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Mm Hi, everyone. I'm just testing out my camera and my microphone. I'll be back in about a minute or so. When we start, I'm just gonna wait for some people to fill in and then I'm gonna start the lecture. So just maybe cycle through the recording for people who are watching later just to a minute or two into the video. OK. So I'll be back in a second. I'm just checking the microphone. OK? Could someone just say in the chats, can you tell me? Can you hear me? OK. All right. Thank. Thank you, Aaron. I'm just trying to fight the controls to give you a smiley face to say thank thank you. Thank you. OK. I'll give it another minute or two before I start and I'll just do a quick intro. I'll explain what brain book is and I'll go through the webinar slash lecture slash course slash talk on a video camp. I'll turn the camera off because frankly, it's making me a little self conscious. I'll be, I'll be back in one minute. OK? All right. So I'm gonna start with some introductions just while people phone. So my name's Doctor William Murphy Baoris. I'm an F one doctor. I'm working at the Roto University Hospital. I'm also executive co-lead of a charity called Brain Book, which primarily focuses on demystifying neurosurgery. It started off as a youtube channel and grew into something more. We're focusing on some patient panels which we'll hopefully be seeing in the next year or so. We also work primarily on religion material. So if you look at us on Instagram, you'll find there's a lot of useful quizzes. There's an advent calendar at the moment, which is basically a useful resource resource to use social media as a way of revising for exams as it regards to things neurosurgery. The aim of the charity is to quote unquote demystify neurosurgery, which works in some ways, in some ways it's good for patients because it helps explain what's neurosurgery is to lay people, but also to medical students and providing resources. We also do talks like these and chats sometimes by different people and doing with 6 p.m. series as a way of reaching out and basically, hopefully getting more people involved. If you follow us on Instagram, you'll see we often promote to get ambassadors, get people on the teams, which is very good for your CV. And I put the links to the website and the Instagram there. So what I'm gonna do is I'm going to share now I got a powerpoint up. So let's get this start, share entire screen. There we go OK, hopefully you should be able to see me. So I'm going to switch over to the slide now, so I won't be able to see the chat. OK. Here we go. So I'm gonna put it on presenter mode. The reason for that is because it has some notes and there's gonna be a recording later. And in all honesty, I think the notes in the notes section are useful to me, but they'll also be useful to you if you want extra information. So I've edited this powerpoint. It's of course something that's come from brain book as an educational resource. There are certain parts of this lecture slash webinar which will be very useful for exams. And I think primarily this is targeted towards people in medical school. It will be useful to junior doctors, but I'd argue less. So the core of it is gonna be useful for passing exams. I will say in some cases, it goes beyond that and I will emphasize the points particularly tables which I think will be very useful to try and learn some parts for your exams to be uh sh should we say targeting the high yield stuff? OK. So let's begin. So the objectives we want to understand a bit more about movement disorders, learn about categorizing them. An instance of this would be looking at gait and walk quite interestingly. Increasingly you can use technology like keyboards to look at the way people type and see how that changes. And when people start having onset of Parkinson's, you find that maybe one side of the keyboard is getting slow and you can use that. It's believed to develop technology which might be able to use informatic technology in order to diagnose people. And of course, gate can be used to identify people with cameras in totalitarian states. But there's also a question of, could you say put a camera in a GP clinic and see people walking differently and you might be able to see certain signs of symptoms to get early medication. Of course, there's a whole ethical debate there of what is and isn't allowed and what is good, what is bad and how you give people the autonomy to make decisions for themselves with that data, which is a different discussion. But the point is gait is important and it's also very medically relevant. We're going to discuss very generally not overly specifically the areas of the brain that are affected. I did biomedical science, I can tell you that a lot of the in detailed circuitry you learn, you're actually told in the lectures and biomed that this isn't actually how it really works. But you've got to learn the old model of how it was believed to work for decades because frankly, it's just a point of reference. It's a bit like the Krebs cycle. It's very long, it's very complicated and frankly admitted to be wrong. But you need to know details in medicine. It's far more about knowing the general picture to understand how it generally interacts with the medicine. And of course, we'll look at some treatments. OK. So, functional neurosurgery, which we're talking about things like deep brain stimulation is one of the more complex areas of a very complex specialty. Already, it requires a lot of knowledge of areas of the brain and where to put the electrodes. So in instance, this would be the subthalamic nucleus, the basal ganglia. But it's also important to remember that when it comes to pathology, you're talking about the weakest link in a chain. So if you stimulate an area that is weaker, it may help it in some ways to put it very crudely. It's about jump starting a car in some ways that that's a gross growth simplification. But basically, if you're thinking about a whole range of places in the brain where things have to go, well, if there's one place where it's not going well, doesn't say it's the most important place, but it is the most fragile place where something can go wrong. OK. So a bit of context, of course, different types of gait. 10% of people in their sixties have a problem with their gait and about 60% of people over 80 have problems with their gait. I think it's actually suspected that Vladimir Putin is currently having a problem with tremor, which isn't quite the same, but shows that everyone, no matter how powerful can have problems with their neurocircuitry. So it is quite uh humanizing and it's, our health is a great leveler mo most often it's a neurological cause. So it can be due to things, for instance, like someone being drunk or someone having low glucose. But generally speaking, a big, big part of that is neurology. So some examples would be sensory ataxia. So generally speaking, it's very hard to coordinate when you have the sensory input to make data about where you are physically in the world. It can be to do with Parkinson's which you're gonna touch on very heavily. It can be frontal brain problems moving on to here. Now, this is a big table. If you're a medical student, you do not need to worry about this. This is only to make you appreciate all the different ways that you get can be affected. So you probably recognize a taxic. So there's a lack of coordination. You probably recognize antalgic, which is something where you see someone leaning on one side because they're trying to avoid pain quite often in osteoarthritis of the hip. The main point here is just to show just what a great amount of types of gait there are. So an instance would be frontal gait disorders. In this case, it can often be cautious, anxious, slight bizarre, and you can find that it's severely depressed. Now, originally, the hope was that I could show you some videos of these. So instead, what I've done is I found some videos on youtube with QR Codes. So later or now or in your own time, you can basically scan these codes and look at the videos and I'd say a good 10 seconds will make it a lot easier to understand what I'm about to read out. Cos a lot of this is going to seem very hard to visualize. So I'll put the QR codes as a backup. So when we're talking about a tactic, this is more cebe more about coordination. You've got broad width, about 12 inches though. Frankly, I don't know how I know if anyone's supposed to measure that just by looking at someone in an ay, it can be a bit more lurching, difficult to turn. It's hard to walk straight because of lack of coordination, more broad based. And if you've got problems with raised intracranial pressure, you can find it varies throughout the day or diurnal variation as we like to say, to sound clever. OK, heroic. Now, this can have a lot of causes and I have shamelessly copied and pasted from a website because the main point is to show you that there is a great many causes and you generally speaking, treat it by trying to treat the cause. Of course, a stroke. It's all about is there salvage all areas of the brain if it's an aneurysm, similar story to stroke, it's all about the brain getting the oxygen needs and it's not always treatable. So you can see how the brain can have a great many ways of having problems and tailoring the treatment for each is going to vary. So it's not just one medication you give someone when they have a hemi paretic gait. So to just describe it very generally, you've got extension and internal rotation of legs and circumduction of the lower limbs are affected, abduction of the shoulders, affection of the elbow and pronation of the wrist. I'm going to be honest with you at this stage of my career, if someone showed me that I wouldn't be able to know that off the top of my head. And I think it's incredibly unlikely to come up in your osk, but it's good to have a general idea of some of the phrases and terminology. Parkinsonian gait. This is something you could imagine coming up in an osk because it is one of the staples of neurology. We'll cover the main trials in about 10 minutes or so. So you can see how people often stoop forwards, they lean forwards, there's difficulty initiating movements, there's small shuffling gait and when they turn around, they don't pivot on the spot, they sort of turn around as if there are a car going round a racecourse very slowly. It's hard to walk. I think the technical term is turning unblock. So they sort of move like a statue. A bit more detail. So the mean onset is around 65. It's a clinical diagnosis though, you can also find that there are tout tangles and amyloid plaques. You find a lot of neurological degenerative conditions overlap. So, Parkinsonism and dementia also overlap and both these have about 40 different subtypes which you won't need to know. And probably most registrars would probably struggle to name most of them. So it's an area that becomes very expansive. It's, it, it's a great area of impact. Primarily for an Os. There's a tribe which you're going to have to know, but it's also worth appreciating that there are other symptoms as well. The main thing to be aware of in Parkinson isn't most of the time except in some Parkinson plus some, uh syndromes where it's a bit different is it's unilateral. It's a one sided problem. Generally speaking, for most of the tremor, the resting tremor, but you can have other things such as stress making it worse. It can be harder to sleep. You can have rigidity, you can have a pardon me, aesthesia, postural instability. And I believe the medications can also cause that. So the sense you stand up and then you fall down and of course, it's not directly tied to neurology, but just as a side note, important for osk questions, systolic drop by 20 diastolic stop by 10. That's basically postural hypotension. So it's important to measure that stand people up at one minute and also take it three minutes later. So that's important for the examination in our skin. That's quite important to remember. Quite simple. But you will be penalized if you don't remember that. And you can see how it affects other things such as autonomic dysfunction. So I'm just gonna remove the microwave cos I think I can hear a bit of my breathing coming onto the mic. So it can affect things leading to constipation, urinary problems, erectile problems, it can cause problems with sleep insomnia. It can make people feel restless, violent and it can also be linked to psychosis and depression. If you asked me an in detailed description of any of these, I would frankly struggle. There is a bit of a general theory I've heard for psychosis, which I'll go into in a second. But it is more of a theory and it's not one that I think I could explain to you with any great certainty. So it is an interesting thing to talk about. Ok. So Career Gate, sorry, Career Form Gate. This is more to do with Huntington's. This is where the movement is much more extreme. It's often described as dance. Like if you have an osk station where someone says, people say my grandfather's, he, he's sort of jerking about randomly like he's doing some sort of dance. I think at Huntington's, there's writhing dance like movement random or limbs, they don't feel comfortable. It's not about balance, but the muscle movement isn't something they control. So that creates a great problem in terms of maintaining themselves. And it's of course, very upsetting because there's a sense of loss of personal autonomy physically. There's also ostracism because you can imagine someone getting in a bus, not being able to drive a car being made fun of and, and it is very stressful and upsetting. I once had a lecturer who well used to do a demonstration of it and they ended up getting in trouble because it was seen as offensive for doing the demonstration because it's one of those things that it's very distressing, very upsetting for people. And well, II don't think any more needs to be said though. OK. So this is one of the tables, most of what I've said to you so far is useful, but I think I'd try and learn some of the main points on this table. So Parkinsonism, which isn't quite the same as Parkinson's disease because you may not have all three of the triad. Generally speaking, it's things affecting the basal ganglia which to put it very, very crudely is basically the decision making circuit of the brain. That's a very simplistic way of putting it. But it's basically like you have an impulse to want to uh let's say, smoke, nicotine or go for a drink or go for a run. That is a big part of your habit center if you like. And of course, the gate here is the shuffling for co problems. It's more scissor walking. So we've talked about that. We've got compression trauma, Syrinx. Am I mispronouncing that? That's basically a rare situation where you get a rare fluid filled neuroglial cavity. I just think of that as like a fluid cyst in the spinal cord, but it's not as common. I've never seen that come from pass me, but I found it to be a useful piece of information to have just as a bit of pub knowledge because medics like to test each other. There's of course, poly neuropathy. So this can be linked to quarter equina and GBS, GBS. So this can be something where you get an infection. For another reason, I think some people possibly it could be linked to vaccines leading to an immune reaction which can cause that they're not the vaccine in and of itself. It could be someone gets a tummy bug and that causes an immune reaction. And it basically causes problems with circumduction and spastic gait. And what we can see here is that generally speaking, for polyneuropathy, you find that it can be bilateral foot drop for anterior horn problems, which can be linked to polio. It can be high stepping gate problems. So you can see there's a diversity of problems here. So these are more motor based. We're gonna move on to century now. OK. So Meniere's viral r uh pardon me? Meniere's viral R it's a stress labyrinthitis and brainstem lesions. You can see in the gates, you can see a Romberg sign, you can see there's ataxia, there's a dependence on vision. So it makes it hard to coordinate when you close someone's eyes. And this is of course linked to the vestibular system because of course, as well as been linked to the eighth cranial nerve, as well as been important for hearing, it's also important for a sense of balance. And of course, if you affect this area with infection, it's more likely to lead to a loss of balance. You can also get a lot of coordination with strokes, but also no surprise there, alcohol which affects the cerebellum, as we said, coordination. And of course, there is also the problems with coordination with things like B12 and alcohol and these can go on to affect the dorsal column and that is a big one to remember. Ok. So Parkinson's, if I had to say what is the most important slide, but probably one that you guys probably know quite a lot about already, it would probably be this one. So the main three are you have a tremor, it's worse at rest. It's generally speaking unilateral. There are some situations with Parkinson plus syndromes, which is basically a fancy way of saying more complicated Parkinson's with extra bells and whistles that you don't need to necessarily know in any great detail as a medical student. But it might be useful to know you can get pill rolling where it looks like the hands shaking, it looks like they're rolling a pill between the hand you can get cog wheel rigidity. This is hypertonic. So the muscles are over contract and it makes it look like a lead pipe when you try and move it up. And it's also very hard to move cos it feels like it's moving, it twitches a bit like a wheel of a ship which sort of moves in creeks as if it's moving at certain angles not fluidly. And of course, bradykinesia. So this is linked to the motion. So the shuffling slowly and micrographia. So this is where someone might start writing, their handwriting will be nice and big. And then as they progress it go, it gets smaller and smaller and smaller and smaller and smaller. This might be something that could come up as a useful trick in an ACY, it might be something one of the simulator patients might know how to do though. It might be a bit of a reach as well. And the main thing to be aware of here, which we've touched on is gait. Cos you'll see reduced arm swing, you'll see there's freezing and you'll see, of course, there's difficulty moving around, there's no pivoting on the spot. It's much more slow and of course, there's difficulty initiating movement. So coming on to causes some of these, there is a logic behind them for these particular ones. I think that's just a case of learning it. Unfortunately, this is one which I found very useful. I found this has come up, at least in a lot of past medicine questions and it's one that often comes up, it's a genetic cause I believe it's build up of copper and it basically leads to a situation where you get Parkinson like symptoms because of damage in the brain. It's not something with a particular rationale. You just think you're getting metal somewhere that where they shouldn't be, it causes damage to the brain which causes Parkinson's disease. Now, what we'll see here in terms of drugs that can cause Parkinsonism is antipsychotics and Parkinson's medications do the opposite to each other. So when someone's psychotic, you give them antipsychotics, which are basically anti dopamine. And the problem in Parkinson's is you don't have enough dopamine because effectively some neurons in the substantia Niagra have died, which are dopaminergic. So you basically give people dopamine to fix the fact that they don't have enough dopamine. But when people are psychotic, you take away dopamine because they arguably have too much bit of a simplification. But it makes sense that if you try and fix one and someone's predisposed to the other, you could end up putting the see saw all the way the other way. And metoclopramide is a similar situation as antipsychotics, I believe that's a dopaminergic antagonist. So you can see how that causes the seesaw to bounce in such a way where people are predisposed can end up with parkinsonism symptoms, manifesting. And that's probably the most important thing to remember. And of course, there is a bit here about having a infarcts. If you have a stroke to that area of the brain, it's not going to work. So it's a similar situation and it could lead to those areas. Those dopaminergic neurons dying because all vessels including nerves do actually need a blood supply and oxygen. Ok. So treatment, this is quite extensive. Generally speaking, levodopa is the first option. You want a medication that can go into the blood. And unlike most medications get past the blood brain barrier, it's kind of like a wall with a lot of cracks in it and it sort of sleeps, uh slips past, it has to be quite small in order to be able to do this, that's your first choice. But as you take medications over time, they start working as well and it means you have to try others. So another one is dopamine agonist. So I think an example would be bromocriptine. The problem with dopamine agonists is they can cause problems. So if we're talking about that CSA of dopamine, when people have more dopamine, when the basal ganglia circuit is working, more people can be to put it very crudely more impulsive. There are examples of people taking dopamine agonists and becoming more prone to gamble, more prone to shopping, more prone to being more impulsive and that's not always a bad thing, but it is a huge disruption which can affect people's personality and sometimes it can lead to a situation where people maybe do things that they may end up regretting. And that can be a big problem because things like gambling addiction, they can really ruin lives and having Parkinson's can in and of itself make it quite difficult for people to look after themselves. Heaven forbid there's a pensioner out there who doesn't have enough money and needs to work and they're finding it hard to hold down a job with their symptoms and then they have a habit of dealing with stress by going out and gambling. So it, there are many, many ways in which it can make life very, very difficult for people. So the thing to be aware of you have to change the medication and of course you need to make sure. And this is a big thing for the oy. You need to make sure that you state that they need to have the medications at the same time every day. Hello? Ok. Sorry about that. The microphone decided to go off. So I just had to plug it in so I had enough charge. Maybe my set isn't doing as well as I thought it was. Ok. So I'm gonna go back to the presentation. Ok. Ok. So on treatments, presentation, apologies for that. Ok. All right. So in a bit, we're going to cover the surgical side of it. So that can be things like DBS, which is quite interesting though. It does have its limitations and it is very much the end of the line. And of course, there is research into basically immunotherapies, gene therapies. Those go well beyond my understanding and frankly, well beyond what they dare test you in the exams because frankly that could change, it could become something that we use, but it's too expensive to be used in the UK. It's the type of thing where most likely for Parkinson's, we're probably looking at a situation where we get better at early detection and better management. But a cure is still a very long way off, albeit a very noble goal to have. Sorry, II, I'm just going to be a bit paranoid. I'm just gonna double check that I do, in fact, find myself recording properly because I'm just paranoid. I'm gonna end up talking to myself. Ok. Check out, ok. Not to apologies about that. Ok. So the thing to be aware of is about getting a bounce, neuroleptic malignant syndrome. This is basically something where you don't get the bounce of dopamine, right? And this can lead to high fever, it can lead to irregular pulse, it can basically lead to an accelerated heartbeat. It can lead to problems with increased refractory and autonomic dysfunction as well as altering mental state. This is very bad and it can be fatal. Generally speaking, this is something that is an emergency and this is one of the reasons why you need to make sure you take it at the same time. My understanding is that it's one of the reasons why in the osk, you have to make sure the patient has it the exact same day. It's rare, it's unlikely to happen. It's one of those things, if you give it to 10,000 people incorrectly, someone's going to be affected by that. That's of course, because a lot of the chemicals that work in one way work secondarily in other ways. So very rarely do drugs actually do only one thing they'll have side effects and some people will be more sensitive than others. I do have these here for those who want more detail. I'm aware that we are on the clock. Ok. So some side effects of L dopa. So we've talked about bromocriptine, dopamine aga having side effects. But here are some of the side effects of levodopa. So dyskinesia motor fluctuations, psychosis, I'll cover that in a second as to what the hypothesis is for that it can cause problems with drop in BP. So, parkinsonism can cause problems with postural instability, but so can the medications, it can cause dry mouth, it can cause insomnia, nausea and vomiting. But then again, all medications can cause that and it can cause excessive daytime sleepiness. So the thing about psychosis is the theory I heard postulated when I was in biomed was that basically, if you think of the basal ganglia as the impulse, the sort of fixation with things, it makes it so people want to do things and that could be smoking cigarettes, it could be doing drugs, it could be doing shopping, it could just be saying something that perhaps they shouldn't say. And the thing to be aware of is that quite often we all have frauds and we can become, we, we can ruminate on thoughts, we can become obsessed with. It, makes them more salient, it makes them more central. And the idea is people can have thoughts that may seem ridiculous to someone of what we may call sane mind. And in a situation where they have the wrong amount of dopamine it can make it. So they basically end up fixating on that thought and not getting rid of it. And it becomes more real than the rest of the world. That is how it was hypothesized and explained to me. But generally speaking, if I put it in a safer way that it is more likely to cover all bases, essentially, if you're throwing dopamine around the brain, which is already probably traumatized by things in one's childhood, it's gonna be multifactorial. It's essentially the straw that breaks the camel's back effectively. Ok. So these are some things about the other parts of Parkinson's and the other forms a lot of the time we call them Parkinson plus syndromes. So generally speaking, if you're finding that it's bilateral, generally speaking, as far as you're concerned, it's not Parkinsonism because it being unilateral is a big thing about it being Parkinson's. But in reality, if you're a registrar, of course, it's gonna be a bit more complicated and there are all sorts of weird and wonderful iterations. So you can have a regular resting tremor, reduced response to levodopa people who are resistant to medication. There is always exceptions. You find that dementia and Parkinson's overlap. So Lewy body dementia, the big thing here to think about, it overlaps with Parkinson's and it causes v visual hallucinations or delusions and the thing to be aware of that, that is the big thing. If you see someone with dementia and that they have visual delusions, think your body, that's, that's the big thing. If there's one thing you take away from the slide take that way. And of course, you can get versions which advance more aggressively or less aggressively. And because Parkinsonism or Parkinson's disease is effectively chronic and it's progressive and there is no cure. It's important that for this chronic situation, this chronic condition, you have input from the multidisciplinary team. So I'm talking about physios because anything to do with muscles, I guarantee you getting them to do specialized exercises can make things better. It is important to talk to occupational therapy. It's important to talk to the nurses because they can give you a full picture of what actually caring for the patient is like. And generally speaking, all these things come together working as a doctor. The one thing that I've noticed above us from moving from a student to a doctor is just how integral the other teams are, how they have a very different point of view to you and how you absolutely need that to be able to treat the quote unquote whole patient. So that it, it really has taken home that it's very much a team in a way that you just can't appreciate until you're actually in a situation of actively depending on people. So that's the number one thing. So if you're in an ay and you want to score extra points, you won't pass based on this alone, but you will get extra brownie points for saying MDT because you need those extra peoples response. OK? This kinesia. Now this bottom part isn't as important. What we're gonna focus on is up here. Generally speaking, the difference between benign essential tremor and Parkinsonism is this, generally speaking, is one sided. It's a resting tremor that is one sided and that's the way you differentiate. Whereas benign essential tremor can be two sides. So you find that it's absent at rest for benign essential tremor, not the case of Parkinson. So, bilateral and worse absence at rest, worse at rest on one sided. And you actually find that this one, it's two arms and the frequency is generally speaking, twice as much as here. So that's how I try and remember it's those three points and it's important for differentiating these. There's other reasons people can have a tremor. So thyrotoxicosis, that's a big one. So you need to make sure you do a screen, you need to look at the thyroid function. TSH, you need to make sure you look at the glucose because that is a big one because it prob it might not be that there's a good chance if they're coming to you that their glucose is fine. But if you miss glucose, then you could be in big trouble because someone who's hyperglycemic who's shaking, that's a terrible, terrible thing to miss and you can't afford to. So don't ever forget glucose even though it's very unlikely. That's, that's the big one to make sure you don't forget. Ok. So Myoclonus. So several causes here, you can have my client epilepsies. You can have neurodegenerative diseases like CJD, I'm gonna try and pronounce it. So Reels Jakob's disease and of course, it can be metabolic. So this can be to do with the liver where you get asteris, where you get flapping hands, which is part of the ABDO examination. And this can be more rhythmic. Essentially, this is just basically sudden, involuntary jerks. OK? In Korea. So we mentioned earlier that this is basically, we have seen random dance like movements, the person isn't in control, they still have a sense of appropriate exception where their arms are, but it's incredibly hard to maintain coordination because they have all these extra movements which they can't account for and they seem to happen randomly. Of course, it's very mentally distressing. And of course, for many of these conditions, an extra thing to be aware of for your osk is think about the whole picture in terms of someone's mental health. You might want to ask them how they feel in terms of the mental health, how they're coping because there's a good chance that part of the management will have something to do with referring them for mental health support if they should want it. Ok. So to cover it in a bit more detail, it can be part of infection, it can be linked to Wilson's and of course, it can be linked to levodopa and it can get particularly complicated where the treatment for parkinsonism may also be causing problems in another condition. So that is not something that will come up in any of your osk, but it's important to be aware that the treatment for one can cause problems in another. OK. So I'm gonna very briefly touch on anticipation. This won't be a no question, but it is something that might potentially come up in exam though less likely. So you have cag repeats and of course, if your parents have them, you find over generations they can increase in number in chromosomes and the more of them you have the greater the risk you are of getting Hansen's disease. So it's auto autosomal dominance and increase the risk of this happening. And of course, there's a whole ethical debate of, should people be screened? Should someone screen their child when the child doesn't have the right to decide? And they've got that hang over them for the rest of their lives. I believe most of the time when people are given the choice to screen their child, they don't because what can they do with that situation except be tortured by it. That's another one of those questions of how technology is moving forwards and how quite often we can do things with technology with big data where there isn't necessarily a way back. And that's one of those situations where you have to realize the answer as a doctor is to empower the person who has the authority to make the decision and you have to make sure that personal decisions don't come into it. Which of course I understand is very difficult and is always a challenge but quite important. Ok, Todd syndromes. So this is about the bounce of dopamine again. So you've probably seen the film where someone has problems where they needed to be given some antipsychotics, but they don't get the amount of dopamine bounced correctly and leads to, to put very crudely and overload. And you get a situation where they're getting twitches where they're getting twisting of the neck or they can get a situation where their eyes are rolling up into the head. That's what you call ocular crisis. And it's basically where you have too much chronic dopamine. So an example would be not getting the bounce right between these. There's always ac contradiction. There's always someone who a situation if you stop the dopamine too quickly. So if you give the acnes too abruptly, too quickly, you can have a situation where someone comes down from having a dopamine or someone's giving it too quickly. So it's about rate of giving and a rate of change as well as the objective amount of people are given. But effectively, it can lead to situations like dystonia, dyskinesia, Akathisia where a sense that people have a great sense of restlessness and how you treat this has a lot to do with medications that treat the actual symptoms. So for Akathisia, where people feel a sense of restlessness a bit like anxiety, you want to treat that with beta blockers. For dyskinesia, you want to treat that with tetraen no tetrabenazine. So the situation of taking each symptom and treating it one by one and being aware that there's a balance between giving too much dopamine and giving too little and making sure there is a good change that isn't too abrupt one way or the other. Ok. So as we come towards a bit more towards the final act, we're going to talk about deep brain stimulation. So what you can see here is as surgeries go, you can imagine that while it goes quite deep into the brain, the actual incision into the skin into the skull isn't actually that extensive. That's something to be aware of. And you can see how it's not just in the brain, it comes down, down the neck and to around the collar bone. So in some ways, it's in a similar situation as positioned to a pacemaker though, not at the exact same place. Of course, it's stimulating the sub formal you can. OK. So here are the pros as operations. It's far less likely to cause infection though. We should be aware that all operations have a risk of infection. And it's basically compared to other operations, it's not to say it has a low risk of infection. Generally. It's always based on what you're comparing to. And it should never be your first choice. You should never want to give someone an operation when there's a medication that could help. And there's always a situation if you could give DBS and medications. But there are downsides. For instance, it doesn't last forever. I remember being on my elective and been told by one of the radiographers, radiologists, sorry, basically told me within five years, 25% of people who have had DBS are back to square one and they've had absolutely no benefit to it. It does not cure Parkinson's, it makes it more manageable and it's something where you can basically change it, change the stimulation rate and frequency. So it becomes better for that patient. And there's basically technology where you can put trackers on people's arms and legs to see how people's tremors vary throughout the day. And you can relate that to the frequency. And you can use that as a way of tailoring it to the individual cos each person is different. Each person's brain that you effectively stabbed a metal rod through is going to respond differently. It's one of the procedures that can be done under general anesthetic or local. A benefit of local is they can still be awake. Generally, memory isn't in a particular part of the brain, it's spread all over the place. It's part of the 1000 brains hypothesis that says that you have lots of little ideas. What an idea is that sort of come together in a sort of democracy that form your concept of what say Darth Vader looks like or what Vladimir Putin looks like. All these different iterations enable you to sort of think. Oh yes, I recognize this as that. So if you destroy one of them, you've still got 10,900 more of those ideas left in your brain. That's generally speaking, why memory isn't generally affected too much in the long term by this operation dot It should be said that someone can have a situation where an electrode is going through their brain and all of a sudden they start speaking funny because most of the ideas we have about the brain compared to its functioning are quite simplistic. We don't have an understanding of the brain the way we do say a car, we didn't build it the same way. And so we have to be very careful about what we do. We have simplistic ideas of what the brain does and to make the matters worse, each individual has lived a different life. Brains are plastic. They have grown throughout their life very differently. So that's why it's useful for it to be local as opposed to general. Cos frankly, there is always gonna be a risk with brain surgery. So you give it at a situation where it's becoming refractory. I remember 10 years ago, which kind of scares me a bit when I was on my work experience. And I think the waiting time for DBS was something like six months nowadays, I think it's around 18 months because it's so expensive and because it doesn't change the course of disease, I think, believe it or not less people are doing it in the UK than they were before. And of course, there's all sorts of stuff like budget constraints. And of course, once you've got electrode in your brain, there's other things there such as it becoming problematic of it. Getting a bit better, then getting worse. There's need to talk to neuropsychology because I said these things are all interconnected Parkinson's can affect people's mental health as well as the fact that they know what the prognosis is in the long term, which can be very upsetting. Obviously. So a reason someone may not go with medication or may well, may not go with the same way. I said the dopamine potentially can make people latch onto ideas. There's a belief that it can make nightmares more vivid and make it more a torture. And if someone's got a background of, let's say, serving in a war zone where they're susceptible to recurrent flashing images or how, well it, it, it can compound with someone's past history which can make it far worse for some people. Meaning medicine isn't a viable route. Ok. So we have three multiple choice questions here. So what we have, we have Parkinson plus occurs in association with all except one of the following. What I'll do is I'll give you roughly 30 seconds to answer. So one of these is the odd one out and we'll cover it in a second. OK. All right. So let's move on to the answer. So it's epilepsies. And one of the reasons for this is that Alzheimer's and frontotemporal dementia are, of course, dementias which are tied to Parkinson's progressive supranuclear palsy is a Parkinson plus. So it, it, it is in essence, one of them epilepsies is the odd one out. OK. So, question two, you have a 55 year old gentleman. He's come to neuro, he has a resting tremor and abnormal gait. It's characterized, characterized by short shuffling steps. What feature would suggest a diagnosis of Parkinson's disease rather than Parkinsonism of another cause? So, it's about differentiating Parkinson's disease from Parkinsonism. Ok. Ok. So, asymmetrical tremor, that's the main one to be aware of that. It has to be asymmetrical, not bilateral. It's supposed to be one sided. And of course, to remember that it is a resting tremor that you find when someone is sitting at rest, when you're talking to them, you'll find that it is going away without them necessarily having to do anything. One thing you can ask people to do to differentiate between resting or not is you can ask people to pour one glass of water into another glass and you'll find that when they put intention behind it that will change the tremor. And of course, if it's benign, essential tremor, then of course, it will get worse because then you have intention and of course, it's bilateral. If you ask them to switch arms. Ok. So onto the final question. So in terms of extrarenal facts, these can be seen with which of the following. So this is true or false for each of the following. So there's in a sense, five mini questions here. So I'll give you a full minute for this one and to give a little hint we're talking about side effects of medications, causing problems with movements. This is tied to Parkinson's and getting the bounce right for the medication. So that's my sort of hint view. Ok. All right. So what we see here is that it's all about whether or not they're affecting the dopamine. It's about that bouncing seesaw. We talked about, about whether or not it's affecting the dopamine that you're gonna get side effects if you're bouncing the dopamine. So, metoclopramide is of course a dopamine antagonist and of course Parkinson's, you don't have enough dopamine. And of course, if you have less, that's going to worsen the problems. They may also have noticed me being silly that I should have gotten rid of this here. So I might have accidentally given you all the point there. Ok. All right. Thank you everyone for listening. So this is me starting giving lectures. I'm sure I've got a long ways to go. I'm sure there's a lot I can learn. Thank you for staying with me to the end. Anyone watching the recording after the fact. Thank you very much. If you could fill out the form, you'll get a certificate and I'll read through all the feedback. I'll take it on board and I'll try and further improve my teaching ability. I wish you all the best with your exams and your finals and I'd recommend past medicine as a resource. Ok. All right. Fantastic. Thank you for your time. Ok. Fantastic. Ok. So Paul Goodlatte, that's a good question. As a junior doctor. I can't tell you the exact procedure. I can tell you whenever there's a problem I have. It's always senior review. Generally speaking, the people who are allowed to bend the rules or get people back on the track from when there's been deviation from the rules. It's always a senior. If it, there's a risk of it becoming something very bad, it'd be either a registrar or a consultant because generally speaking, most likely it wouldn't be too bad. But it's one of the situations where there's a risk that something could happen. That is bad. Ok. Thank you so much guys. It's been intimidating but also a privilege to well teach you all and I hope you will have the best experience with your exams. And I hope you all go on to have a fun time in F one. Ok? So I'm going to end the live stream now. I wish you all the best. We're going to have some more teaching sessions. I'm gonna progressively try and refine my craft as I go on. So I'll read through the feedback. You guys give me. Thank you very much. I'm gonna stop sharing now. OK. So I'll just hang up. Thank you. And I'll.