An audit of electroencephalography requests: Use and misuse

SummaryObjectiveTo investigate whether electroencephalogram (EEG) requests at St George's Hospital (SGH) are being made according to clinical guideline recommendations.MethodsA retrospective audit at a regional neurology and neurosurgery referral centre, also serving a district population. All adult National Health Service patients undergoing standard EEG between 1st November 2003 and 31st January 2004, for whom the request originated within the hospital, were identified. Data was collected from each subject's case notes, request form and EEG report and compared to predetermined criteria.ResultsFifty sets of notes from ninety patients meeting the inclusion criteria were available for review. Twenty-six percent of requests were considered ‘inappropriate’, with respect to clinical guidelines, of which 92% were for ‘funny turns’ where there appeared to be insufficient clinical evidence to justify the request. The EEG contributed to diagnosis or management in only 22% of cases, all of which had been appropriately requested. Neurologists/epileptologists appeared better than non-specialists in terms of appropriateness of referrals, though the numbers were too small to reach significance (p=0.173, Fisher's exact). Forty-two percent of all patients, and less than 10% of outpatients, had their EEG within the guideline target wait of 4 weeks.ConclusionsOver a quarter of EEG referrals are not being made in accordance with guidelines, mainly because of the misconception that an EEG can confirm or exclude a diagnosis of epilepsy in patients with “funny turns”. In addition, less than 10% of out patient requests are being met within 4 weeks. Strategies to maximise service utilisation are discussed

Functional consequences of the 3460-bp mitochondrial DNA mutation associated with Leber’s hereditary optic neuropathy

Complex I is the largest of the mitochondrial respiratory chain proteins, and contains subunits encoded by both mitochondrial and nuclear genomes. Leber's hereditary optic neuropathy has been clearly linked to mutations of mitochondrial DNA complex I genes, and variable complex I functional defects have been reported. We have confirmed an approximate 60% defect in mitochondrial NADH CoQ(1) reductase activity in cultured fibroblasts bearing the 3460-bp G to A mutation within the ND1 gene. However complex I-Linked ATP synthesis was found to be normal in these fibroblasts. A 60% rotenone-induced decrease in complex I activity was shown to reduce ATP synthesis in normal fibroblasts, indicating that this level of complex I activity was below the threshold required to affect ATP synthesis. Although 3460 LHON mitochondria were less sensitive to rotenone inhibition, this did not explain the decreased complex I activity as the rotenone insensitive activity was not increased, nor did the inhibitor diphenyleneiodonium inhibit the NADH CoQ(1) reductase activity to a greater extent. Decreased NADH cytochrome c reductase activity in cybrids homoplasmic for the 3460 LHON mtDNA mutation confirmed that the decrease in complex I activity was not specific to the assay used and was not caused by inhibitory effects of ubiquinone analogues used in the NADH CoQ(1) reductase assay. These findings have important implications for our understanding of complex I dysfunction in the pathogenesis of 3460 Leber's hereditary optic neuropathy. (C) 1999 Published by Elsevier Science BN. All rights reserved

Hiding in plain sight: Functional neurological disorders in the news

Objective: Functional movement and seizure disorders are still widely misunderstood and receive little public and academic attention. This is in stark contrast to their high prevalence and levels of associated disability. In an exploratory observational study, the authors examined whether the relative lack of media coverage of functional neurological disorders is in part due to misidentification in “human in-terest” news stories. Methods: Thirteen recent news stories from high-impact English-language media outlets that portrayed patients with complex symptoms either attributed to other diagnoses or presented as medical mysteries were identified using online keyword searches. All selected news stories contained video or still images displaying relevant symptoms. Cases were categorized into movement disorders or seizure disorders and were then independently assessed by 10 respective expert raters. For each category, one story of a patient whose symptoms were due to a well-recognized neurological disease was also included. Both the diagnostic category and the respective confidence level were reported by each rater for each case. The interrater agreement was calculated for each group of disorders. Results: The raters confirmed almost unanimously that all presented news stories except the negative control cases portrayed misidentified functional movement or seizure disorders. The interrater agreement and average diagnostic confidence were high. Conclusions: Functional neurological disorders are often wrongly considered a rare medical curiosity of the past. However, these findings suggest that, while they are largely absent from public discourse, they often appear in the news incognito, hiding in plain sight. © 2019, American Psychiatric Association. All rights reserved

From pesticides to genetically modified plants: history, economics and politics

AbstractTwo technologies of crop protection are compared, crop protection by pesticides and by Genetically Modified Plants (GMPs). The history of pesticides provides lessons relevant to the future of GMPs; (1) high pesticide usage is counter-productive, (2) the technology requires intensive regulation and (3) has nonetheless many external effects which strongly reduce its social benefits, (4) early calculations on net benefits of pesticides were over-optimistic, and (5) intensive use of pesticides made farmers so dependent on them that they lost important options. These lessons are used to construct a framework for the economic analysis of GMPs which can be applied once sufficient empirical information becomes available. Conceptually the framework can be used for a comparison of crop protection strategies indicated as chemical crop protection, threshold-based crop protection, crop protection by ecotechnology and organic agriculture. Given the current state of knowledge on the impact of GMPs where (1) benefits are assumed rather than proven, (2) regulatory costs are rising and (3) environmental and human health risks have yet to be fully identified, one conclusion is that ex ante economic analysis which draws upon some of the lessons learned with chemical pesticides may help to bridge the gap between the proponents and the opponents of GMT (Genetic Modification Technology)