain brain functions remaining are not compatible with a diagnosis of BD, including EEG activity, evoked potential activity, and hypothalamic neuroendocrine function. Many also responded that brain blood flow and lack of brainstem destruction are not compatible with a diagnosis of BD.
Conclusions
American neurologists do not have a consistent rationale for accepting BD as death, nor a clear understanding of diagnostic tests for BD.
doi:10.1186/2110-5820-2-4
PMCID: PMC3310851  PMID: 22339807
19.  Neurology in the United Kingdom. II: A study of current neurological services for adults. 
Health care planning relies on accurate data, yet there are few published data on neurological services in the United Kingdom. This paper describes the number and distribution of consultant neurologists in the UK and is based on a questionnaire completed by Regional Health Authorities and their equivalents, by Special Health Authorities, and by regional representatives of the Association of British Neurologists. The data were published by the ABN in 1988 but have not previously been widely available. The study identified 190 consultant neurologists (152 whole time equivalents). Overall there was one whole time neurologist for 373,000 persons but the ratio varied by a factor of four in different regions. There was a wide variation in the distribution of consultant neurological sessions between Health Districts. One group of neurologists was based in centres. A second group spent most of their time within the Health District, but had an attachment to a Regional Centre.
PMCID: PMC1087970  PMID: 1564509
20.  Neurologic Complications of HIV-1 Infection and Its Treatment in the Era of Antiretroviral Therapy 
Continuum : Lifelong Learning in Neurology  2012;18(6 Infectious Disease):1319-1337.
Purpose of Review: Neurologic complications of HIV infection are unfortunately common, even in the era of effective antiretroviral treatment (ART). The consulting neurologist is often asked to distinguish among neurologic deterioration due to opportunistic infection (OI), immune reconstitution, or the effect of the virus itself, and to comment on the role of immunomodulatory agents in patients with HIV infection. Additionally, as successful virologic control has extended the life span of patients with HIV infection, neurologists are called upon to manage long-term complications, such as neurocognitive disorders and peripheral neuropathy.
Recent Findings: Despite the use of ART, significant numbers of patients continue to be affected by HIV-associated neurocognitive disorders, although with milder forms compared to the pre-ART era. Regimens of ART have been ranked according to CNS penetration and are being studied with regard to neuropsychological outcomes. Nucleoside analogs with the greatest potential for peripheral neurotoxicity are no longer considered first-line agents for HIV treatment. Efavirenz, a non-nucleoside reverse transcriptase inhibitor, has the greatest frequency of neurologic side effects among newer ART regimens. The spectrum of clinical manifestations of immune reconstitution inflammatory syndrome (IRIS) continues to grow, including IRIS without underlying OI. A greater understanding of pathophysiology and risk factors has shown that while HIV should be treated early to prevent severe immunocompromise, delayed initiation of ART may be helpful while treating OIs.
Summary: This article reviews the neurologic complications of HIV infection, or its treatment, most commonly encountered by neurologists.
doi:10.1212/01.CON.0000423849.24900.ec
PMCID: PMC3760534  PMID: 23221843
21.  Lessons for neurologists from the United Kingdom Third National Morbidity Survey. 
The Third National Morbidity Survey lists data about the primary care consultations for more than 300,000 person-years at risk. Data of interest to neurologists have been extracted from the complex tables of the Survey, many of which are on micro-fiche. Assuming that any one subject has only one neurological symptom, 9.5% of the population will consult their general practitioner about a neurological symptom each year. The five most common groups of disorders for which advice is sought are headache/migraine, dizziness, syndromes related to the cervical or lumbar spine, faints or fits, and symptoms due to cerebrovascular disease. About 7% of all patients seen with neurological symptoms are referred to hospital clinics for further advice.
PMCID: PMC1032280  PMID: 2786920
22.  Pattern of neurological outpatient practice: implications for undergraduate and postgraduate training. 
A case analysis has been performed on 4000 successive outpatient referrals to one consultant neurologist, representing 72% of all referrals to Charing Cross Hospital and 82% to Hillingdon Hospital. A specific diagnosis was not possible in 1013 patients (25.3%). Amongst the remainder certain diagnoses were predictably common: for example, migraine (241), tension headaches (296) and epilepsy (470). Based on data obtained for the incidence of various neurological disorders in the community, an attempt has been made to assess what proportion of patients with certain diagnoses are likely to be seen by a neurologist. The rarity with which certain classical conditions, for example syringomyelia, is encountered is stressed and the implications for teaching discussed.
PMCID: PMC1290532  PMID: 3795209
23.  Management of primary chronic headache in the general population: the Akershus study of chronic headache 
The Journal of Headache and Pain  2011;13(2):113-120.
Primary chronic headaches cause more disability and necessitate high utilisation of health care. Our knowledge is based on selected populations, while information from the general population is largely lacking. An age and gender-stratified cross-sectional epidemiological survey included 30,000 persons aged 30–44 years. Respondents with self-reported chronic headache were interviewed by physicians. The International Classification of Headache Disorders was used. Of all primary chronic headache sufferers, 80% had consulted their general practitioner (GP), of these 19% had also consulted a neurologist and 4% had been hospitalised. Co-occurrence of migraine increased the probability of contact with a physician. A high Severity of Dependence Scale score increased the probability for contact with a physician. Complementary and alternative medicine (CAM) was used by 62%, most often physiotherapy, acupuncture and chiropractic. Contact with a physician increased the probability of use of CAM. Acute headache medications were taken by 87%, while only 3% used prophylactic medication. GPs manage the majority of those with primary chronic headache, 1/5 never consults a physician for their headache, while approximately 1/5 is referred to a neurologist or hospitalised. Acute headache medication was frequently overused, while prophylactic medication was rarely used. Thus, avoidance of acute headache medication overuse and increased use of prophylactic medication may improve the management of primary chronic headaches in the future.
doi:10.1007/s10194-011-0391-8
PMCID: PMC3274574  PMID: 21993986
Primary chronic headache; Chronic migraine; Medication-overuse headache; Health care utilisation; General population
24.  Management of primary chronic headache in the general population: the Akershus study of chronic headache 
The Journal of Headache and Pain  2011;13(2):113-120.
Primary chronic headaches cause more disability and necessitate high utilisation of health care. Our knowledge is based on selected populations, while information from the general population is largely lacking. An age and gender-stratified cross-sectional epidemiological survey included 30,000 persons aged 30–44 years. Respondents with self-reported chronic headache were interviewed by physicians. The International Classification of Headache Disorders was used. Of all primary chronic headache sufferers, 80% had consulted their general practitioner (GP), of these 19% had also consulted a neurologist and 4% had been hospitalised. Co-occurrence of migraine increased the probability of contact with a physician. A high Severity of Dependence Scale score increased the probability for contact with a physician. Complementary and alternative medicine (CAM) was used by 62%, most often physiotherapy, acupuncture and chiropractic. Contact with a physician increased the probability of use of CAM. Acute headache medications were taken by 87%, while only 3% used prophylactic medication. GPs manage the majority of those with primary chronic headache, 1/5 never consults a physician for their headache, while approximately 1/5 is referred to a neurologist or hospitalised. Acute headache medication was frequently overused, while prophylactic medication was rarely used. Thus, avoidance of acute headache medication overuse and increased use of prophylactic medication may improve the management of primary chronic headaches in the future.
doi:10.1007/s10194-011-0391-8
PMCID: PMC3274574  PMID: 21993986
Primary chronic headache; Chronic migraine; Medication-overuse headache; Health care utilisation; General population
25.  Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome: a survey of German neurologists 
Journal of Neurology  2012;259(10):2076-2089.
Diagnosis and decisions on life-sustaining treatment (LST) in disorders of consciousness, such as the vegetative state (VS) and the minimally conscious state (MCS), are challenging for neurologists. The locked-in syndrome (LiS) is sometimes confounded with these disorders by less experienced physicians. We aimed to investigate (1) the application of diagnostic knowledge, (2) attitudes concerning limitations of LST, and (3) further challenging aspects in the care of patients. A vignette-based online survey with a randomized presentation of a VS, MCS, or LiS case scenario was conducted among members of the German Society for Neurology. A sample of 503 neurologists participated (response rate 16.4%). An accurate diagnosis was given by 86% of the participants. The LiS case was diagnosed more accurately (94%) than the VS case (79%) and the MCS case (87%, p < 0.001). Limiting LST for the patient was considered by 92, 91, and 84% of the participants who accurately diagnosed the VS, LiS, and MCS case (p = 0.09). Overall, most participants agreed with limiting cardiopulmonary resuscitation; a minority considered limiting artificial nutrition and hydration. Neurologists regarded the estimation of the prognosis and determination of the patients’ wishes as most challenging. The majority of German neurologists accurately applied the diagnostic categories VS, MCS, and LiS to case vignettes. Their attitudes were mostly in favor of limiting life-sustaining treatment and slightly differed for MCS as compared to VS and LiS. Attitudes toward LST strongly differed according to circumstances (e.g., patient’s will opposed treatment) and treatment measures.
doi:10.1007/s00415-012-6459-9
PMCID: PMC3464386  PMID: 22407274
End-of-life decisions; Limitation of life-sustaining treatment; Diagnosis; Vegetative state; Minimally conscious state

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