Graduating medical students often identify the neurologic examination (NE) as one of the clinical skills with which they are least comfortable. We hypothesized that this is because they are unsure ...about which elements of the NE are important, and conducted a study 1) to identify whether neurologists agree about the essential elements of the NE and 2) to determine whether the views of medical students about what is essential differ from those of neurologists.
Using a Delphi process, we asked McGill University neurologists which elements of the NE they would perform at least 80% of the time in a common clinical scenario. We confirmed the results in a sample of Canadian neurologists, and then compared the results of the McGill neurologists to a sample of graduating McGill University medical students.
The neurologists surveyed rated 22 items of the NE as essential, and there was a high degree of consensus about which items were essential. Medical student ratings of the importance of NE items were largely similar to those of the neurologists, although there were some noteworthy discrepancies.
The anxiety felt by medical students regarding the neurologic examination (NE) seems unlikely to be solely due to uncertainty about which elements of the NE are important. Expert consensus about the essential elements of the NE and awareness of areas where neurologist and student views differ should be used to guide teaching of the NE.
Background
Polyneuropathy, a common complication of diabetes mellitus, causes pain and sensory and motor deficits in the limbs, and is also an important independent predictor of foot ulceration. ...Inhibiting the metabolism of glucose by the polyol pathway using aldose reductase inhibitors is a potential mechanism to slow or reverse the neuropathy's progression.
Objectives
To assess the effects of aldose reductase inhibitors on the progression of symptoms, signs or functional disability in diabetic polyneuropathy.
Search methods
We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to May 2007), EMBASE (from January 1980 to May 2007) and LILACS (from 1982 to May 2007). We reviewed bibliographies of randomized trials identified, and contacted authors and experts in the field.
Selection criteria
We included randomized controlled trials comparing an aldose reductase inhibitor with control, and lasting at least six months.
The primary outcome measure was change in neurological function, measured in various ways, including strength testing, sensory examination, and composite scores of neurological examination. Secondary outcome measures were nerve conduction studies, neuropathic symptoms, quality of life, occurrence of foot ulcers and adverse effects.
Data collection and analysis
Trials included in the review were selected and assessed independently by at least two of us. Methodological criteria and study results were recorded on data extraction forms.
Main results
Thirty‐two randomized controlled trials meeting the inclusion criteria were identified. Many had significant methodological flaws. Change in neurological function, our primary outcome measure, was assessed in 29 trials, but sufficient data for meta‐analysis were only available in 13 studies, involving 879 treated participants and 909 controls. There was no overall significant difference between the treated and control groups (SMD ‐0.25, 95% CI ‐0.56 to 0.05), although one subgroup analysis (four trials using tolrestat) favored treatment. A benefit for neuropathic symptoms was suggested by a group of trials using a dichotomized endpoint (improvement or not), but this was contradicted by another group of trials which measured symptoms on a continuous scale. There was no overall benefit on nerve conduction parameters (27 studies) or foot ulceration (one study). Quality of life was not assessed in any of the studies. While most adverse events were infrequent and minor, three compounds had dose limiting adverse events that lead to their withdrawal from human use: severe hypersensitivity reactions with sorbinil, elevation of creatinine with zenarestat, and alteration of liver function with tolrestat.
Authors' conclusions
We found no statistically significant difference between aldose reductase inhibitors and placebo in the treatment of diabetic polyneuropathy. Any future clinical trials of aldose reductase inhibitors should be restricted to compounds proven to have substantial biological or preclinical advantages over previously tested agents.
Background:
Immunoglobulin supplies are limited; their access for patients diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) may have been difficult during the COVID-19 ...pandemic.
Methods:
A retrospective cross-sectional study was conducted with CIDP patients (n=16, 68.8% female, mean age 60.4±11.3) recruited from three Montreal tertiary care institutions. Inclusion criteria were patients over 18 years old who were receiving immunoglobulin treatment as of March 1st, 2020. Patients were asked to complete a questionnaire inquiring about changes in their immunoglobulin treatment during the pandemic and about their quality of life. Their charts were reviewed by an independent investigator. We used weighted chi-squared statistical tests and Cramer’s V correlation ratios to measure associations with treatment change.
Results:
Eighteen months after the pandemic started, 50% of patients were receiving the same treatment, 25% were receiving immunoglobulin treatment at a different frequency, 6.3% were receiving a different dose, 12.5% were receiving a different dose and frequency, and 6.3% were receiving a different treatment. Reasons associated with treatment change were worsening of neurological condition (18.8%; Cramer’s V=0.480; p-value=0.055), improvement of neurological condition (25%; Cramer’s V=0.577; p-value=0.021) and reduced availability of treatment (6.3%; Cramer’s V=0.258; p-value=0.302). There were no significant correlations between lower quality of life (p-value=0.323) or lower Rasch-built Overall Disability Scale score (p-value=0.574) and treatment change.
Conclusion:
Difficulty accessing immunoglobulin treatment was infrequent and not significantly associated with treatment change for CIDP patients during the COVID-19 pandemic. A larger multicentre study across multiple sites might identify other treatment access problems resulting from the pandemic.
Background
: Multiple sclerosis (MS) has a profound impact on patients’ health-related quality of life (HRQoL). It is unclear how HRQoL can be best assessed for different purposes. This study aimed ...to compare two HRQoL questionnaires of differing lengths for feasibility of administration, patient perceptions and psychometric properties.
Methods
: This was an open-label, 24-month study in 334 patients with relapsing MS treated with subcutaneous interferon β-1a. At baseline and months 6, 12, 18 and 24, patients completed the Multiple Sclerosis International Quality of Life (MusiQoL) and Multiple Sclerosis Quality of Life-54 (MSQOL-54) questionnaires and compared them using an evaluation questionnaire. HRQoL scores over time and psychometric properties (correlations with clinical disease measures, relative validity and responsiveness to change) of the questionnaires were assessed.
Results
: A minority of patients had missing items on either HRQoL measure. Completion time was significantly shorter for MusiQoL versus MSQOL-54 (p<0.0001). Patients felt that MusiQoL was easier to use than MSQOL-54 but preferred MSQOL-54 in terms of thoroughness. Mean HRQoL scores increased significantly from baseline to 24 months; correlations of both measures were stronger with an anxiety and depression measure than with disability or recent relapse occurrence. Relative validity and responsiveness to change were similar for both instruments.
Conclusion
: The shorter MusiQoL is suitable for evaluating HRQoL in patients with MS and may be more practical to administer than the more thorough MSQOL-54.
Comparaison, dans un échantillon national, de deux mesures de la qualité de vie dans la sclérose en plaques :
Contexte:
La sclérose en plaques (SP) a un impact important sur la qualité de vie reliée à la santé (QVS) chez les patients qui en sont atteints. La meilleure façon d’évaluer la QVS à différentes fins demeure à préciser. Le but de l’étude était de comparer deux questionnaires de QVS de différente longueur pour évaluer la faisabilité d’administration, les perceptions des patients et les propriétés psychométriques.
Méthode:
Il s’agit d’une étude ouverte de 24 mois portant sur 334 patients atteints de SP cyclique traités par l’interféron ß-1a sous-cutané. Les patients ont complété les questionnaires Multiple Sclerosis International Quality of Life (MusiQoL) et Multiple Sclerosis Quality of Life-54 (MSQOL-54) au début de l’étude, à 6, 12, 18 et 24 mois du début et ils les ont comparés au moyen d’un questionnaire d’évaluation. Les scores au QVS et les propriétés psychométriques (corrélations avec les mesures de la maladie clinique, la validité relative et la capacité d’adaptation au changement) des questionnaires ont été évalués.
Résultats:
L’une ou l’autre des mesures de la QVS comportait des items manquants pour une minorité de patients. Le temps requis pour compléter les questionnaires était significativement plus court pour le MusiQoL que pour le MSQOL-54 (p<0,0001). Les patients estimaient que le MusiQoL était plus facile à utiliser que le MSQOL-54, mais préféraient le MSQOL-54 qui est plus approfondi. Les scores moyens aux QVS avaient augmenté significativement à 24 mois par rapport aux scores initiaux. Les corrélations entre les deux mesures étaient plus fortes pour la mesure de l’anxiété et de la dépression que pour l’invalidité ou une récurrence récente de la maladie. La validité relative et l’adaptation au changement étaient semblables pour les deux instruments.
Conclusion:
Le Questionnaire MusiQoL, qui est plus court, est approprié pour évaluer la QVS chez les patients atteints de SP et peut être plus pratique à administrer que le MSQOL-54 qui est plus approfondi.
Prior studies have shown that the electroencephalogram (EEG) is of low diagnostic yield in the evaluation of syncope but have not looked at the yield according to referring physician specialty. The ...goals of this study were to determine if the yield of the EEG is higher when ordered by neurologists and whether EEGs with abnormal findings resulted in any significant change in patient management.
We retrospectively reviewed the records of the EEGs requested for a clinical diagnosis of syncope, convulsive syncope, loss of consciousness, or falls from 2003 to 2007 at our institution. We obtained further information from the medical record of patients with an abnormal EEG.
Of 517 EEGs meeting our inclusion criteria, only 57 (11.0%) were read as abnormal. No EEG was positive for epileptiform activity and only 9 (1.6%) showed potentially epileptic activity. EEGs ordered by neurologists did not have a higher yield compared to non-neurologists. Five abnormal EEGs resulted in further investigations being ordered. One patient was ultimately started on phenytoin.
EEGs requested for the evaluation of patients with suspected syncope have an extremely low diagnostic yield and do not significantly alter the management of the patients, regardless of the specialty of the referring physician.
The COVID-19 pandemic has had a major impact on clinical practice. Safe standards of practice are essential to protect health care workers while still allowing them to provide good care. The Canadian ...Society of Clinical Neurophysiologists, the Canadian Association of Electroneurophysiology Technologists, the Association of Electromyography Technologists of Canada, the Board of Registration of Electromyography Technologists of Canada, and the Canadian Board of Registration of Electroencephalograph Technologists have combined to review current published literature about safe practices for neurophysiology laboratories. Herein, we present the results of our review and provide our expert opinion regarding the safe practice of neurophysiology during the COVID-19 pandemic in Canada.
Determine if distributed practice of of neurological exam (NE) skills in first year medical school produces sustained improvements in the skills of second year students.
A prospective, controlled, ...non-blinded study conducted at McGill University (class size = 180 students). Expanded teaching of muscle stretch reflexes was provided to first year medical students. A structured examination of muscle stretch reflexes (max score = 100) was administered in second year medical school after a required two week rotation in Neurology. Results for class A (received the intervention in first year) were compared to the results for the preceding class B (had not received the intervention).
77 of 177 (44%) eligible in class A and 69 of 166 (42%) eligible students in class B participated. Results were analyzed separately for each of the two examiners. Mean (SD) scores were 95.2 (5.6) for class A (intervention) and 81.7 (11.1) for class B (control) for the first examiner and 90.4 (8.2) for class A and 83.8 (11.7) for class B for the second examiner. Results were statistically significant (Mann-Whitney test z = 5.27, p<0.0001 first examiner and z = 2.67, p<0.0038 second examiner).
Distributed practice of muscle stretch reflexes during first year medical school results in improved performance by second year medical students after their mandatory clinical rotation in neurology, even when examined up to 14 months after the intervention. This finding has implications for the teaching of the NE.
Abstract Purpose Multiple sclerosis diagnostic criteria include the presence of gadolinium-enhancing lesions when determining dissemination in space and time. Gadolinium is expensive, increases scan ...time and patient discomfort, and can, rarely, cause serious adverse effects. Our objective was to determine the usefulness of including gadolinium-enhanced images as part of a follow-up brain magnetic resonance imaging (MRI) in patients with a clinically isolated syndrome. Methods Consecutive patients seen between 2008 and 2010 with a clinically isolated syndrome suggestive of multiple sclerosis were prospectively enrolled, had a non–gadolinium-enhanced brain MRI, and consented to a follow-up gadolinium-enhanced brain MRI. The primary outcome was a comparison of the number of patients diagnosed with multiple sclerosis compared with the number who would have been diagnosed without the gadolinium-enhanced images. Results Twenty-one patients enrolled, and 2 withdrew. Follow-up MRIs were performed a median of 241 days after the initial MRI. Eleven patients met the primary outcome and were diagnosed with multiple sclerosis: 6 as a result of a second clinical attack and 5 by using imaging criteria for dissemination in space and time. If the gadolinium-enhanced images had not been obtained, then there would have been no change in the primary outcome. Conclusions In Canadian centers with similar MRI waiting times to those in our study, the routine use of gadolinium as part of a follow-up MRI in patients with suspected multiple sclerosis may not be clinically useful. Gadolinium-enhanced images could still be obtained on an as-needed basis for specific clinical indications.
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