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Publication The effects of rivastigmine on neuropsychiatric symptoms in the early stages of Parkinson's disease : a systematic review(Wiley, 2023-11-17) Reilly, Siobhan; Dhaliwal, Simran; Arshad, Usman; Macerollo, Antonella; Husain, Nusrat; Da Costa, Antonio; Greater Manchester Mental Health NHS Foundation Trust; George Eliot Hospital NHS Trust, Nuneaton; Pakistan Institute of Living and Learning, Karachi, Pakistan; The University of Manchester; The Walton Centre NHS Foundation Trust, Liverpool; University of Liverpool; Mersey Care NHS Foundation Trust, Liverpool; Peninsula Health, Frankston South, Melbourne, Australia; Neurology; Medical and Dental; Dhaliwal, SimranBackground and purpose: Neuropsychiatric symptoms including depression, apathy and psychosis occur frequently in patients with Parkinson's disease. A subgroup of patients develop cognitive impairment, which may increase the risk of falls due to reduced attention. The acetylcholinesterase inhibitor rivastigmine is beneficial in Parkinson's disease dementia, but whether the use of rivastigmine is effective earlier in the disease course is unclear. The aim of this systematic review was to assess the evidence for rivastigmine in the treatment of neuropsychiatric symptoms in Parkinson's disease without dementia. Methods: Embase, Medline, PsychINFO, Cochrane CENTRAL, NGLC, National Institute for Health and Care Excellence Evidence and medRxiv.org were searched for studies with terms relating to population (Parkinson's disease) and intervention (rivastigmine). Of 1922 references identified, 358 were duplications. Following title and abstract review, 1331 articles were excluded. After full-text review, nine articles remained. Results: Outcomes were heterogenous, therefore, the results are presented in narrative form. The articles included six randomized controlled trials, two open-label trials and one case series. Outcome measures included: time to develop psychosis; frequency of rapid eye movement sleep behaviour disorder (RBD) episodes; apathy; gait variability; falls; cognitive ability; Neuropsychiatric Inventory score; and regional spontaneous brain activity. Conclusions: There is evidence that rivastigmine is beneficial for RBD and apathy in Parkinson's disease patients without dementia. There is high level evidence that rivastigmine reduces falls, which may be due to improved attention. The impact of rivastigmine on psychotic symptoms is less clear, but is supported by current theoretical models which involve acetylcholine dysfunction in the generation of visual hallucinations in Parkinson's disease. Keywords: Parkinson disease; acetylcholinesterase; hallucinations; neuropsychiatry; rivastigmine.Publication The effects of rivastigmine on neuropsychiatric symptoms in the early stages of Parkinson's disease : a systematic review(Cambridge University Press, 2023-07-07) Reilly, Siobhan; Dhaliwal, Simran; Arshad, Usman; Husain, Nusrat; Macerollo, Antonella; Da Costa, Antonio; Greater Manchester Mental Health NHS Foundation Trust; George Eliot Hospital NHS Trust, Nuneaton; Pakistan Institute of Living and Learning, Lahore, Pakistan; University of Manchester; The Walton Centre NHS Foundation Trust, Liverpool; Frankston Hospital, Melbourne, Australia; Neurology; Medical and Dental; Dhaliwal, SimranAims Neuropsychiatric symptoms including depression, apathy and psychosis are experienced by the majority of patients with Parkinson's disease. A subgroup of patients develop cognitive impairment, which may increase the risk of falls due to reduced attention. Acetylcholine deficit is thought to contribute to neuropsychiatric symptoms in Parkinson's disease. The acetylcholinesterase inhibitor rivastigmine is beneficial in Parkinson's disease dementia (PDD), but the consensus for the use of rivastigmine earlier in the disease course is unclear. This systematic review aims to assess the evidence for rivastigmine in the treatment of neuropsychiatric symptoms in Parkinson's disease without dementia. Methods EMBASE, MEDLINE, PsychINFO, Cochrane CENTRAL, NGLC, NICE Evidence and medRxiv.org were searched for studies with terms relating to Population (Parkinson's disease) and intervention (rivastigmine). 1922 references were identified, of which 358 were duplications. Inclusion criteria were: diagnosis of Parkinson's disease, rivastigmine intervention and the presence of neuropsychiatric symptoms or falls. Articles were excluded if they only related to patients with dementia. Following title and abstract review, 1331 articles were excluded. After full text review, 9 articles remained, which underwent a risk of bias analysis. Results Outcomes were heterogenous, so were not suitable for meta-analysis. Therefore, the results are presented in narrative form. The articles included 6 Randomised Controlled Trials (RCTs), 2 open-label trials and 1 case-series. Three of the studies focused on psychosis. Two of these studies indicated a benefit of rivastigmine on psychotic symptoms in Parkinson's disease. However, these studies were an open label trial and a case series, and the results were not reproduced during RCT. One RCT indicated benefit of rivastigmine in rapid eye movement behaviour disorder (RBD). One RCT showed improvements in apathy after treatment with rivastigmine. Two RCTs demonstrated a reduction in falls with rivastigmine treatment compared to placebo. One RCT showed a significant improvement on a performance-based measure of cognitive ability. One study identified brain areas that were hypoactive in hallucinating Parkinson's patients, and the reduced activity could be restored with rivastigmine. This restoration of activity was associated with improved attention compared to baseline. Conclusion There is evidence that rivastigmine is beneficial for RBD and apathy in Parkinson's disease, independently from the presence of dementia. There is high level evidence that rivastigmine reduces falls, which may be due to improved attention. The impact of rivastigmine on psychotic symptoms is less clear, but is supported by current theoretical models which involve acetylcholine dysfunction in the generation of visual hallucinations in Parkinson's disease.Publication Implementation of virtual rapid access outpatient clinics for suspected gastrointestinal malignancies during the COVID-19 pandemic: could they become the default in the future?(Termedia, 2022-03-18) Zohdy, Mohamed; Seretis, Charalampos; George Eliot Hospital NHS Trust; General Surgery; Medical and Dental; Zohdy, Mohamed; Seretis, CharalamposLetter to the Editor on Implementation of virtual rapid access outpatient clinics for suspected gastrointestinal malignancies during the COVID-19 pandemic: could they become the default in the future?Publication Infected unstable Charcot ankle neuroarthropathy, any hope before amputation? A prospective study(Springer, 2022-04-21) Galhoum, Ahmed E; Abd-Ella, Mohamed M; El Zahlawy, Hany; Tejero, Sergio; Valderrabano, Victor; Trivedi, Vineet; ElGebeily, Mohamed; George Eliot Hospital NHS Trust; Ain Shams University, Cairo, Egypt; Hospital Virgen del RocÃo, University of Seville, Seville, Spain; Swiss Ortho Center, Schmerzklinik, Basel, Switzerland; Ashford and St Peters Hospital NHS.; Trauma and Orthopaedics, George Eliot Hospital NHS Trust; Medical and Dental; Galhoum, Ahmed EBackground: Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures, and instability. In this study, we present the results of salvage procedure of the ankle Charcot neuroarthropathy using aggressive debridement and Ilizarov frame fusion with early weight bearing. Methods: Twenty-three patients with severely infected ulcerated and unstable Charcot neuroarthropathy of the ankle were treated between 2013 and 2018. The mean age was 63.5 ± 7.9 years; 16 males and seven females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, was performed followed by external fixation with an Ilizarov frame along with early weight-bearing. The primary outcome was a stable plantigrade infection-free foot and ankle that allows weight-bearing in accommodative footwear. Results: Limb salvage was achieved in 91.3% of cases at the end of a mean follow-up time of 19 months (range: 17-29). Fifteen (71.4%) solid bony unions evident clinically and radiographically were achieved, while six (28.5%) patients developed stable painless pseudarthrosis. Two patients had below-knee amputations due to uncontrolled infection. Conclusion: Aggressive debridement and arthrodesis using ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing, and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection.