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Neurology

Mental health Letters 5 March 2018 Free

Why medically unexplained symptoms and health anxiety don’t need to make your heart sink

To the Editor: We read the article by Newby and Andrews1 with great interest and wholeheartedly agree with both the prevalence of health anxiety and the effectiveness of cognitive behaviour therapy. We would add that, firstly, the scope of this problem is not confined to the primary care practitioner, and secondly, cognitive behaviour therapy can also be used to treat psychosomatic symptoms not just health anxiety.2 A proportion of medically unexplained symptoms are psychosomatic or functional in origin.3 Functional symptoms are those experienced by patients due to a problem in the nervous system or other organs not functioning appropriately, in the absence of structural abnormalities or pathological changes. Studies estimate that 15% of patients seen in a standard neurology practice are diagnosed with a functional disorder.4,5 These symptoms and syndromes are also common in other specialties; for example, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, idiopathic chronic cough, idiopathic chronic pelvic pain and globus pharyngeus, to name a few.6 The successful management of functional neurological disorders requires careful assessment of the patient’s history, presentation and investigation findings, followed by an honest clear discussion of the diagnosis and treatment options.7,8 A good explanation of the symptoms to a patient with a functional disorder — while reassuring them of the validity of their symptoms — is vital to ensure successful treatment.7,8 Metaphorical descriptions are often used in the neurological explanation of functional disorders (eg, “the hardware is fine, but there is a software problem”).7 We find that emphasising to the patient that functional symptoms are common and often reversible and that self-help is a key part of getting better also assist in empowering the patient. We direct the reader to well written articles about components of a good explanation.5-8 Finally, we often educate the patient about basic cognitive behaviour therapy concepts, including challenging negative thoughts, distraction techniques and mindfulness, as strategies to deal with or terminate the symptoms. Once this is done, patients are often more receptive to psychology or psychiatry referrals for further work. Our experience with educating and empowering patients with these strategies is that they often lead to successful treatments and grateful patients.

Benjamin Nham · Anna Williard

Letter to the Editor1
Neurology Letters 16 October 2017 Free

Clot retrieval and acute stroke care

To the Editor:While highlighting the benefits of endovascular clot retrieval (ECR), Hwang and Gawarikar1 identified Victoria as establishing the first statewide 24/7 ECR service in Australia. We agree with the authors’ caution against focusing on a singular therapy for a few patients at the cost of delivering basic, high quality stroke care to all. As they note in the article, offering ECR requires capacity to appropriately assess patients with advanced imaging and to treat or transfer patients if ECR is indicated.1 We want to provide some background to the ECR service and the role of telemedicine for delivering evidence-based stroke care across regional Victoria, including ECR access. In Victoria, stroke telemedicine has been an important linchpin for overcoming clinical practice variation. The Victorian Stroke Telemedicine (VST) program (www.vst.org.au), operational since 2011, is a statewide service providing 16 regional hospitals with remote access to stroke specialists 24/7.2 The first VST patient eligible for ECR was identified in May 2015, with 78 identified to date. The Victorian Government statewide ECR protocol3 was released in May 2016, with VST being pivotal in identifying and transferring suitable patients from regional areas. Working with regional colleagues through telemedicine has led to numerous benefits,4 including capacity building and incorporating the latest evidence into local stroke protocols. So far, 1600 patients have received a VST consultation, the thrombolysis rate for ischaemic stroke under 4.5 hours is 38% (nationally, 24%),5 some hospitals have provided thrombolysis therapy for the first time, more patients are receiving thrombolysis in under 60 minutes and haemorrhagic complications rates are comparable with those of metropolitan hospitals. Moreover, VST delivers a broader neurological service: 38% of VST consultations receive a “not stroke” diagnosis. We agree that attention to guideline adherence (ie, stroke unit access, care plans and preventive medication) is required.1 Telemedicine may improve access to both basic and specialised care, and in our experience, it provides important infrastructure to incorporate new evidence rapidly. If systems of care could be improved to support rapid uptake of evidence, then geographical boundaries may be overcome: a national acute stroke telemedicine service may be one solution. Commensurate with the need to ensure value, we are undertaking a comprehensive cost effectiveness analysis to support optimal stroke care policy and practice decisions.

Kathleen L Bagot · Dominique A Cadilhac · Chris Bladin

Neurology Letters 2 October 2017 Free

Risk-adjusted hospital mortality rates for stroke: evidence from the Australian Stroke Clinical Registry (AuSCR)

To the Editor:Cadilhac and colleagues1 explore an important issue in the measurement and reporting of stroke outcomes. We agree that appropriate risk-adjustment methods are essential to compare hospital outcomes. We also agree that stroke severity is an important predictor of mortality for individual patients. However, we do not agree that determining stroke severity is essential for robust risk-adjustment approaches. The Bureau of Health Information has recently published its second report on 30-day mortality.2 Our approach includes adjustment for comorbidity, and we developed separate models for ischaemic and haemorrhagic stroke, given the significant differences in outcomes and risk factors. The approach of Cadilhac and colleagues does neither, which means that we do not know the impact of including comorbidity adjustment and severity in the same model. Further, our method is applicable to small hospitals with as few as 50 patients in a 3-year period. In settings such as Australia, where many patients reside outside major cities, it is important to assess outcomes in both small and large hospitals. The results of Cadhilac et al show that adjusting for stroke severity affected hospital rankings, and across the two models, hospital rates changed on average by 0.01 (range, 0.001–0.026). The impact on outlier status is not described. In our view, it is the outlier status that is the most salient element of public reporting, and indirect standardisation should not be used to rank hospitals.3 Measurement approaches in the United States and Canada do not adjust for severity, and it is not currently possible to do so using administrative records in Australia. While Cadhilac et al have shown that including severity information can affect rankings, such rankings are not appropriate to assess hospital performance when they are based on indirect standardisation and do not take account of hospital size.

Kim Sutherland · Jean-Frederic Levesque · Julia Chessman

Neurology Research 1 May 2017 Free

Risk-adjusted hospital mortality rates for stroke: evidence from the Australian Stroke Clinical Registry (AuSCR)

Comparisons of hospital mortality rates for stroke are critically affected by the statistical approach employed

Dominique A Cadilhac · Monique F Kilkenny · Christopher R Levi · Natasha A Lannin · Amanda G Thrift · Joosup Kim · Brenda Grabsch · Leonid Churilov · Helen M Dewey · Kelvin Hill · Steven G Faux · Rohan Grimley · Helen Castley · Peter J Hand · Andrew Wong · Geoffrey K Herkes · Melissa Gill · Douglas Crompton · Sandy Middleton · Geoffrey A Donnan · Craig S Anderson

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