Research to inform the care of neurologically deceased organ donors is complicated by a lack of standards for research consent. In this systematic review, we aim to describe current practices of soliciting consent for participation in prospective studies of neurologically deceased donors, including the frequency and justification for these various models of consent. Among the 74 studies included, 14 did not report on any regulatory review, and 13 did not report on the study consent procedures. Of the remaining 47 studies, 24 utilized a waiver of research consent. The most common justification for a waiver of research consent related to the fact that neurologically deceased donors are not considered human subjects. In conclusion, among studies of neurologically deceased donors, research consent models vary and are inconsistently reported. Consensus and standardization in the application of research consent models will help to advance this emerging field of research.
Holmes tremor (HT), also known as midbrain, rubral, or cerebellar pathway outflow tremor, occurs due to disturbances of the cerebellothalamic pathway. This tremor is usually related to lesions in the midbrain peduncular region involving the superior cerebellar peduncle, red nucleus, and possibly the nigrostriatal circuitry. Common etiologies resulting in HT include tumor, ischemia, and demyelination. We report a case of progressive left sided HT in an otherwise healthy male with additional symptoms of parkinsonism, hypoesthesia, right oculomotor nerve palsy, cognitive dysfunction and hypersomnolence. Imaging investigations revealed a right sided thalamic and midbrain glioma. Dopamine transport imaging demonstrated significant dopaminergic denervation in the right caudate and putamen. The degree of striatal dopamine transporter deficiency was more severe than expected in a Parkinson’s disease patient. A trial of dopaminergic agent resulted in significant improvement of the tremor and associated symptoms. Interruption of the nigrostriatal pathway can occur in cases of HT due to midbrain peduncular lesion. The striatal dopaminergic function imaging may have a role in assessing pre-synaptic dopamine dysfunction and guiding treatment.
One of the main subtypes of immune-mediated necrotizing myopathies (IMNM) is defined by the presence of autoantibodies against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR). Statins lower cholesterol through inhibition of HMGCR. 1 Rarely, they can cause a severe immune-mediated anti-HMGCR positive myopathy that persists despite discontinuation of statins and requires immunosuppression. 1 In addition, patients with anti-HMGCR-related myositis do not always have history of statin exposure.
Background: Pediatric neurology referral wait times are increasing, often leading to emergency department (ED) utilization. On average 5% of ED patients present with neurological symptoms and 35% of ED neurological diagnoses are revised after specialist review. A Stollery Rapid Access Neurology (RAN) clinic was created to decrease wait time, and initiate an efficient referral process. Methods: The RAN clinic ran weekly from March 2018 until February 2019. This was a prospective study approved by the University of Alberta ethics board. Inclusion criteria were met. Information was collected for diagnosis, along with confidential patient satisfaction surveys. Results: Seventy-five patients were referred, 49% from the ED. Wait time averaged 6 weeks. The most frequent referral reason was seizures, with 60% of referring diagnosis being correct. Prior to RAN appointment, 61% of patients presented to the ED, whereas only 0.1% returned in the following 3 months. Neurology follow up was required in 81% of patients. Overall satisfaction was ranked 9.6/10. Conclusions: The RAN clinic created an effective urgent triage method. Neurologist review revised 40% of diagnoses. This ongoing study reveals that a RAN clinic can reduce visits to the ED following appointment and initiate appropriate follow up. Future evaluation in cost effectiveness and telehealth appointments are required.
Aim
Referral wait times for paediatric neurological patients are increasing, leading to an increased burden on the emergency department (ED). The paediatric Rapid Access Neurology (pRAN) clinic was created for paediatric patients who are clinically stable, but require an urgent paediatric neurology consultation. The objectives were to evaluate the pathways of referral, accuracy of referring diagnoses, adherence to clinic appointments, impact of clinic visitation on ED visits and patient satisfaction.
Methods
Data were collected from the pRAN clinic from March 2018 until April 2019. Information was obtained from patient charts including the referring and final diagnosis, management plan and the number of visits made to the ED before and after visiting the pRAN clinic.
Results
Of the 256 referred patients, 91 met inclusion criteria. The most frequent referral diagnosis was a seizure. Referring physicians and pRAN clinic neurologists differed significantly in the level of diagnostic agreement for patients <2 years of age (P = 0.03; 95% confidence interval (CI) −0.294, 0.373). There was a significant reduction in visits to the ED made by patients 3 months after the pRAN appointment compared with before the visit (P < 0.001; 95% CI −0.9070, −0.4088). The majority of patients felt that the clinic had high value and were satisfied with their follow‐up plan.
Conclusion
This pilot study showed that a pRAN clinic can improve the accuracy of neurological diagnoses and management, especially for children <2 years of age. In addition, pRAN clinic patients make fewer subsequent visits to the ED and express high satisfaction with their care.
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