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Cullinane PW, Wrigley S, Bradshaw TY, Shaw K, Shribman S, de Pablo Fernandez E, Warner TT, Jaunmuktane Z. Late Presentation of Chronic Traumatic Encephalopathy in a Former Association Football Player. Mov Disord Clin Pract 2023; 10:1414-1418. [PMID: 37772307 PMCID: PMC10525051 DOI: 10.1002/mdc3.13829] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/28/2023] [Accepted: 06/11/2023] [Indexed: 09/30/2023] Open
Abstract
Background Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease characterized by widespread accumulation of hyperphosphorylated tau that typically occurs in people who have suffered repetitive head impacts. To date, very few cases have been reported in association football players. Objectives To describe the clinicopathological features of a case of CTE in an 84-year-old former football player who was clinically diagnosed as having dementia with Lewy bodies (DLB). Methods A retrospective review of the patient's primary care and hospital medical records was performed along with a comprehensive neuropathological examination. Results This patient presented at age 84 with symmetrical parkinsonism and cognitive impairment that was exacerbated by prochlorperazine. His condition was rapidly progressive with recurrent falls within 1 year. Other features included headaches, depression, anxiety, suicidal ideation, disturbed sleep and aggression. He received a clinical diagnosis of DLB and died approximately 2 years after the onset of symptoms. A post-mortem examination revealed stage 4 CTE. Conclusions While the contemporaneous onset of parkinsonism and cognitive symptoms in the context of possible neuroleptic sensitivity is suggestive of DLB, the additional symptoms of aggressive behavior, depression and suicidality in a former football player are consistent with the neuropathological diagnosis of CTE. This case, which is notable for the late presentation, demonstrates that CTE may masquerade as other dementias and highlights the importance of seeking a history of repetitive head impacts.
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Affiliation(s)
- Patrick W. Cullinane
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
- Queen Square Brain Bank for Neurological DisordersUCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Sarah Wrigley
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
- Queen Square Brain Bank for Neurological DisordersUCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Teisha Y. Bradshaw
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
| | - Karen Shaw
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
- Queen Square Brain Bank for Neurological DisordersUCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Samuel Shribman
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
| | - Eduardo de Pablo Fernandez
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
- Queen Square Brain Bank for Neurological DisordersUCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Thomas T. Warner
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
- Queen Square Brain Bank for Neurological DisordersUCL Queen Square Institute of NeurologyLondonUnited Kingdom
- Queen Square Movement Disorders CentreUCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Zane Jaunmuktane
- Department of Clinical and Movement NeurosciencesUCL Queen Square Institute of Neurology, University College LondonLondonUnited Kingdom
- Queen Square Brain Bank for Neurological DisordersUCL Queen Square Institute of NeurologyLondonUnited Kingdom
- Division of Neuropathology, National Hospital for Neurology and NeurosurgeryUniversity College London NHS Foundation TrustLondonUnited Kingdom
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Shribman S, Burrows M, Convery R, Bocchetta M, Sudre CH, Acosta-Cabronero J, Thomas DL, Gillett GT, Tsochatzis EA, Bandmann O, Rohrer JD, Warner TT. Neuroimaging Correlates of Cognitive Deficits in Wilson's Disease. Mov Disord 2022; 37:1728-1738. [PMID: 35723521 PMCID: PMC9542291 DOI: 10.1002/mds.29123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/19/2022] [Accepted: 05/23/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Cognitive impairment is common in neurological presentations of Wilson's disease (WD). Various domains can be affected, and subclinical deficits have been reported in patients with hepatic presentations. Associations with imaging abnormalities have not been systematically tested. OBJECTIVE The aim was to determine the neuroanatomical basis for cognitive deficits in WD. METHODS We performed a 16-item neuropsychological test battery and magnetic resonance brain imaging in 40 patients with WD. The scores for each test were compared between patients with neurological and hepatic presentations and with normative data. Associations with Unified Wilson's Disease Rating Scale neurological examination subscores were examined. Quantitative, whole-brain, multimodal imaging analyses were used to identify associations with neuroimaging abnormalities in chronically treated stable patients. RESULTS Abstract reasoning, executive function, processing speed, calculation, and visuospatial function scores were lower in patients with neurological presentations than in those with hepatic presentations and correlated with neurological examination subscores. Deficits in abstract reasoning and phonemic fluency were associated with lower putamen volumes even after controlling for neurological severity. About half of patients with hepatic presentations had poor performance in memory for faces, cognitive flexibility, or associative learning relative to normative data. These deficits were associated with widespread cortical atrophy and/or white matter diffusion abnormalities. CONCLUSIONS Subtle cognitive deficits in patients with seemingly hepatic presentations represent a distinct neurological phenotype associated with diffuse cortical and white matter pathology. This may precede the classical neurological phenotype characterized by movement disorders and executive dysfunction and be associated with basal ganglia damage. A binary phenotypic classification for WD may no longer be appropriate. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London
| | - Maggie Burrows
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London
| | - Rhian Convery
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Martina Bocchetta
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Carole H Sudre
- MRC Unit for Lifelong Health and Ageing, University College London, London, United Kingdom.,Centre for Medical Image Computing, University College London, London, United Kingdom.,Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom
| | | | - David L Thomas
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom.,Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, London, United Kingdom.,Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Godfrey T Gillett
- Department of Clinical Chemistry, Northern General Hospital, Sheffield, United Kingdom
| | - Emmanuel A Tsochatzis
- UCL Institute of Liver and Digestive Health and Royal Free Hospital, London, United Kingdom
| | - Oliver Bandmann
- Sheffield Institute of Translational Neuroscience, Sheffield, United Kingdom
| | - Jonathan D Rohrer
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom
| | - Thomas T Warner
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London
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Shribman S, Marjot T, Sharif A, Vimalesvaran S, Ala A, Alexander G, Dhawan A, Dooley J, Gillett GT, Kelly D, McNeill A, Warner TT, Wheater V, Griffiths W, Bandmann O. Investigation and management of Wilson's disease: a practical guide from the British Association for the Study of the Liver. Lancet Gastroenterol Hepatol 2022; 7:560-575. [PMID: 35429442 DOI: 10.1016/s2468-1253(22)00004-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 02/07/2023]
Abstract
Wilson's disease is an autosomal-recessive disorder of copper metabolism with hepatic, neurological, psychiatric, ophthalmological, haematological, renal, and rheumatological manifestations. Making a diagnosis can be challenging given that no single test can confirm or exclude the disease, and diagnostic delays are common. Treatment protocols vary and adverse effects, including paradoxical neurological worsening, can occur. In this Review, we provide a practical guide to the diagnosis of Wilson's disease. We include recommendations on indications for testing, how to interpret results, and when additional investigations are required. We also cover treatment initiation, ideally under the guidance of a specialist centre for Wilson's disease, and the principles behind long-term management. This guidance was developed by a multidisciplinary group of Wilson's disease experts formed through the British Association for the Study of the Liver. The guidance has been endorsed by the British Society of Gastroenterology and approved by the Association of British Neurologists.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Thomas Marjot
- Oxford Liver Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Abubakar Sharif
- Liver Unit, Birmingham Women and Children's Hospital, Birmingham, UK
| | - Sunitha Vimalesvaran
- Paediatric Liver, GI and Nutrition Centre and Mowat Labs, King's College Hospital, Denmark Hill, London, UK
| | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey NHS Foundation Trust, Guildford; Institute of Liver Studies, King's College Hospital, London, UK
| | - Graeme Alexander
- University College London Institute of Liver and Digestive Health, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre and Mowat Labs, King's College Hospital, Denmark Hill, London, UK
| | - James Dooley
- University College London Institute of Liver and Digestive Health, London, UK
| | - Godfrey T Gillett
- Laboratory Medicine, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Deirdre Kelly
- Liver Unit, Birmingham Women and Children's Hospital, Birmingham, UK
| | | | - Thomas T Warner
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | | | | | - Oliver Bandmann
- Sheffield Institute for Translational Neuroscience (SITraN), Department of Neuroscience, University of Sheffield, UK.
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Shribman S, Heller C, Bocchetta M, Burrows M, Gillett GT, Tsochatzis E, Zetterberg H, Bandmann O, Rohrer JD, Warner TT. Plasma neurofilament light levels as a novel biomarker for neurological involve- ment in Wilson’s disease. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundSerum and urine copper levels are used to monitor chelation therapy for Wilson’s disease (WD) but do not reflect neurological involvement. Biomarkers of end-organ damage are needed to optimise chelation therapy and prepare for clinical trials for gene therapy.MethodsWe measured neurofilament light (NfL) levels in plasma samples, Unified WD Rating Scale (UWDRS) scores and brain volumes on T1-weighted MRI at baseline visits for a longitudinal, observational study. Participants were divided into neurological (n=25) and hepatic (n=15) groups according to UWDRS neurological examination (UWDRS-N) scores. Those with new diagnoses (n=2) or recent neurological dete- rioration associated with non-adherence (n=3) were subcategorised as having active disease. Plasma NfL levels were measured in age-matched healthy controls (n=38) for comparison.ResultsPlasma NfL levels were higher in neurological compared with hepatic and healthy control groups (8.6 vs 7.6 vs 7.6 ng/L, p=0.046) and higher in neurological cases with active disease (22.2 vs 8.3 ng/L, p=0.004). In cases without active disease, they correlated with UWDRS-N scores (p=0.003) and cortical grey matter (p<0.001) but not subcortical grey matter (p=0.071) or white matter volumes (p=0.895).ConclusionsPlasma NfL is a promising biomarker for neurological involvement that, in a small cohort, appears to be associated with neurological disease activity and clinical severity and reflects neuroaxonal injury in cortical grey matter.s.shribman@ucl.ac.uk
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Shribman S, Bocchetta M, Burrows M, Gillett GT, Tsochatzis E, Bandmann O, Rohrer JD, Warner TT. Biomarkers for brain injury and copper toxicity in Wilson’s disease: a diffusion tensor imaging study. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IntroductionChelation therapy is used to ‘de-copper’ patients with Wilson’s disease but neurological outcomes are unpredictable and biomarkers of end-organ damage are needed.MethodsWe prospectively performed clinical assessments, venepuncture and 3T MRI in 40 patients with Wilson’s disease. Using tract-based spatial statistics, we compared diffusion tensor imaging parameters across white matter tracts between patients with neurological (n=23) and hepatic (n=17) presentations and active (n=5) and stable (n=35) disease. We also tested associations with neurological examination scores and serum free copper concentrations in stable patients.ResultsThere were no differences in DTI parameters between patients with neurological and hepatic presentations, however examination scores were negatively associated with axial diffusivity in subcortical tracts in stable patients. Patients with active disease had widespread increases in mean, axial and, to a lesser extent, radial diffusivity. In contrast, increasing serum copper concentrations in stable patients were associated with widespread increases in mean, radial and, to a lesser extent, axial diffusivity.ConclusionsWe demonstrate that distinct patterns of abnormal white matter diffusivity are associated with brain injury and copper toxicity in Wilson’s disease. Decreases in axial diffusivity in chronically-treated patients likely reflect axonal loss. Increases in axial and radial diffusivity are a promising biomarker for monitoring treatment response.s.shribman@ucl.ac.uk
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Ross Russell AL, Zarkali A, Shribman S, Alexander SK, Warner TT, Jones M, Pereira A, Hughes TAT, Kipps C, Mummery CJ. 187 Variation in training: Results from a survey of UK neurology trainees. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundNeurology training in the UK is governed by a national curriculum defining the outcomes every trainee must achieve. However, the delivery of neurology training and trainee satisfaction differs significantly across the UK1.The Association of British Neurologists Trainees (ABNT) recently completed a qualitative study of the highest and lowest performing trusts for neurology training across the UK and identified key indicators associated with trainee satisfaction2.AimTo establish the variation in these indicators across the country.MethodsWe conducted a survey of UK neurology trainees to audit regional performance against the indicators identified in the previous qualitative study.ResultsWe had responses from 50 trainees, covering all deaneries.There was consultant supervision reported >98% of the time. 56% of supervising consultants were on-site during working hours, and 66% were present during clinics. In 74% of cases, the supervising consultant for inpatient referrals also had pre-booked clinics.Adaptation of daily roles according to trainee level was only reported by 26% of trainees, with <20% reponses reporting variation in clinic lists, or examples of ST3 shadowing.52% of trainees were required to relocate during training.There was significant variation within deaneries, suggesting these factors are often determined at a trust level.1. Shribman S, Alexander SK, Zarkali A, et al. doi:10.1136/practneurol-2018–002129 amyrossrussell@gmail.com
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Ahmad H, Zarkali A, Kemp MJ, Banerjee G, Rees RN, Shribman S, Grote H, Ross Russell AL. 189 Association of British Neurology trainees: biennial national census. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundThe Association of British Neurology Trainees (ABNT) conducts a biennial census of neurology trainees.This acquires data on training, education, research, out of program experiences and trainees’ future plans, which are invaluable in shaping the future workforce. This is particularly important given the introduction and implementation of Shape of Training in 2022.AimTo review trainee perspectives on neurology specialist training in 2020.MethodsOnline questionnaire, designed by the ABNT committee, sent by email to all specialist neurology trainees and associate ABN members.ResultsResults will be reviewed and compared with previous data by members of the ABNT committee. We hope to present these results to an audience of aspiring neurologists, trainees and consultant neurologists.ConclusionThe results of this census, in combination with those conducted in 2015 and 2017, will influence Shape of Training discussions and new curriculum design. We hope the information it provides will facili- tate communication and collaboration between the ABN, Specialty Advisory Committee, Joint Royal College of Physicians Training Board and other external bodies. This will inform future workforce planning and guide the transition through curriculum reforms.hena.ahmad2@nhs.net
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Shribman S, Bocchetta M, Sudre CH, Acosta-Cabronero J, Burrows M, Cook P, Thomas DL, Gillett GT, Tsochatzis EA, Bandmann O, Rohrer JD, Warner TT. Neuroimaging correlates of brain injury in Wilson's disease: a multimodal, whole-brain MRI study. Brain 2022; 145:263-275. [PMID: 34289020 PMCID: PMC8967100 DOI: 10.1093/brain/awab274] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/25/2021] [Accepted: 07/04/2021] [Indexed: 11/23/2022] Open
Abstract
Wilson's disease is an autosomal-recessive disorder of copper metabolism with neurological and hepatic presentations. Chelation therapy is used to 'de-copper' patients but neurological outcomes remain unpredictable. A range of neuroimaging abnormalities have been described and may provide insights into disease mechanisms, in addition to prognostic and monitoring biomarkers. Previous quantitative MRI analyses have focused on specific sequences or regions of interest, often stratifying chronically treated patients according to persisting symptoms as opposed to initial presentation. In this cross-sectional study, we performed a combination of unbiased, whole-brain analyses on T1-weighted, fluid-attenuated inversion recovery, diffusion-weighted and susceptibility-weighted imaging data from 40 prospectively recruited patients with Wilson's disease (age range 16-68). We compared patients with neurological (n = 23) and hepatic (n = 17) presentations to determine the neuroradiological sequelae of the initial brain injury. We also subcategorized patients according to recent neurological status, classifying those with neurological presentations or deterioration in the preceding 6 months as having 'active' disease. This allowed us to compare patients with active (n = 5) and stable (n = 35) disease and identify imaging correlates for persistent neurological deficits and copper indices in chronically treated, stable patients. Using a combination of voxel-based morphometry and region-of-interest volumetric analyses, we demonstrate that grey matter volumes are lower in the basal ganglia, thalamus, brainstem, cerebellum, anterior insula and orbitofrontal cortex when comparing patients with neurological and hepatic presentations. In chronically treated, stable patients, the severity of neurological deficits correlated with grey matter volumes in similar, predominantly subcortical regions. In contrast, the severity of neurological deficits did not correlate with the volume of white matter hyperintensities, calculated using an automated lesion segmentation algorithm. Using tract-based spatial statistics, increasing neurological severity in chronically treated patients was associated with decreasing axial diffusivity in white matter tracts whereas increasing serum non-caeruloplasmin-bound ('free') copper and active disease were associated with distinct patterns of increasing mean, axial and radial diffusivity. Whole-brain quantitative susceptibility mapping identified increased iron deposition in the putamen, cingulate and medial frontal cortices of patients with neurological presentations relative to those with hepatic presentations and neurological severity was associated with iron deposition in widespread cortical regions in chronically treated patients. Our data indicate that composite measures of subcortical atrophy provide useful prognostic biomarkers, whereas abnormal mean, axial and radial diffusivity are promising monitoring biomarkers. Finally, deposition of brain iron in response to copper accumulation may directly contribute to neurodegeneration in Wilson's disease.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London WC1N 1PJ, UK
| | - Martina Bocchetta
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3AR, UK
| | - Carole H Sudre
- MRC Unit for Lifelong Health and Ageing, University College London, London WC1E 7HB, UK
- Centre for Medical Image Computing, University College London, London WC1V 6LJ, UK
- Biomedical Engineering and Imaging Sciences, King’s College London, London WC2R 2LS, UK
| | | | - Maggie Burrows
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London WC1N 1PJ, UK
| | - Paul Cook
- Department of Clinical Biochemistry, Southampton General Hospital, Southampton SO16 6YD, UK
| | - David L Thomas
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3AR, UK
- Neuroradiological Academic Unit, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
- Wellcome Centre for Human Neuroimaging, UCL Queen Square Institute of Neurology, London WC1N 3AR, UK
| | - Godfrey T Gillett
- Department of Clinical Chemistry, Northern General Hospital, Sheffield S5 7AU, UK
| | - Emmanuel A Tsochatzis
- UCL Institute of Liver and Digestive Health and Royal Free Hospital, London NW3 2PF, UK
| | - Oliver Bandmann
- Sheffield Institute of Translational Neuroscience, Sheffield S10 2HQ, UK
| | - Jonathan D Rohrer
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3AR, UK
| | - Thomas T Warner
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London WC1N 1PJ, UK
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Shribman S, Poujois A, Bandmann O, Czlonkowska A, Warner TT. Wilson's disease: update on pathogenesis, biomarkers and treatments. J Neurol Neurosurg Psychiatry 2021; 92:1053-1061. [PMID: 34341141 DOI: 10.1136/jnnp-2021-326123] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/08/2021] [Indexed: 12/22/2022]
Abstract
Wilson's disease is an autosomal-recessive disorder of copper metabolism caused by mutations in ATP7B and associated with neurological, psychiatric, ophthalmological and hepatic manifestations. Decoppering treatments are used to prevent disease progression and reduce symptoms, but neurological outcomes remain mixed. In this article, we review the current understanding of pathogenesis, biomarkers and treatments for Wilson's disease from the neurological perspective, with a focus on recent advances. The genetic and molecular mechanisms associated with ATP7B dysfunction have been well characterised, but despite extensive efforts to identify genotype-phenotype correlations, the reason why only some patients develop neurological or psychiatric features remains unclear. We discuss pathological processes through which copper accumulation leads to neurodegeneration, such as mitochondrial dysfunction, the role of brain iron metabolism and the broader concept of selective neuronal vulnerability in Wilson's disease. Delayed diagnoses continue to be a major problem for patients with neurological presentations. We highlight limitations in our current approach to making a diagnosis and novel diagnostic biomarkers, including the potential for newborn screening programmes. We describe recent progress in developing imaging and wet (fluid) biomarkers for neurological involvement, including findings from quantitative MRI and other neuroimaging studies, and the development of a semiquantitative scoring system for assessing radiological severity. Finally, we cover the use of established and novel chelating agents, paradoxical neurological worsening, and progress developing targeted molecular and gene therapy for Wilson's disease, before discussing future directions for translational research.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Aurelia Poujois
- Department of Neurology, National Reference Centre for Wilson's Disease, Rothschild Foundation Hospital, Paris, France
| | - Oliver Bandmann
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, Sheffield, UK
| | - Anna Czlonkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Thomas T Warner
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
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Shribman S, Heller C, Burrows M, Heslegrave A, Swift I, Foiani MS, Gillett GT, Tsochatzis EA, Rowe JB, Gerhard A, Butler CR, Masellis M, Bremner F, Martin A, Jung L, Cook P, Zetterberg H, Bandmann O, Rohrer JD, Warner TT. Plasma Neurofilament Light as a Biomarker of Neurological Involvement in Wilson's Disease. Mov Disord 2021; 36:503-508. [PMID: 33078859 PMCID: PMC8436757 DOI: 10.1002/mds.28333] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Outcomes are unpredictable for neurological presentations of Wilson's disease (WD). Dosing regimens for chelation therapy vary and monitoring depends on copper indices, which do not reflect end-organ damage. OBJECTIVE To identify a biomarker for neurological involvement in WD. METHODS Neuronal and glial-specific proteins were measured in plasma samples from 40 patients and 38 age-matched controls. Patients were divided into neurological or hepatic presentations and those with recent neurological presentations or deterioration associated with non-adherence were subcategorized as having active neurological disease. Unified WD Rating Scale scores and copper indices were recorded. RESULTS Unlike copper indices, neurofilament light (NfL) concentrations were higher in neurological than hepatic presentations. They were also higher in those with active neurological disease when controlling for severity and correlated with neurological examination subscores in stable patients. CONCLUSION NfL is a biomarker of neurological involvement with potential use in guiding chelation therapy and clinical trials for novel treatments. © 2020 University College London. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Samuel Shribman
- Department of Clinical and Movement NeurosciencesReta Lila Weston Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Carolin Heller
- Dementia Research Centre, Department of Neurodegenerative DiseaseUCL Queen Square Institute of NeurologyLondonUnited Kingdom
- Department of Neurodegenerative DiseaseUK Dementia Research Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Maggie Burrows
- Department of Clinical and Movement NeurosciencesReta Lila Weston Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Amanda Heslegrave
- Department of Neurodegenerative DiseaseUK Dementia Research Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Imogen Swift
- Department of Neurodegenerative DiseaseUK Dementia Research Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Martha S. Foiani
- Department of Neurodegenerative DiseaseUK Dementia Research Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Godfrey T. Gillett
- Department of Clinical ChemistryNorthern General HospitalSheffieldUnited Kingdom
| | - Emmanuel A. Tsochatzis
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUnited Kingdom
| | - James B. Rowe
- Department of Clinical NeurosciencesUniversity of Cambridge and Cambridge University Hospitals TrustCambridgeUnited Kingdom
| | - Alex Gerhard
- Division of Neuroscience and Experimental Psychology, Wolfson Molecular Imaging CentreUniversity of ManchesterManchesterUnited Kingdom
- Departments of Geriatric Medicine and Nuclear MedicineUniversity of Duisburg‐EssenDuisburgGermany
| | - Chris R. Butler
- Department of Brain SciencesImperial College LondonLondonUnited Kingdom
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUnited Kingdom
| | - Mario Masellis
- Departamento de NeurologíaPontificia Universidad Católica de ChileSantiagoChile
- Sunnybrook Health Sciences CentreSunnybrook Research Institute, University of TorontoTorontoOntarioCanada
| | - Fion Bremner
- Neuro‐OphthalmologyNational Hospital for Neurology and NeurosurgeryLondonUnited Kingdom
| | - Alison Martin
- Department of Clinical ChemistryNorthern General HospitalSheffieldUnited Kingdom
| | - Lynne Jung
- Department of Clinical BiochemistrySouthampton General HospitalSouthamptonUnited Kingdom
| | - Paul Cook
- Department of Clinical BiochemistrySouthampton General HospitalSouthamptonUnited Kingdom
| | - Henrik Zetterberg
- Department of Neurodegenerative DiseaseUK Dementia Research Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
- Clinical Neurochemistry LaboratorySahlgrenska University HospitalMölndalSweden
- Department of Psychiatry and NeurochemistryInstitute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of GothenburgMölndalSweden
| | - Oliver Bandmann
- Sheffield Institute for Translational Neuroscience, University of SheffieldSheffieldUnited Kingdom
| | - Jonathan D. Rohrer
- Dementia Research Centre, Department of Neurodegenerative DiseaseUCL Queen Square Institute of NeurologyLondonUnited Kingdom
| | - Thomas T. Warner
- Department of Clinical and Movement NeurosciencesReta Lila Weston Institute, UCL Queen Square Institute of NeurologyLondonUnited Kingdom
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Schreier DR, Di Lorenzo F, Iodice F, Shribman S. Do you want to perform endovascular therapy? Perspectives from neurology trainees across Europe. Eur J Neurol 2020; 27:2646-2650. [PMID: 32918361 DOI: 10.1111/ene.14519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy (EVT) has become standard care for acute ischaemic stroke caused by large-vessel occlusion in the anterior circulation. However, access to this treatment in Europe remains poor. The lack of operators is a contributing factor and there is on-going discussion as to whether other specialists, including neurologists, could contribute to the EVT workforce. The question remains whether the next generation of neurologists want to become 'interventional neurologists'. The aim of this study was to address this question. METHODS We conducted a short survey within the National Representatives Network (a division of the Resident and Research Fellow Section, European Academy of Neurology) in order to determine the interest of future neurologists in performing EVT. RESULTS A total of 1218 responses from 27 European countries were received, with some variation in the number of respondents and results among individual countries. In total, 568 neurology trainees (47%) stated that they would want to be an 'interventional neurologist'. CONCLUSION Our findings suggest that neurologists could make a significant contribution to the workforce performing EVT and have important implications for the development and uptake of training programmes in Europe.
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Affiliation(s)
- D R Schreier
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - F Di Lorenzo
- Non Invasive Brain Stimulation Unit, Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - F Iodice
- Institute of Neurology, Catholic University of the Sacred Heart, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - S Shribman
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
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Shribman S, Webb G, Taylor R, Warner TT, Duckworth A, Gimson A, Shenoy A, Griffiths W. Liver transplantation for late-onset presentations of acute liver failure in Wilson's disease: The UK experience over 2 decades. JHEP Rep 2020; 2:100096. [PMID: 32322813 PMCID: PMC7163315 DOI: 10.1016/j.jhepr.2020.100096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/04/2020] [Accepted: 02/22/2020] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Acute liver failure as the initial presentation of Wilson’s disease is usually associated with onset in childhood, adolescence or early adulthood. Outcomes after transplantation for late-onset presentations, at or after 40 years, are seldom reported in the literature. Methods We report a case, review the literature and provide unpublished data from the UK Transplant Registry on late-onset acute liver failure in Wilson's disease. Results We describe the case of a 62-year-old man presenting with acute liver failure who was successfully treated with urgent liver transplantation. We identified 7 cases presenting at age 40 years or over in the literature, for which individual outcomes were reported; 3 were treated with transplantation and 2 survived. We identified a further 8 cases listed for transplantation in the UK between 1995 and 2014; 7 were treated with transplantation and 6 survived. One patient was de-listed for unknown reasons. Conclusions Wilson's disease should be considered in older adults presenting with acute liver failure. We suggest that urgent liver transplantation has good outcomes for late-onset presentations and recommend that urgent transplantation should always be considered in Wilson's disease presenting as acute liver failure. Lay summary Wilson's disease is a rare inherited disease that causes copper accumulation in the liver and brain and usually manifests during childhood, adolescence or early adulthood. We report the case of a 62-year-old who developed acute liver failure and was successfully treated with urgent liver transplantation. We discuss the outcomes of other late-onset cases of acute liver failure due to Wilson's disease in the literature and provide additional data from the UK Transplant Registry. We describe the case of a 62-year-old transplanted for acute liver failure in Wilson's disease. Outcomes after transplantation were previously reported in 3 late-onset cases. We describe a further 7 late-onset cases from the UK Transplant Registry. Wilson's disease should be considered in acute liver failure presenting at any age. Transplantation should always be considered in acute liver failure presentations.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Gwilym Webb
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge, UK
| | | | - Thomas T Warner
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Adam Duckworth
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge, UK
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Abstract
There is no consensus on how to structure and deliver neurology training. The General Medical Council's annual National Training Survey indicates that the quality of UK neurology training is very variable, but does not explain this variation. We used the survey data to identify the four highest and lowest performing sites for neurology training across the UK. We conducted semistructured interviews with groups of local trainees and, separately, local trainers in an exploratory qualitative study, and identified common themes across a range of aspects of neurology training. Here we present our findings, share case studies from top-performing sites and make recommendations on how best to train a neurologist.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | | | - Angelika Zarkali
- Dementia Research Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - Thomas T Warner
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | | | - Tom A T Hughes
- Department of Neurology, University Hospital of Wales, Cardiff, UK
| | - Catherine J Mummery
- Dementia Research Centre, National Hospital for Neurology and Neurosurgery, London, UK
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Abstract
The main presenting features of Wilson disease, many of which mimic common hepatic and neurologic disorders, are discussed. There is a need for specialists in these and related fields to be aware of hints from within and, more importantly, outside their area of expertise that should alert them to consider the diagnosis. Delayed diagnosis and treatment are potentially damaging for the patient. The importance of recognising and promptly investigating Wilson disease at the initial presentation should be understood by all those who assess patients with hepatic or neurologic disorders and/or train others in their specialty.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | - Thomas T Warner
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | - James S Dooley
- UCL Institute for Liver and Digestive Health, Division of Medicine, Royal Free Campus, London, UK
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Shribman S, Noyce A, Gnanapavan S, Lambourne J, Harrison T, Schon F. Cryptococcal meningitis in apparently immunocompetent patients: association with idiopathic CD4+ lymphopenia. Pract Neurol 2017; 18:166-169. [PMID: 29223998 DOI: 10.1136/practneurol-2017-001800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 11/04/2022]
Abstract
We present two cases of cryptococcal meningitis in people subsequently diagnosed with idiopathic CD4+ lymphopenia. Both presented with new onset headaches without sinister features and were sent home on multiple occasions from emergency departments. Cryptococcal meningitis in HIV-negative patients poses major diagnostic and management problems; the associated mortality is 9%-27%. We suggest performing blood and cerebrospinal fluid cryptococcal antigen tests in all people with lymphocytic meningitis.
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Affiliation(s)
| | - Alastair Noyce
- Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | | | - Jonathan Lambourne
- Departments of Infection and Immunology, Royal London Hospital, London, UK
| | - Thomas Harrison
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Frederick Schon
- Department of Neurology, Croydon University Hospital, Croydon, UK
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Shribman S, Hasan H, Hadavi S, Giovannoni G, Noyce AJ. The BRAIN test: a keyboard-tapping test to assess disability and clinical features of multiple sclerosis. J Neurol 2017; 265:285-290. [PMID: 29204963 PMCID: PMC5808056 DOI: 10.1007/s00415-017-8690-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/20/2017] [Accepted: 11/22/2017] [Indexed: 11/28/2022]
Abstract
Background The BRadykinesia Akinesia INcordination (BRAIN) test is an online keyboard-tapping test previously validated as a sensitive tool for detecting signs of Parkinson’s disease. Objectives To determine whether the BRAIN test can measure disability in MS and identify the presence of pyramidal or cerebellar dysfunction. Methods Kinesia scores (KS, number of key taps in 30 s), akinesia times (AT, mean dwell time on each key) and incoordination scores (IS, variance of travelling time between keys) were calculated in 39 MS patients. These were correlated against the Expanded Disability Status Scale (EDSS) scores, pyramidal and cerebellar functional system scores and 9-hole peg test scores. Results EDSS correlated with KS (r = − 0.594, p < 0.001), AT (r = 0.464, p = 0.003) and IS (r = 0.423, p = 0.007). 9-HPT scores strongly correlated with KS (r = 0.926, p < 0.001). Pyramidal scores correlated with KS (r = − 0.517, p < 0.001). Cerebellar scores correlated with KS (r = − 0.665, p < 0.001), AT (r = 0.567, p < 0.001) and IS (r = 0.546, p = 0.007). Receiver operating characteristic curves demonstrate that KS can distinguish between the presence or absence of pyramidal and cerebellar dysfunction with area under curve 0.840 (p < 0.001) and 0.829 (p < 0.001), respectively. Conclusions The BRAIN test can remotely measure disability in MS. Specific scores differ according to the presence and severity of pyramidal or extrapyramidal dysfunction. It demonstrates huge potential in monitoring disease progression in clinical trials. Electronic supplementary material The online version of this article (10.1007/s00415-017-8690-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Hasan Hasan
- Reta Lila Weston Institute of Neurological Studies, UCL Institute of Neurology, London, UK
| | - Shahrzad Hadavi
- Department of Neurophysiology, Kings College Hospital, London, UK
| | - Gavin Giovannoni
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alastair J Noyce
- Reta Lila Weston Institute of Neurological Studies, UCL Institute of Neurology, London, UK. .,Preventive Neurology Unit, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London, UK.
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Adams-Carr KL, Bestwick JP, Shribman S, Lees A, Schrag A, Noyce AJ. Constipation preceding Parkinson's disease: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2016; 87:710-6. [PMID: 26345189 DOI: 10.1136/jnnp-2015-311680] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 08/10/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To systematically review published literature to estimate the magnitude of association between premorbid constipation and later diagnosis of Parkinson's disease. BACKGROUND Constipation is a recognised non-motor feature of Parkinson's and has been reported to predate diagnosis in a number of observational studies. METHODS A systematic review and meta-analysis was carried out following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) criteria. A literature search was undertaken in December 2014 using PubMed and the search terms 'Parkinson's disease' and 'constipation'. Articles were screened for suitability and reviewed against inclusion and exclusion criteria. Studies were included if they assessed constipation by means of a structured questionnaire or if constipation/drugs used to treat constipation were coded in patient medical records. Data were extracted using a standardised template and effect size estimates combined using a fixed-effects model. Heterogeneity was explored with the I(2) statistic. RESULTS 9 studies were included in the meta-analysis, with a combined sample size of 741 593 participants. Those with constipation had a pooled OR of 2.27 (95% CI 2.09 to 2.46) for developing subsequent Parkinson's disease compared with those without constipation. Weak evidence for heterogeneity was found (I(2)=18.9%, p=0.282). Restricting analysis to studies assessing constipation more than 10 years prior to Parkinson's disease gave a pooled OR of 2.13 (95% CI 1.78 to 2.56; I(2)=0.0%). CONCLUSIONS This systematic review and meta-analysis demonstrates that people with constipation are at a higher risk of developing Parkinson's disease compared with those without and that constipation can predate Parkinson's diagnosis by over a decade.
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Affiliation(s)
| | - Jonathan P Bestwick
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, London, UK
| | - Samuel Shribman
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Andrew Lees
- Institute of Neurology, University College London, London, UK
| | - Anette Schrag
- Institute of Neurology, University College London, London, UK
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Adams-Carr K, Schrag A, Shribman S, Bestwick J, Lees A, Noyce A. CONSTIPATION PRECEDING PARKINSON'S DISEASE–META-ANALYSIS. J Neurol Neurosurg Psychiatry 2015. [DOI: 10.1136/jnnp-2015-312379.98] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Constipation is a well-recognised non-motor feature of Parkinson's disease (PD) and has been reported to predate PD in a number of observational studies, in some cases by over two decades. A systematic review and meta-analysis was carried out following MOOSE criteria. The literature search was undertaken on 7 December 2014 using PubMed and the relevant search terms ‘Parkinson's disease’ and ‘Constipation’. Articles were screened for suitability and included if they met the specific criteria: observational studies with a cohort or case–control design; cases were patients with PD according to standard clinical criteria; controls were healthy or had no history of neurological disease; cohorts were representative of the general population; constipation in controls was assessed over the same time period as for patients; original data were reported. Data were extracted and combined using a fixed-effects model. Nine studies were included in the meta-analysis. Constipation was associated with an OR of 2.28 (95% confidence interval 2.10-2.46; p<0.001) for subsequent PD, offering further evidence that people with constipation are at a higher risk of developing PD and constipation may predate PD diagnosis by many years. This could have implications for our understanding of the pathogenesis of disease and planning of neuroprotective interventional trials.
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Shribman S, Torsney KM, Noyce AJ, Giovannoni G, Fearnley J, Dobson R. A service development study of the assessment and management of fracture risk in Parkinson's disease. J Neurol 2014; 261:1153-9. [PMID: 24718980 PMCID: PMC4072921 DOI: 10.1007/s00415-014-7333-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/25/2014] [Accepted: 03/26/2014] [Indexed: 12/31/2022]
Abstract
Parkinson's disease (PD) is associated with an increased risk of fragility fracture. FRAX and Qfracture are risk calculators that estimate the 10-year risk of hip and major fractures and guide definitive investigation for osteoporosis using dual X-ray absorptiometry (DEXA) imaging. It is unclear which PD patients should be considered for fracture risk assessment and whether FRAX or Qfracture should be used. Seventy-seven patients with PD were recruited in the movement disorders clinic. Data were collected on PD-related characteristics and fracture risk scores were calculated. Patients with previous osteoporotic fractures had a higher incidence of falls (p = 0.0026) and use of bilateral walking aids (p = 0.0187) in addition to longer disease duration (p = 0.0037). Selecting patients with falls in combination with either disease duration >5 years, bilateral walking aids, or previous osteoporotic fracture distinguished patients with and without previous osteoporotic fracture with specificity 67.7 % (95 % CI 55.0-78.8) and sensitivity 100.0 % (95 % CI 73.5-100.0). Qfracture calculated significantly higher fracture risk scores than FRAX for hip (p < 0.0001) and major (p = 0.0008) fracture in PD patients. Receiver operating characteristic curves demonstrated that FRAX outperformed Qfracture with an area under the curve of 0.84 (95 % CI 0.70-0.97, p = 0.0004) for FRAX and 0.68 (95 % CI 52-86, p = 0.0476) for Qfracture major fracture risk calculators. We suggest that falls in combination with either a disease duration longer than 5 years or bilateral walking aids or previous osteoporotic fracture should be used as red flags in PD patients to prompt clinicians to perform a FRAX fracture risk assessment in the neurology clinic.
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Affiliation(s)
- Samuel Shribman
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University London, 4 Newark Street, London, E1 2AT, UK,
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Ackland FM, Chandrakantha LE, Collinson J, Davis T, Griffin N, Hewertson J, Shribman S, Thompson F, Williams AN, Zaw W. The Good Samaritan. Arch Dis Child 2004; 89:688. [PMID: 15210512 PMCID: PMC1720001 DOI: 10.1136/adc.2003.042549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
We examined hospital and domestic infant care practices in Oxfordshire and Northampton Health Districts to measure changes in prevalence of sudden infant death syndrome (SIDS) risk factors, and to evaluate a specific educational intervention restricted to Oxfordshire. We sent a postal questionnaire to 2781 parents of babies newly born in January 1992, July 1992 and January 1993 and achieved an 88% response rate. Overall, in hospital a relatively constant proportion (81%) slept on their sides and few prone, whereas at home 52% (but increasing) slept supine and 8% prone part or all of the time. Significant differences existed by district, both in hospital and at home, with more sleeping supine in Oxfordshire and more side-sleeping/propping in Northampton. First-time parents were more receptive to safety guidelines about sleeping position and several other risk factors also. We detected no modifying effect of the Oxfordshire advice. Professional practice can influence parental behaviour but general media coverage may produce the biggest effects.
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Affiliation(s)
- M Rose
- Community Paediatric Department, Churchill Hospital, Oxford, UK
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Booy R, Hodgson S, Carpenter L, Mayon-White RT, Slack MP, Macfarlane JA, Haworth EA, Kiddle M, Shribman S, Roberts JS. Efficacy of Haemophilus influenzae type b conjugate vaccine PRP-T. Lancet 1994; 344:362-6. [PMID: 7914306 DOI: 10.1016/s0140-6736(94)91400-1] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Efficacy of the Haemophilus influenzae type b (Hib) conjugate vaccine PRP-T (Pasteur-Merieux) was evaluated in a controlled community intervention study in the Oxford region, UK. PRP-T was offered to infants from May 1, 1991 in three of the region's eight districts and from July 1, 1991, in a fourth district. It was given by separate injection in addition to the standard diphtheria, tetanus, and pertussis vaccine according to an accelerated 2, 3, and 4 month schedule without a booster dose in the second year of life. By October 1, 1992, more than 90% of infants in vaccine districts had received at least one dose of PRP-T. None of the infants given three doses had developed Hib infection, whereas 11 infections occurred in the control population (vaccine efficacy 100%, 95% CI 80-100%). Intention-to-treat analysis also showed a high estimate of efficacy for the vaccine (90%, 50-99%). Follow-up of study children until November 1, 1993, has shown only 1 vaccine failure in an infant, and no invasive infections in those older than 1 year (average age 22 months). PRP-T vaccine had high protective efficacy with an accelerated immunisation schedule. Furthermore, the vaccine appears to remain protective through the second year of life without a booster dose. These findings provide encouragement for use of PRP-T in the Expanded Programme of Immunisation.
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Affiliation(s)
- R Booy
- Department of Paediatrics, Oxford Radcliffe Hospital, Headington, UK
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Hopkisson B, Arnold P, Billingham B, McGarrigle M, Shribman S. Can retinoscopy be used to screen infants for amblyopia? A longitudinal study of refraction in the first year of life. Eye (Lond) 1992; 6 ( Pt 6):607-9. [PMID: 1289138 DOI: 10.1038/eye.1992.131] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
One hundred normal babies were refracted by two observers in a double-masked study within 24 hours of delivery and 30 minutes after instillation of 1% cyclopentolate. The procedure was repeated at 6 weeks, 3 months, 6 months and 1 year. At birth agreement between the two refractionists to within 1 dioptre spherical equivalent was 82%, rising to 94% at 1 year. Astigmatism of greater than 1 dioptre increased from 10% at birth to 42% at 6 months but decreased to 15% at 1 year. Myopia was uncommon (4%) but 80% of eyes were hypermetropic more than +2 dioptres and 25% more than +4 dioptres at birth, although these percentages decreased to 5% and 3% at 1 year. Anisometropia of more than 1 dioptre between the two eyes was uncommon but in the two cases where it persisted in the presence of high hypermetropia, reversible amblyopia was encountered in both cases.
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Affiliation(s)
- B Hopkisson
- Eye Department, Northampton General Hospital, UK
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