A novel tool for characterising upper limb function in progressive multiple sclerosis through kinematic assessment.

INTRODUCTION: Current upper limb assessment methods in MS rely on measuring duration in tasks like the nine-hole peg test (9HPT). Kinematic techniques may provide a more useful measure of functional change in clinical and research practice. The aim of this study was to assess upper limb function prospectively in people with progressive MS using a kinematic 3D motion capture system and compare with current measures. METHODS: 42 people with progressive MS (PwPMS) and 15 healthy controls reached-and-grasped different objects whilst recorded by a kinematic assessment system. 9HPT, Expanded Disability Status Scale (EDSS), and patient reported outcome measures (PROs) were collected. All measures were taken at baseline for PwPMS and controls, and again at six months for PwPMS. RESULTS: Relative to controls, PwPMS had significantly longer reaction (0.11 s, p < 0.05) and reach (0.25 s, p < 0.05) times. PwPMS took longer to pick-up (0.34 s, p < 0.05), move (0.14 s, p < 0.05), and place (0.18 s, p < 0.05) objects. PwPMS had lower peak velocities when reaching (7.4 cm/s, p < 0.05) and moving (7.3 cm/s, p < 0.05) objects. Kinematic assessment demonstrated consistent differences between PwPMS with mild and severe upper limb dysfunction as defined by PROs, which were not captured by 9HPT or EDSS in this group. PwPMS demonstrated altered grip apertures profiles, as measured by their ability to complete individual parts of the reach and grasp task, between the baseline and follow-up timepoints. CONCLUSIONS: We have created and tested a novel upper limb function assessment tool which has detected changes and characteristics in hand function, not currently captured by the EDSS and 9HPT.

Refractory status epilepticus arrested by vagus nerve stimulation.

A 54-year-old man developed altered mental state and generalised tonic-clonic seizures after 1 week of upper respiratory tract symptoms and diarrhoea, having been previously well. His MR scan of brain showed multifocal progressive T2 cortical signal changes. He was diagnosed with new-onset refractory status epilepticus (NORSE), initially treated as being secondary to autoimmune/paraneoplastic limbic encephalitis, although subsequent investigations were negative. His seizures and electrographic epileptiform activity continued despite escalating doses of antiseizure medications, immunosuppression with corticosteroids, immunoglobulins, plasma exchange and rituximab, and thereafter anaesthetic agents. A vagus nerve stimulator (VNS) was implanted 6 weeks after admission and its voltage rapidly increased over 4 days; his seizure activity resolved in the third week after VNS implantation. This case highlights the role of VNS in the early management of NORSE.

Physician trainee research collaboratives: a mixed methods exploration of UK experience.

BACKGROUND: Physician trainee research collaboratives (TRCs) help trainees develop research skills and establish peer networks. We aimed to identify the structure, activity and views of physician TRCs in the UK. METHODS: Representatives from physician TRCs in the UK were invited to complete an online survey and participate in a focus group. RESULTS: Representatives from 23 physician TRCs completed the survey. There was wide variation in collaborative structure, senior input and funding resources. Seventy-four per cent of physician TRCs had published peer-reviewed articles, with 70% reporting ongoing projects at the time of the survey. The survey and focus group identified improved patient care, research and leadership skills as benefits of collaborative work; while institutional and consultant support, limited time for research, funding opportunities and restrictions on group authorship were cited as challenges to collaborative success. CONCLUSION: Physician TRC activity continues to grow and demonstrates a dynamic approach to research for all trainees.

The contemporary role of MRI in the monitoring and management of people with multiple sclerosis in the UK.

BACKGROUND: Compare the contemporary use of magnetic resonance imaging (MRI) in the monitoring and management of people with MS in the UK to current consensus guidelines. METHODS: This retrospective multicentre audit of clinical practice gathered data on 2567 patients with MS from 25 MS centres across the UK. RESULTS: Routine monitoring (44.7%), and recent clinical relapse (20.3%) were the most common scan indications. In routine monitoring, the addition of spinal imaging to brain showed no significant difference in disease modifying treatment (DMT) decision at subsequent clinical review. Approximately 1 in 5 gadolinium administered scans showed enhancement, and in 1 in 20 patients, gadolinium enhancement was the only evidence of radiological disease activity. Mean inter-scan intervals in relapsing-remitting MS for routine monitoring was 19.2 months (SD 20.7) with wide variation between centres. Only 53.8% of patients under progressive multifocal leukoencephalopathy (PML) surveillance met the recommended scanning frequency. MRI protocols demonstrated heterogeneity in the sequences used for diagnostic, monitoring and PML surveillance scans. CONCLUSIONS: MS centres across the UK demonstrate varied practice and protocols when using MRI to monitor people with MS. In this cohort, gadolinium use and spinal imaging demonstrates limited impact on subsequent DMT decisions.

Peripheral nerve blocks for headache disorders.

Headache is a common neurological referral and a frequent cause for acute hospital admissions. Despite peripheral nerve blocks being widely used in headache and pain services to treat patients with headache disorders, there is no readily accessible resource with instructions for the delivery of peripheral nerve blocks. Here we provide a practical approach for administering peripheral nerve blocks and cover the current evidence base for such procedures in different headache disorders. We provide instructions and an audiovisual guide for administering greater and lesser occipital, supratrochlear, supraorbital and auriculotemporal nerves blocks, and give information on their adverse effects and potential complications. This information will provide a reference for headache practitioners when giving peripheral nerve blocks safely to people with headache.

The role of the future physician: building on shifting sands.

The role of the future physician in the NHS is of interest to current doctors, patients, policymakers and the wider public. Amid the COVID-19 pandemic, it has never been more clear that the healthcare needs of the population, and the technical and scientific advances with which to solve them, are rapidly evolving and the medical workforce must adapt to these changes to deliver personalised healthcare. This article considers the current challenges that need to be addressed to deliver a future physician-led healthcare service that works for its patients. Key themes are expanded upon, including the changing healthcare workforce, digital and technological innovation, service delivery, complex conditions and changing patient demographics. The impact and challenges of the ongoing COVID-19 pandemic on these factors are highlighted. Avenues for development are suggested, both in postgraduate medical training and the health service as a whole. These changes will be required to deliver the physicians of the future, imbued with the skills and attributes they will need to provide a high standard of care in the mid-21st century.

Multiple Cranial Nerve Blocks as an Alternative Preventative Therapy for Chronic Migraine.

OBJECTIVE: The objective of this prospective cohort study is to evaluate the efficacy of multiple cranial nerve blocks (MCNBs) as a preventative therapy for chronic migraine. BACKGROUND: MCNBs, namely greater occipital nerve (GON) blocks, are frequently used for the acute and transitional treatment of migraine. There is little evidence on the efficacy of repeated MCNBs as a preventative treatment for chronic migraine. DESIGN: This single-center, prospective cohort study collected demographic and outcome data on chronic migraine patients who had MCNBs in the headache service between June 2017 and March 2019. Outcome measures included reduction in headache days, Headache Impact Test 6 (HIT6) scores and patient-reported effectiveness of the blocks. RESULTS: Outcomes for 64 patients with a diagnosis of chronic migraine or chronic migraine with aura (MWA) were collected. Average age at first block procedure was 41 years (range 21-72) with a female predominance of 54/64 patients (84%). About 37/64 patients (58%) had repetitive occipital nerve blocks only, and 27/64 patients (42%) had occipital and trigeminal nerve blocks. Mean (±SD) reduction in headache days post-MCNBs was 5.4 (±5.0) days and mean (±SD) reduction in HIT6 scores was 5.3 (±10.3). About 42/64 patients (66%) responded to the MCNBs with at least a 30% reduction in headache days. Mean (±SD) duration of effect was 5.7 (±5.4) weeks. About 13/64 of the patients transformed to low-frequency episodic migraine on follow-up. About 22/64 patients (34%) showed no reduction in headache days or HIT6 scores. About 9/112 (8%) instances of minor post block complications were documented with a total of 501 injections. CONCLUSION: This study demonstrates that repetitive MCNBs could provide effective prevention in patients with chronic migraine.

Stroke in Association with Thyroid Goitre: A Case Report.

Ischaemic stroke secondary to isolated internal carotid artery thrombus without risk factors is uncommon. A 55-year-old woman presented to the acute stroke unit with acute right middle cerebral artery territory infarction secondary to right internal carotid artery occlusion. There were no risk factors for cerebrovascular disease, but mediastinal imaging showed the presence of a large retrosternal goitre which was displacing the mediastinal structures including the brachiocephalic and common carotid artery. Intraluminal thrombus is visible in the displaced innominate artery and is the underlying cause for the stroke in our patient. This case highlights the importance of appropriate imaging of the mediastinum in cases with thyroid goitre.