Pandemics in ancient Greek and Roman coinage: medical memories at the service of hope.

Medical goddesses and gods invoked in the Hippocratic Oath were called on in times of pandemics along with Greek physicians such as Galen of Pergamum. Ancient Greek and Roman coinage provide insights into the coexisting religious and rational approaches to medicine rooted in Classical Antiquity, portraying medical symbols and gestures akin to contemporary medicine.

Impact and implementation of a sustainable regional telestroke network.

BACKGROUND: Telestroke uses videoconferencing technology to allow off-site experts to provide stroke thrombolysis decision support to less experienced front line clinicians. AIM: To assess the impact of a new telestroke service on thrombolysis rates and door-to-needle times in participating provincial hospitals and service resources to aid transition to a sustainable telestroke service. METHODS: This is a sequential comparison of 'pre' (December 2015 to May 2016) and 'post' (June 2016 to December 2016) implementation outcomes. The main outcomes were thrombolysis rate and door-to-needle time. All patient data were captured prospectively in a central database. Data captured and analysed also included technical problems, consumer and clinician feedback, and additional service resources required. RESULTS: Over the study period, 164 telestroke assessments were completed, including the 'hub' hospital. Among the participating provincial hospitals, 21 of 343 patients (6.1%) were thrombolysed in the 6-months prior to June 2016 and 50 of 318 patients (15.7%) during the 6-month following implementation of telestroke; odds ratio 2.86 (95% confidence interval 1.68-4.89); P = 0.0001. Overall, mean (standard deviation) regional hospital door-to-needle time reduced from 79.6 (31.4) to 62.7 (23.3) min (P = 0.015). Videoconferencing failure occurred in 4.8% of cases. Consumer and clinician feedback was positive. The main resource challenge was doubling of out-of-hours neurologist workload. CONCLUSION: Telestroke was associated with a significant increase in thrombolysis rate and reduction in door-to-needle time in provincial hospitals indicating improved patient care. Quantification of the extra neurologist workload allowed for a seamless transition to 'business as usual' using a novel annual subscription funding and service model.

EpiNet as a way of involving more physicians and patients in epilepsy research: Validation study and accreditation process.

OBJECTIVE: EpiNet was established to encourage epilepsy research. EpiNet is used for multicenter cohort studies and investigator-led trials. Physicians must be accredited to recruit patients into trials. Here, we describe the accreditation process for the EpiNet-First trials. METHODS: Physicians with an interest in epilepsy were invited to assess 30 case scenarios to determine the following: whether patients have epilepsy; the nature of the seizures (generalized, focal); and the etiology. Information was presented in two steps for 23 cases. The EpiNet steering committee determined that 21 cases had epilepsy. The steering committee determined by consensus which responses were acceptable for each case. We chose a subset of 18 cases to accredit investigators for the EpiNet-First trials. We initially focused on 12 cases; to be accredited, investigators could not diagnose epilepsy in any case that the steering committee determined did not have epilepsy. If investigators were not accredited after assessing 12 cases, 6 further cases were considered. When assessing the 18 cases, investigators could be accredited if they diagnosed one of six nonepilepsy patients as having possible epilepsy but could make no other false-positive errors and could make only one error regarding seizure classification. RESULTS: Between December 2013 and December 2014, 189 physicians assessed the 30 cases. Agreement with the steering committee regarding the diagnosis at step 1 ranged from 47% to 100%, and improved when information regarding tests was provided at step 2. One hundred five of the 189 physicians (55%) were accredited for the EpiNet-First trials. The kappa value for diagnosis of epilepsy across all 30 cases for accredited physicians was 0.70. SIGNIFICANCE: We have established criteria for accrediting physicians using EpiNet. New investigators can be accredited by assessing 18 case scenarios. We encourage physicians with an interest in epilepsy to become EpiNet-accredited and to participate in these investigator-led clinical trials.

International Telestroke: The First Five Cases.

Telestroke services can improve access to stroke thrombolysis. To address challenges of night time coverage we explored the feasibility of an international telestroke service between Scotland and New Zealand taking advantage of international time zone differences. After addressing medico-legal, governance, and technical issues we tested this international service model and here we present the first 5 cases. Based on our initial experience this new model of care appears feasible and has the potential to improve patient care through reduced doctor fatigue and improved access to expert care in regions where stroke specialist input is limited.

Epilepsy in Dostoevsky.

Fyodor M. Dostoevsky (Moscow, 1821-Saint Petersburg, 1881) suffered epilepsy throughout his whole literary career. The aim here is to understand his condition in light of his novels, correspondence, and his contemporaries' accounts as well as through the eyes of later generations of neurologists. From Murin (The landlady, 1847) to Smerdyakov (The brothers Karamazov, 1880), Dostoevsky portrayed up to six characters with epilepsy in his literature. The first symptoms of the disease presented in early adulthood, but he was only diagnosed with epilepsy a decade later. In 1863 he went abroad seeking expert advice from the famous neurologists Romberg and Trousseau. Dostoevsky made an intelligent use of epilepsy in his literature (of his experiential auras or dreamy states particularly) and through it found a way to freedom from perpetual military servitude. His case offers an insight into the natural history of epilepsy (a cryptogenic localization related one of either fronto-medial or temporal lobe origin using contemporary medical terms), thus inspiring later generations of writers and neurologists. Furthermore, it illustrates the good use of an ordinary neurological disorder by an extraordinary writer who transformed adversity into opportunity.

Tomas Tranströmer's stroke of genius: language but no words.

In 1990, the widely acclaimed Swedish poet Tomas Tranströmer lost his speech and the ability to use his right hand as a result of a stroke. As if anticipating his own fate, in 1974, he referred in his longest poem Baltics the story of the Russian composer Vissarion Shebalin who suffered the same symptoms as Tranströmer following a brain bleed: "Then, cerebral hemorrhage: paralysis on the right side with aphasia." An amateur pianist himself, Tranströmer carried on playing left-handed piano pieces after the stroke. In spite of a severe nonfluent dysphasia with dysgraphia, Tranströmer kept producing a poetic language of the highest caliber in accordance with his 1979 no less prophetic verse "language but no words." And through music and poetry, overcame the great communication barriers imposed by a large dominant hemispheric stroke. A nonprolific writer before the stroke, after it Tranströmer became disproportionately brief compared to his prestroke production, confining most of his poetry to the agrammatical and telegraphic haiku style.

John Hughlings Jackson and our understanding of the epilepsies 100 years on.

The term Jacksonian epilepsy was coined by Jean Martin Charcot following John Hughlings Jackson's 1870 paper 'A study of convulsions', where he had defined a convulsion as "a symptom resulting from an occasional, an excessive and a disorderly discharge of nerve tissue on muscles". His earlier writings had included cases of syphilis related epilepsy, and the introduction of the first successful antiepileptic drugs-the bromides. Based on careful clinical observation or, as Hughlings Jackson himself put it, on the "experiments performed by disease", 'A study of convulsions' was a synthesis of those previous reports which has contributed to our practical understanding of epilepsy, a contribution which continues to inform our thinking to the present day.

Transient loss of consciousness with convulsions in two young adults with potentially fatal underlying heart disease: syncope versus seizures.

The differential diagnosis of syncope versus seizures represents a daily challenge for cardiologists and neurologists. Long Q-T syndrome and hypertrophic cardiomyopathy (HCM) are two hereditary arrhythmogenic heart conditions causing syncope in early adulthood. We report the cases of two patients who were reassessed for transient loss of consciousness (TLOC) with convulsions despite treatment. The first patient, a 40-year-old woman, had been diagnosed with epilepsy and was given phenytoin. Her episodes took place while swimming or when in emotional distress and were not followed by post-ictal confusion. An electrocardiogram showed a very prolonged Q-Tc interval. The second patient, a 30-year-old man with HCM in whom a defibrillator had been implanted on the assumption that he was having cardiogenic syncopes, was actually found to have epilepsy. Adequate treatment rendered both patients asymptomatic. In conclusion, the clinical history and 12-lead electrocardiography remain crucial in the management of TLOC, ideally involving both cardiologists and neurologists.