Wednesday, 9 November 2011

A new technique could improve the quality of life for patients with Parkinson's Disease


Cardiff University new Parkinson's therapy hope

MRI scan of a patient with Parkinson's DiseaseA brain scan of a patient with Parkinson's disease. The blue box highlights a damaged region

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A new technique could improve the quality of life for patients with Parkinson's Disease, according to research led by Cardiff University.
Patients with the early stages of the disease were trained to control areas of the brain associated with movement by using the power of thought alone.
A clinical evaluation later found their movement had improved by up to a third.
The charity Parkinson's UK described the research as "exciting" but stressed "these are very early days".
The study, published in The Journal of Neuroscience, involved ten patients with the disease that affects the brain and results in slow movements and a tremor.
Five patients received the brain regulation feedback technique and five acted as a control.
Activity mapping

“Start Quote

We wanted them to activate the brain regions associated with movement through the force of their mind”
Professor David LindenCardiff University
Patients undergoing the training were placed in a Magnetic Resonance Imaging (MRI) scanner in Bangor, Gwynedd. At first, they were asked to squeeze a hand as the team mapped the regions of the brain responsible for controlling movement.
Then, in real time, the subjects were shown the level of activity in these regions displayed on a gauge above them.
They were asked to imagine making complex movements in order to activate the brain centres, and saw a corresponding increase on the gauge. With practice, they were able to increase and decrease the level of activity at will, through thought alone.
Prof David Linden from Cardiff University, who led the research, described the process as "real-time neural feedback".
Motor function
"Self-regulation of brain activity in humans based on real-time feedback is emerging as a powerful technique," said Prof Linden.
Diagram from Cardiff University showing the principle of feedback in the researchPatients experienced a feedback effect as they learnt to control motion centres in their brain
"In this study we assessed whether patients with Parkinson's disease are able to alter their brain activity to improve their motor function. We wanted them to activate the brain regions associated with movement through the force of their mind," he explained.
The professor stressed that the technique did not offer a cure but he said that improved function could lead to a better quality of life.
"We found that the five patients who received neuro feedback were able to increase activity in brain networks important for movements and that this intervention resulted in an overall improvement in motor speed - in this case, finger tapping," said Prof Linden.
"The training resulted in clinically relevant improvement of motor functions - so assuming patients can learn to transfer the strategies used during neuro feedback into real-life settings, it might also become possible to sustain the clinical benefits," he added.
The research team said the study was a small scale proof of principle and they now hope to stage a larger, randomised, clinical trial.

“Start Quote

While these results are exciting, these are very early days”
Claire BaleParkinson's UK
'Amazing' brain
Claire Bale, senior research communications officer at Parkinson's UK, said: "This study showed that people with Parkinson's were able to alter their own brain activity to improve their movement symptoms using neurofeedback from brain scans. This highlights the amazing ability of the brain to change and adapt".
"While these results are exciting, these are very early days. We need much larger, in-depth studies to help us understand the potential these techniques may have to tackle some of the symptoms of Parkinson's," said Ms Bale.
The research into Parkinson's disease was the result of a collaboration between Cardiff University and scientists and doctors from north Wales, London and the Netherlands.
Prof Linden has also carried out a pilot trial using the neuro feedback technique on patients suffering with depression. The findings of that study are yet to be published.

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Elderly care - 'shameful attitudes'


NHS: Elderly care dossier shows 'shameful attitudes'

Nurse and patientAttitudes to elderly people in the NHS are shameful, says the Patients Association

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A dossier containing "shameful" stories about the care elderly patients receive in NHS hospitals in England has been published by campaigners.
The Patients Association said the 16 cases include people being denied pain relief, left to sit in their own faeces and going without food and drink.
It comes after criticism from other groups and the charity said it was highlighting the tip of the iceberg.
The government said it was determined to "root out poor performance".
A programme of unannounced inspections would continue, the Department of Health added.
Last month the Care Quality Commission attacked hospitals for what the regulator said were "alarming" levels of care.
The Health Service Ombudsman also raised concerns about the issue in February, reporting that nearly a fifth of complaints it got were related to the care of the elderly.
As well as highlighting the 16 cases, the Patients Association said the number of calls to its helpline regarding care on hospital wards had already hit 961 this year - a third more than the total made throughout the whole of 2010.

Left sitting in faeces

George Taylor was admitted to Chase Farm Hospital in London in August with a urinary tract infection and chest problem. His family said he received a shocking level of care q=while there.
On one day, he was told by a nurse to go to the toilet sitting in his chair because she did not have time to take him to a bathroom. He did and his family then found him sitting in his own faeces. His wife had to clean him up.
His family also said he was often not washed, and the smell became overpowering at times. He was also discharged too early and was soon admitted to another hospital, where doctors said he should not have been released at all.
Mr Taylor's daughter, Gaynor Marshall, said: "The nursing staff treated him as an object that they had to treat rather than a human being." A complaint has now been made about his care.
The Patients Association said the failings fell into four broad categories - communication, assistance going to the toilet, pain relief and nutrition.
And it called on NHS trusts to sign up to a pledge to ensure these four areas of care become top priorities.
It said responsibility for the problems lay with everyone from individual staff on the wards to senior managers on the board.
Among the cases highlighted are a patient who was left sitting in his own faeces for hours after a nurse told him he should empty his bowels in his chair because she did not have time to help him go to the toilet.
In another case, a family of a patient had to beg for pain relief for a dying woman before waiting for nearly two hours for help to arrive.
And one man had to wait for 15 minutes to have his call buzzer answered despite having to desperately struggle for breath.
It is the third time the Patients Association has published individual stories like this.
'Poor performance'
Katherine Murphy, the charity's chief executive, said: "We cannot ignore the fact that some trusts are not even paying lip service to the fundamentals of care.

Dying patient in 'terrible' pain

Sally Abbott-Sienkiewicz
Sally Abbott-Sienkiewicz was admitted to Glenfield Hospital in Leicester in November last year. She was terminally ill with cancer and had developed pneumonia. She died within two days.
But throughout her time there, her family had to battle to get her pain relief. They said she was left in terrible pain - sometimes for more than an hour - as they argued with staff to give her sedatives. The worst problems were experienced during the night.
Her daughter Samantha White said at times her pain was "horrendous and horrific", but staff were too slow to react.
Suzanne Hinchliffe, chief nurse at the trust which runs Glenfield, said: "It is clear that we completely failed Mrs Abbott-Sienkiewicz and her family, and for that we remain very sorry." She added that measures were being taken to improve practices.
"The issues we continue to highlight are human rights issues. They show a lack of compassion and care and a shameful attitude to treatment of the elderly."
Peter Carter, general secretary of the Royal College of Nursing, said the patients had been "clearly failed" in the cases highlighted.
"Each and every nurse is personally accountable for their own actions and must act promptly to raise concerns if staffing levels or other pressures get in the way of delivering good patient care."
But he also said managers must take responsibility, pointing out that job cuts were making it more difficult to provide good care.
The publication of the Patients Association report has also coincided with an announcement by the government that it is looking to improve standards for healthcare assistants, who are providing an increasing amount of care on wards.
These staff are currently unregulated, but the Department of Health is looking to introduce new rules by 2013 to ensure that they reach a minimum training levels before being allowed to work. However, indications are that this will be a voluntary requirement, which has disappointed some.
A spokesman for the Department of Health said: "The Patients Association is right to raise these examples and issues, and we will work with them and with the NHS to sort these problems out."

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Tuesday, 8 November 2011

strange and curious history of lobotomy

The strange and curious history of lobotomy


A brain

Deep in the archives of London's Wellcome Collection, that great treasure trove of medical curiosities, is a small white cardboard box.It's 75 years since the first lobotomy was performed in the US, a procedure later described by one psychiatrist as "putting in a brain needle and stirring the works". So how did it come to be regarded as a miracle cure?
Inside is a pair of medical devices. They are simple. Each consists of an eight-centimetre steel spike, attached to a wooden handle.
"These two gruesome things are lobotomy instruments. Nothing sophisticated," says senior archivist Lesley Hall. "It's not rocket science is it?"

These spikes once represented the leading edge of psychiatric science. They were the operative tools in lobotomy, also known as leucotomy, an operation which was seen as a miracle cure for a range of mental illnesses.
For millennia, mankind had practised trepanning, drilling holes into skulls to release evil spirits.

“

The idea behind lobotomy was different. The Portuguese neurologist, Egas Moniz, believed that patients with obsessive behaviour were suffering from fixed circuits in the brain.
In 1935, in a Lisbon hospital, he believed he had found a solution. "I decided to sever the connecting fibres of the neurons in activity," he wrote in a monograph titled "How I came to perform frontal leucotomy".
His original technique was adapted by others, but the basic idea remained the same.
Surgeons would drill a pair of holes into the skull, either at the side or top, and push a sharp instrument - a leucotome - into the brain.
The surgeon would sweep this from side to side, to cut the connections between the frontal lobes and the rest of the brain.
Moniz reported dramatic improvements for his first 20 patients. The operation was seized on with enthusiasm by the American neurologist Walter Freeman who became an evangelist for the procedure, performing the first lobotomy in the US in 1936, then spreading it across the globe.
The hyperactive McMurphy, played by Nicholson, is lobotomised in One Flew Over the Cuckoo's Nest
From the early 1940s, it began to be seen as a miracle cure here in the UK, where surgeons performed proportionately more lobotomies than even in the US.
One Flew Over The Cuckoo's Nest
Despite opposition from some doctors - especially psychoanalysts - it became a mainstream part of psychiatry with more than 1,000 operations a year in the UK at its peak. It was used to treat a range of illnesses, from schizophrenia to depression and compulsive disorders.
The reason for its popularity was simple - the alternative was worse.

"When I visited mental hospitals… you saw straitjackets, padded cells, and it was patently apparent that some of the patients were, I'm sorry to say, subjected to physical violence," recalls retired neurosurgeon Jason Brice.

Find out more

  • The Lobotomists was broadcast on Radio 4 on Monday 7 November
  • Listen again using the link below
The chance of a cure through lobotomy seemed preferable to the life sentence of incarceration in an institution.
"We hoped it would offer a way out," says Mr Brice. "We hoped it would help."
There were centres for lobotomy across the UK, in Dundee, North Wales and Bristol. But by far the most prolific lobotomist in the country, and indeed the world, was the neurosurgeon Sir Wylie McKissock, based at the Atkinson Morley hospital in Wimbledon.
"He was one of the great men of medicine of the 20th Century," says Terry Gould, who worked as McKissock's anaesthetist.
Walter Freeman and Egas MonizFreeman (left) built on Moniz's discovery
He believes his former boss performed around 3,000 lobotomies, as part of his famously speedy approach to surgery. "It was a five-minute procedure. Very quickly done," says Dr Gould.
As well as operating at Atkinson Morley, McKissock would travel across the south of England at weekends, performing extra leucotomies at smaller hospitals.
"He was quite prepared to travel down to whatever the hospital was on a Saturday morning and do three or four leucotomies and then drive away again," says Mr Brice.
He says the operation could have dramatic benefits for some patients, including one who was terrified of fire. "Funnily enough she finished up after I had done the operation very much better, but she went and bought herself a fish and chip shop with grossly hot oil in it."




































































I
The reality was very different. "She was irreversibly damaged," he said. Eileen became apathetic and listless. "I've cracked, haven't I?" as she put it. Several years later, she was told that the first operation had failed and she agreed to a second round of psychosurgery.
"I still felt that these were very eminent gentlemen and if were confident would be a success, it would be a success. They did it and it was a disaster," said Sid. Instead of curing her, she became more apathetic and had severe incontinence problems.
However, he had increasing doubts about lobotomy, especially for patients with schizophrenia.
Psychiatrist Dr John Pippard followed up several hundred of McKissock's patients. He found that around a third benefited, a third were unaffected and a third were worse off afterwards.
Although he himself had authorised lobotomies, he later turned against the practice.
"I got increasingly conservative about it because I don't think any of us were ever really happy about putting in a brain needle and stirring the works," he says. "Not a nice thought."
But from the mid-1950s, it rapidly fell out of favour, partly because of poor results and partly because of the introduction of the first wave of effective 


psychiatric drugs.



n 1949, Egas Moniz won the Nobel Prize for inventing lobotomy, and the operation
 peaked in popularity around the same time.
But from the mid-1950s, it rapidly fell out of favour, partly because of poor results and partly because of the introduction of the first wave of effective psychiatric drugs.

What's the modern equivalent?

"I'm not criticising chemotherapy because it's effective but compared to other treatments, in decades to come it will seem to be overly destructive and something that needed to be changed and will be changed.
"It's a very similar judgement, that the pluses outweigh the minuses."
Jack El-Hai, author of The 
LobomotistDecades later, when working as a psychiatric nurse in a long-stay institution, Henry Marsh used to see former lobotomy patients.
"They had been lobectimised 30-40 years ago, they were chronic schizophrenics and they were often the ones were some of the most apathetic, slow, knocked-off patients," he says.
Mr Marsh, who is now one of Britain's most eminent neurosurgeons, says the operation was simply bad science. "It reflected very bad medicine, bad science, because it was clear the patients who were subjected to this procedure were never followed up properly."
"If you saw the patient after the operation they'd seem alright, they'd walk and talk and say thank you doctor," he observes. "The fact they were totally ruined as social human beings probably didn't count."

'I wish I'd never had it'

British housewife Eileen Davie suffered depression after the birth of her second son in 1948. Conventional treatment failed to help her, so her doctor recommended a leucotomy.
Speaking in a BBC documentary in 1976, her husband Sid, who signed the consent forms, said: "I got the impression that it was no more serious than having a tooth extracted."






Start Quote"I still felt that these were very eminent gentlemen and if were confident would be a success, it would be a success. They did it and it was a disaster," said Sid. Instead of curing her, she became more apathetic and had severe incontinence problems.

Lesley Hall
These two gruesome things are lobotomy instruments”
Lesley HallWellcome Collection, London
Walter Jackson Freeman II

Walter Freeman (right) and James Wattsperforming a lobotomy.
BornNovember 14, 1895
Philadelphia, Pennsylvania, United States
DiedMay 31, 1972 (aged 76)
EducationYale University
University of Pennsylvania Medical School
Known forPopularizing the lobotomy
Invention of the "ice pick" lobotomy
ChildrenWalter Jackson Freeman III
ParentsWalter Jackson Freeman I
RelativesWilliam Williams Keen, grandfather
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