Neurology! Adieau? (Part 1)


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Neurology! Adieau? (Part 1)

  1. 1. Neurology! Adieau? (Part 1) Prof. Dr. Szirmai Imre Department of Neurology University Semmelweis 1083 Budapest Balassa u 6 e-mail: Summary The neurological practice suffered considerable changes during the last twenty years. The recent therapeutic methods and the acceptance of the ideology of evidence based medicine, which is based on confidence in statistics, changed the reasoning of the neurologists. Therapy protocols intrude into the field of individual medicine, and doctors accept treatment schemes to alleviate responsibility of their decisions. In contrast with this, recent achievements in pharmacogenetics emphasize the importance of individual drug therapies. The protocol of intravenous cerebral thrombolysis does not require defining the origin of cerebral ischemia in the acute stage, therefore, this procedure can be regarded as human experiment. Following the strict protocol thrombolysis might be indicated only in 1-8% of patients with cerebral ischemia. According to the Cohrane database more trials are needed to clarify which patients are most likely to benefit from treatment. Because of the change in therapeutic principles transient ischemic attack has been newly defined as „acute neurovascular syndrome”. Multiplication of neurological subspecialties has been facilitated by the development of diagnostic tools and the discovery of effective new drugs. The specialization led to narrowing of interest and competency of clinicians. Several new neurological scientific societies were founded for the representation of specific disorders. In Hungary, between 1993 and 2000 nine scientific societies were grounded within the field of clinical neurology. These societies should be thankful to the pharmaceutical industries for their existence. In some European countries in 2007 only three neurological subspecialties were accepted, which are neurophysiology, neuro-rehabilitation and child-neurology. Neuro-radiology is in the hands of general radiologists, the specialization is not granted for neurologists. Because of the subspecialization the general professionalism of neurologists has diminished. Among young neurologists the propedeutic skills suffered most seriously. Subspecialisation of teachers also interferes with the practice oriented teaching of medical students and residents. Contents of the part1: Summary – 1. Who needs hospitalist neurologists? 2. The evidence based ideology. 3. Thrombolysis near sighted. 4. Risk of therapeutic experiments. 5. If is it doubtful change the name! 6. The specialization. It's not what you know, it's how you think about what you know. J.W. Pelley Literature 1. Finger S.: Origins of neuroscience. A History of Exploration into Brain Function. Oxford University Press, 1994. 2. Freeman DW, Gronsth G, Eidelman BH.: Is it time for neurohospitalists? Neurology 2008; 70:1282-1288. 1
  2. 2. 3. Szirmai I: Nyelvi és/vagy fogalmi zavarok a neurológiában. Magyar Orvosi Nyelv 2005, V.évf. 2:41-5. 4. Avitzur O.: Stipends for stroke call create new pressures, demands on neurologists. Neurol. Today 2006; 6:6-7. 5. Singh S, Ernst E.: Trick or Treatment? Alternative medicine on trial. Bantam Press London 2008. pp: 86-87. 6. Editorials:Medicine based evidence, a prerequisite for evidence based medicine. BMJ, 1997; 315:1109-1110. 7. Verghese A.: If “evidence based medicine” is like… The Atlantic Magazine. Health/Medicine. 2009, maj. 14. 8. Steiberg EP, Luce BR.: Evidence Based? Caveat Emptor! Health Affairs 2005; 24: 80-92. 9. Schwab St, Hacke W.: Surgical Decompression of Patients With Large Middle Cerebral Artery Infarcts Is Effective. Stroke. 2003; 34:2304. 10. Depondt C.: The potential of pharmacogenetics in the treatment of epilepsy. European J. of Peadiatric Neurology. 2006; 10:56-65. 11. Wolf CR, Smith G, Smith RL.: Science, medicine and the future. Pharmacogenetics. BMJ 2000; 320:987-990. 12. Breckenridge A, Lindpainter K, Lipton P, McLeod H, Rothstein M, Wallace H.: Pharmacogenetics: ethical problems and solutions. Nat.Rev.Genet. 2004; 5:676-680. 13. Gage BF, Lesko LJ.: Pharmacogenetics of warfarin: regulatory, scientific and clinical issues. J. Thromb. Thrombolysis 2008; 25: 45-51. 14. Boxel-Dezaire AH van, Trigt-Hoff, SC van, Killestein J, Schrijver HM, Houwelingen JC van, Polman CH, Nagelkerken L.: Contrasting responses to interferon beta-1b treatment in relapsing-remitting multiple sclerosis: does baseline interleukin-12p35 messenger RNA predict the efficacy of treatment? Annals of neurology. 2000; 48:313-322 15. Talan J.: Different Genes Expressed in Those Who Respond (or Don't) to Interferon Beta for MS. Neurology Today. 8(6):31-32, March 20, 2008. 16. Byun E, Caillier SJ, Montalban X, Villoslada P, Fernández O, Brassat D, Comabella M, Wang J, Barcellos LF, Baranzini SE, Oksenberg JR.: Genome-wide pharmacogenomic analysis of the response to interferon beta therapy in multiple sclerosis. Arch Neurol. 2008; 65:337-344. 17. Brice P.: New pharmacogenetics research consortium 2007, 10. 02. ( 18. Swan Norman : Pharmacogenetics questioned. 2008/05/19/2244158.htm 19. Hossmann V, Heiss W-D, Bewermeyer H, Wiedemann, G .: Controlled Trial of Ancrod in Ischemic Stroke. Arch Neurol. 1983;40:803-808. 2
  3. 3. 20. Hennerici MG, Kay R, Bogousslavsky J, Lenzi GL, Verstraete M, Orgogozo JM; Intravenous Ancrod for acute ischaemic stroke in the European Stroke Treatment with Ancrod Trial: a randomised controlled trial. Lancet 2006; 25:1845-1846 21. Leibman JB.: Clinical controversies. The case against thrombolysis. Israeli J. of Emergency Medicine 2005; 5/1: 26 22. Viana Baptista M, Van Melle G, Bogousslavsky J.: Prediction of in-hospital mortality after first-ever stroke. J. Neurol. Sciences 1999; 166: 107-114. 23. Hand R, Klemka-Walden L, Inczauskis D.: Rural hospital mortality for myocardial infarction in Medicare patients in Ilionis. AHSR FHSR Ann. Meet. Abstr.Book. 1995; 12:58. 24. Bateman BT, Schumacher HCh Boden-Albala B, Berman MF, Mohr JP, Sacco RL, Pile- Spellman J.: Factors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients: An analysis of the nationwide inpatient sample 1999 to 2002. Stroke 2006; 37: 440-446. 25. Katzan JL et al.: Use of tissue type plasminogen activator for acute ischemic stroke JAMA 2000; 283: 1151-1158. 26. Caplan LR.: Hemorrhage into Embolic Brain Infarcts. Pharmacotherapy 19(2):125-127, 1999. 27. Rose S.: Précis of Lifelines: Biology, freedom, determinism. Behavioral and Brain Sciences. 1999; 22: 871–921 28. Ergin A, Ergin N. Is thrombolytic therapy associated with increased mortality: meta-analysis of randomized controlled trials. Archives of Neurology 2005; 62(3): 362-366 29. Demaerschalk BM.: Thrombolytic therapy for Acute Ischemic Stroke. The likehood being helped versus harmed. (Editorial) Stroke 2007; 38:2215-2216. 30. Mindaugas P.; Osvaldas P et al: Cerebral Venous Steal: Blood Flow Diversion with Increased Tissue Pressure Neurosurgery 2002, 51: 1267-1274. 31. Schaller B, Graf R.: Cerebral Venous Infarction: The pathophysiological concept. Cerebrovasc.Dis. 2004; 18:179-188. 32. Derex L, Nighoghossia N.: Intracerebral haemorrhage after thrombolysis for acute ischaemic stroke: an update. Journal of Neurology, Neurosurgery, and Psychiatry 2008;79:1093-1099 33. Trouillas P, Kummer von R.: Classification and pathogenesis of cerebral haemorrhages after thrombosis in ischemic stroke. Stroke 2006; 37:556-561. 34. Kummer von R: Cerebral Hemorrhage Following Thrombolysis in Stroke. Stroke update. 2002.: 271-277. 35. Molina C, Alvarez-Sabin J, Montaner J, Abilleira S, Arenillas J, Coscojuela P, Romero F, Codina A.: Thrombolysis-related hemorrhagic infarction (HI1 -HI2): a marker of early reperfusion, reduced infarct size and improved outcome in patients with proximal MCA occlusion. Stroke. 2002; 33: 1551-1556. 3
  4. 4. 36. Szirmai I, Surek Gy, Kamondi A, Magyar H, Juhász Cs: Az illogikus "therapia". Kritikai megjegyzések az agyi ischemiás betegek gyógyitásának gyakorlatához. Clin. Neurosci.-Ideggy. Szle. 1993;46:374-386 37. Mielke O, Wardlaw JM, Liu M. Thrombolysis (different doses, routes of administration and agents) for acute ischaemic stroke. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000514. DOI: 10.1002/14651858.CD000514.pub2. 38. Simon K.: Megatrial, metaanalysis, statisztika - klinikum Magyar Kardiológusok Társasága 1997; 26. kötet 04. szám. 39. William T. C. Yuh, Masayuki Maeda, Ay-Ming Wang, Daniel L. Crosby, Robert D. Tien, Randall T. Higashida, and Fong Y. Tsai .: Fibrinolytic Treatment of Acute Stroke: Are We Treating Reversible Cerebral Ischemia? AJNR 16:1994–2000, Nov 1995 40. Nedeltchev K, Schwegler B, Haefeli T, Brekenfeld C, Gralla J, Fischer U; Arnold M; Remonda L; Schroth G; Mattle HP.: Outcome of stroke with mild or rapidly improving symptoms. Stroke. 2007; 38:2531-2535. 41. Easton, JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann, E, Thomas S. Hatsukami TS, Higashida RT, Johnston SC, Kidwell CS, Lutsep HL, Miller E, Sacco RL: Definition and Evaluation of Transient Ischemic Attack. Stroke. 2009;40:2276-2293 42. Shah SH, Saver JL, Kidwell CS, Albers GW, Rothwell PM, Ay H, Koroshetz WJ, Inatomi Y, Uchino M, Demchuk AM, Coutts SB, Purroy F, Alvarez-Sabin JS, Sander D, Sander K, 43. Samuels MA.: Manual of Neurologic Therapeutics. VIth ed. Lippicot Williams and Wilkins, 1999. 44. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41(7):646-57. 45. Grisold W, Galvin R, Lisnic V, Lopes Lima J, Mueller E, Oberndorfer St, Vodusek DB.: One Europe, one neurologist? European Journal of Neurology, 2007; 14:241-247 4
  5. 5. Neurology! Adieau? Part 2. Summary Teaching of neurologists is indisposed worldwide. University tutors are engaged in teaching, research and patient-care. This triple challenge is very demanding, and results in permanent insecurity of University employees. To compensate for the insufficient clinical training, some institutes in the USA employ academic staff members exclusively for teaching. The formation of new subspecialties hinders the education and training of general neurologists. At the present four generations of medical doctors are working together in the hospitals. The two older generations educate the younger neurologists who have been brought up in the world of limitless network of sterile information. Therefore their manual skills at the bedside and knowledge regarding emergency treatment are deficient. Demographics of medical doctors changed drastically. Twice as many women are working in neurology and psychiatry than men. Integrity of neurology is threatened by: (1) Separation of the cerebro-vascular diseases from general neurology. Development of “stroke units” was facilitated by the better reimbursement for treatment and the interest of the pharmaceutical companies. The healthcare politics assisted to split the neurology into two parts. The independent status of „stroke departments” will reduce the rest of clinical neurology to outpatient service. (2) The main argumentation to segregate the rare neurological diseases was that their research will provide benefit for the diseases with high prevalence. This argumentation can rather be considered territorial imperative. The separation of rare diseases interferes with the teaching of differential diagnostics during neurological training. The traditional pragmatic neurology can not be retrieved. The faculty of neurology could retain its integrity because of the improvement of diagnostic methods and the more and more effective drugs. Nevertheless, even the progression of neurological sciences induces dissociation of clinical neurology. Neurology shall suffer fragmentation if the professional authorities fail to control the separation of subspecialties, if teaching of future neurologists, including practical knowledge and skills of diagnostic decision making, is not supported. Content of the Part 2.: 1. Change of mentality of neurologists. 2. Qualification of neurologists a) Challenges of medical faculties b) Specialization is an obstacle in the training of general neurology. 3. Medical generations and choosing specialization in neurology. 4. Gathering rare diseases. 5. Splitting the neurology in two. 6. “Scientific” clinical researches. Truth exists, only falsehood has to be invented Georges Braque Literature 1. Sox HC, Blatt MA, Higgins MC, Marton KI (Eds): Medical decision making. Butterworths. Boston, 1988. 5
  6. 6. 2. Elkind MSV.: Teaching the next generation of neurologists. Neurology 2009; 72:657-663. 3. Feldman MD, Ford Ch V, Reinhold T.: Patient or pretender. John Wiley and Sons. Inc. New York, 1994. 4. Teaching neurology in the 21st century (Suggestions for UK Medical Schools planning their Core Curriculum). Association of British Neurologists. Ormond House, 27 Boswell St, London WC1N 3JZ (1994) 5. Lancaster LC, Stillman D.: When Generations Collide. New York: HarperCollins, 2003. 6. Pelley JW, Dalley BK.: SuccessTypes In Medical Education. A Program for Improving Academic Performance. Version1.1. Published by John W. Pelley, PhD, Department of Cell Biology and Biochemistry, Texas Tech University Health Sciences Center School of Medicine, 2008. 7. Győrffy Zs, Ádám Sz.: Szerepkonfliktusok az orvosnői hivatásban LAM (Orvosi szociologia) 2003; 13:159-164. 8. Hess, C.: New institute treats rare neurological disorders. The Business journal 2009; 26/21. 9. Buckley BM. Clinical trials of orphan medicines. Lancet 2008; 371: 2051–55. 10. Schieppati A, Henter JI, Daina E, Aperia A.: Why rare diseases are an important medical and social issue? The Lancet 2008; 371:2039-2041. 11. Fischer A, Cavazzana-Calvo M.: Gene therapy for inherited diseases. Lancet 2008; 371: 2044–47. 12. Aymé S, Kole A, Groft S. Empowerment of patients: lessons from the rare diseases community. Lancet 2008; 371: 2048–51. 13. Haffner ME, Torrent-Farnell J, Maher PD.: Does orphan drug legislation really answer patients’ needs? Lancet 2008; 371: 2041–44. 14. Joppi R, Bertele V, Garattini S. Orphan drug development is progressing too slowly. Br J Clin Pharmacol 2006; 61: 355–60. 15. Mota da H.C.: Trocar de receita. Revista Ordem dos Médicos, 2009; 99: 28-29. 16. NORD (National Organization for Rare Disorders) http// 17. Alper JS, Beckwith J.: Genetic fatalism and social policy: The implications of behavior genetics research. Yale J. of Biology and Medicine. 1993; 66: 511-524. 18. Rose S.: Précis of Lifelines: Biology, freedom, determinism. Behavioral and Brain Sciences. 1999; 22: 871–921 19. Adams HP, Kenton EJ, Scheiber SC, Juul D.: Vascular Neurology. A new neurologic subspeciality. Neurology 2004; 63:774-776. 6
  7. 7. 20. Lang W, Lalouschek W.: Ein Netzwerk gegen den Schlaganfall. J. Neurol. Neurochir. Psychiatr. 2002; 2: 48-52. 21. Glick TH, Cranberg LD, Hanscom RB, Sato L. Neurologic patient safety: An in-depth study of malpractice claims. Neurology 2005:65:1284-1286. 22. Kareka A, Antal J.: Klinikai gyógyszervizsgálatok Magyarországon – egészségügyi intézményekben végzett kérdőíves felmérés tükrében. Egészségügyi Gazd. Szle. 2007; 3: 32-40. 7