BMJ Neurology Open最新文献

Background: Access to palliative care for patients with neurological diseases remains limited. Contributing factors include difficulties in predicting disease trajectories, resource constraints in long-term care and challenges in identifying the end-of-life phase-often compounded by communication and cognitive impairments.

Methods: We conducted a national point-prevalence survey among German inpatient hospices using an online questionnaire.

Results: The response rate was 44%, with 83% of participating hospices providing complete datasets. Most patients in hospices suffered from oncological diseases (n=785; 77.3%), including primary brain tumours (n=102; 10.0%). At the time of the survey, neurological diagnoses accounted for approximately 5% of hospice admissions. While 51% of hospices reported having access to neurological consultation, this was usually informal or ad hoc. 19% reported no current access to a neurologist but considered such collaboration desirable.

Conclusions: This survey provides an overview of the current representation of patients with neurological conditions in German inpatient hospices. The findings reveal limited structured collaboration between neurology and palliative care, alongside structural and societal barriers that complicate timely hospice referral and end-of-life planning. Strengthening interdisciplinary cooperation, enhancing neurologists' engagement in palliative care and expanding specialised outpatient support for patients and families are essential to improving equitable and needs-based end-of-life care for individuals with neurological conditions.

Background: Ischaemic stroke due to cancer is becoming more common with high mortality rate. There is an unmet need to predict cancer aetiology in patients with stroke using brain imaging alone, to facilitate early diagnosis and treatment.

Aims: To describe unique brain imaging patterns of cancer-related stroke and thereby develop a predictive model for diagnosis of stroke due to cancer. Our hypothesis was that such imaging patterns would be more closely associated with metastatic cancer.

Methods: Retrospective cohort study at two neighbouring sites in Australia from 2014 to 2022. The cohort group included patients with acute ischaemic stroke due to active cancer. The control group consisted of conventional stroke aetiologies and no active cancer diagnosis. Brain imaging using MRI diffusion-weighted imaging sequences classified lesions by distribution, vascular territories, lesion number and whether multifocal, crossed territories or scattered. Statistical analysis used adjusted logistic regression models. Machine learning-based predictive modelling evaluated the predictive capacity on a diagnosis of metastatic cancer.

Results: There were 138 patients available for analysis. A three-territory sign was the only significant imaging predictor for cancer aetiology in the multivariable analysis (OR 20.79; 95% CI 2.44 to 177.47, p=0.006). In the machine learning modelling, both logistic regression and support vector machines models predicted the presence of metastatic cancer well with a balanced accuracy of 75% and 79%, respectively, and area under the curve (receiver operating characteristic area) scores of 0.85 and 0.87, respectively.

Conclusions: Brain imaging alone might potentially predict cancer aetiology with good accuracy in patients with stroke, especially in metastatic cancer.

Background: There is a shortage of neurologists at a time when brain disorders have become major contributors to disability and death worldwide. This is the first national study of Egyptian early-career physicians, exploring their attitudes towards neurology and neuroscience.

Methods: This cross-sectional study took place in September and October 2024 using a structured, self-administered online questionnaire, comprising Likert-scale, multiple-choice and closed-ended questions. We calculated the mean and SD for the score of each speciality in different characteristics (ie, interest, difficulty, confidence and knowledge). The concept of neurophobia was defined as a combined confidence and difficulty score of ≤4 points. Data analysis was done using R Statistical Software (V.4.4.2, R Core Team).

Results: Our study included 445 participants, comprising 384 interns (86%), 23 primary care physicians (5.2%) and 38 residents (8.5%). Around 51% of interns and primary care physicians were males, compared with 34% of residents. A total of 205 (50.4%) of the interns and primary care physicians exhibited neurophobia, followed by 197 (48.4%) to cardiology, and 132 (32.4%) to geriatrics. The most common factors for neurophobia were trouble with neuroanatomy (48.9%), lack of curative treatment or poor prognosis (35.6%), too many rare diagnoses (34.2%), poor teaching (25.8%) and trouble with basic neuroscience (22.4%). Interns and primary care physicians showed a moderate likelihood of specialising in neurology with a mean (SD) score of 2.55 (1.09).

Conclusions: The current study provided a summary of residents' perspectives toward neurology and neuroscience as well as suggestions to combat neurophobia.

Background: Functional neurological disorder (FND) is a complex neuropsychiatric condition. While psychological factors have been widely studied, less is known about the role of perinatal, neurodevelopmental and childhood/adolescent physical health factors.

Objective: This retrospective case record review aimed to examine the prevalence of perinatal, neurodevelopmental and childhood/adolescent physical health factors in patients with FND and their associations with FND subtypes.

Methods: Clinical records of 282 individuals diagnosed with FND were analysed for perinatal problems, neurodevelopmental problems and childhood/adolescent medical history. Functional symptoms were categorised into seizure, motor, sensory and cognitive subtypes.

Results: Perinatal problems (31.9%), neurodevelopmental delays (18.1%) and neurodivergent conditions (19.6%) were frequently reported in this cohort. Additionally, 48.2% had a significant physical illness during childhood or adolescence. Functional seizures were significantly associated with neurodevelopmental delays.

Conclusion: Neurodevelopmental and childhood/adolescent physical health problems were frequently identified in this FND cohort and may be relevant to the heterogeneity and complexity of symptom presentation. These findings support considering neurodevelopmental vulnerability as an associated clinical dimension in patients with FND, while not implying or precluding a mechanistic role.

Background: Although both particulate matter with a diameter of 2.5 μm (PM 2.5) and black carbon are associated with cardiovascular disease, data on the correlation of PM 2.5 and black carbon with acute ischaemic stroke, particularly based on ecological research, remain limited.

Aim: To evaluate the association of PM 2.5 and black carbon with cases of acute ischaemic stroke in Thailand adjusted for physical factors.

Methods: In our ecological study, we collected data from the Health Insurance Database, which covers approximately 70% of Thailand's population from 77 provinces, about numbers of patients with acute ischaemic stroke who were admitted and reimbursed. The data of PM 2.5 and black carbon were collected. The predictive model of cases of acute ischaemic stroke in relation to PM 2.5 and black carbon was computed by Poisson regression analysis adjusted for physical factors.

Results: During the study period, 201 023 patients were diagnosed as having acute ischaemic stroke in 77 provinces in Thailand. The median of PM 2.5 and black carbon of all provinces was 29.19 (range: 18.88-34.50) and 1.17 (range: 0.43-2.29) µg/m³, respectively. PM 2.5 and black carbon were significantly associated with cases of acute ischaemic stroke with adjusted coefficients of 0.008 and 0.179, respectively (p<0.001 for both factors).

Conclusions: Our ecological study showed that both PM 2.5 and black carbon are associated with cases of acute ischaemic stroke in Thailand.

Background: The use of telestroke to support patient care beyond geographical boundaries remains underexplored.

Methods: We report the first international telestroke experience between Papua New Guinea (PNG) and Australia, as well as a review of the existing evidence of telestroke support beyond borders.

Results: In this case vignette, a PNG physician sought support and a second opinion from an Australian stroke neurologist on the management of a patient presenting with stroke symptoms. Despite the 'ad hoc' nature of the process and lack of protocol for such consultation at the time of the review, the patient was successfully treated and had an excellent recovery.

Conclusion: In our opinion, international telestroke support is currently underused to guide patient care and physician education in low- and middle-income countries.

Aims: To describe the Aotearoa New Zealand (NZ) neurology workforce, estimate neurology capacity, trends over time and future projections to assist with health sector planning.

Methods: 2024 neurology workforce demographics, capacity and productivity were derived from multiple overlapping data sources including a nationwide individual neurologist and public hospital neurology unit head surveys, Health NZ and Royal Australasian College of Physicians data, and annual survey data from the Australian and New Zealand Association of Neurologists. Neurological service demand was assessed using epidemiological data, prior reported demand models and considered local practice patterns. Comparisons were made to our 2014 NZ report, Australian and international data. Projections were made modelling several scenarios.

Results: In 2024, there were 83 individual neurologists in NZ providing 67.3 full-time equivalents (FTEs) including 52.6 public adult, 8.3 paediatric and 6.4 private neurology FTE. The public sector FTE compared with 36 FTE in 2014. The combined adult headcount equates to 1 neurologist per 74 604 people (1.34/100 000) compared with Australia where there is 1 neurologist per 41 000 people (2.77/100 000) and 1 in 14 000 (7.1/100 000) in other high-income countries around the globe. A recent Australian workforce model estimated a minimum demand of 1 neurologist per 28 000 based on updated neurological disease and best-practice management requirements. If current training, recruitment, retention and practice patterns persist, projections indicate there will be a gradual worsening in the NZ neurology workforce over time.

Conclusions: The NZ neurology workforce has increased over the past 10 years, but NZ ranks well below other high-income countries globally, and demand continues to significantly exceed supply. This remains true, even after adjusting for NZ practice patterns which favour generalist over subspecialist care. If current trends continue, the gap is expected to widen rather than narrow over the next 12 years.

Objectives: The identification of bi-allelic intermediate ATXN2 repeat expansions in a pedigree with amyotrophic lateral sclerosis (ALS) through clinical testing prompted us to investigate its relevance in the wider ALS population.

Methods: ATXN2 repeat size was assessed in a large international cohort of ALS patients (n=6653 from Project MinE) and in neurologically intact control populations (n=13 515 controls from Project MinE and gnomad). For bi-allelic cases, we retrieved medical records, family history and MRI imaging. For familial cases, we obtained DNA samples from relatives for segregation analyses.

Results: In total, we identified bi-allelic intermediate ATXN2 repeat expansions in five familial cases from three different pedigrees and five apparently sporadic cases. There is a relatively homogeneous phenotype characterised by lower limb onset and long survival (median 6 years) without significant cerebellar atrophy. Bi-allelic expansions were absent in controls (0 out of 13 515).

Discussion: Here we report an apparently novel autosomal recessive form of familial ALS caused by bi-allelic intermediate ATXN2 repeat expansions, which is characterised by high penetrance, lower limb onset and slow progression. Although rare, testing for ATXN2 expansions should be performed in the clinical setting given its relevance to prognosis and genetic counselling.

Background: Oscillatory whole-body vibration (WBV) training improves strength and movement skills in healthy adults and individuals with various medical conditions. Studies examining the effects of WBV on gait disorder in people with multiple sclerosis (PwMS) of progressive disease form (progressive MS (PMS)), however, produced inconsistent results.

Objectives: To assess the feasibility and explore effects of WBV training on spastic gait in PwMS.

Design and methods: Single-centre randomised, single-blind, pilot study involving 30 PwMS with mild-to-moderate spastic gait disorder (Expanded Disability Status Scale (EDSS) 3.0-6.5). Patients were randomised 1:1 into arm 1 (12-week standard-of-care before WBV) and arm 2 (immediate WBV). WBV was delivered using a side-alternating Galileo Med 25 TT platform as a home-training programme, complemented by a standardised exercise protocol. The primary endpoint was the 6-minute walking distance (6MWD).

Results: The distribution between arms concerning age, sex, body mass index, EDSS and baseline 6MWD was balanced. Adherence to the protocol was similar across both arms, with 70% of all patients completing all three study visits, with four dropouts per arm. Efficacy analyses included participants completing ≥50% of WBV sessions, comprising 17 participants (57%). 67% of all participants experienced AEs, which were equally distributed across both groups and not severe. Participant satisfaction with the intervention was high, with 70% indicating willingness to repeat the training. After 12 weeks of WBV training, a non-significant numerical increase in median 6MWD was observed. Patient-reported spasticity, assessed using the MSSS88 (Multiple Sclerosis Spasticity Scale), showed a non-significant numerical decrease following WBV.

Conclusions: In this exploratory pilot study, we could demonstrate feasibility of a WBV intervention study in PwMS. As only 57% of the participants were able to complete the per-protocol training specifications, larger studies that intend to explore the efficacy of the WBV intervention in PMS should consider a less ambitious and a more individualised training protocol.

Trial registration number: DRKS00022962.