Functional Neurological Disorders in the medical education: An urgent need to fill the gaps.

BACKGROUND: FND is a disabling disease that accounts for 5 to 10% of the reason for consultation in neurology. However, young physicians often say they have little or no training in their management. AIM: The aim of the present study was to assess whether French junior neurologists, psychiatrists and physical and rehabilitation medicine (PRM) specialists received teaching on FND during their medical studies, including the residency, and to evaluate their knowledge and perception of the disorder. METHODS: The survey was distributed by the means of a Google form questionnaire to specialist registrars and young specialists with the help of resident's organizations. RESULTS: 568 respondents from the 3 specialties were included in the study. Most respondents (72.4%) were specialists registrars. Almost half of the respondents (45.5%) answered they never received any teaching on FND, and only 20.5% of them knew the Hoover's sign, a positive sign specific of functional weakness. A large majority of respondents felt they were not sufficiently trained in FND (87.9%), and they did not have sufficient knowledge of these disorders (85.3%). DISCUSSION: Better training would allow clinicians to make a diagnosis earlier, to better explain it to patients, and to limit the costs associated with diagnosis delays. A better training of clinicians about FND would also improve the prognosis of patients, as early diagnosis and good explanation is associated with a better prognosis. CONCLUSION: This survey shows that there is a gap about FND in the training programs in the medical studies and during the specialization training of young doctors in France.

The "Neurological Hat Game": A fun way to learn the neurological semiology.

INTRODUCTION: In-class courses are deserted by medical students who tend to find it more beneficial to study in books and through online material. New interactive teaching methods, such as serious games increase both performance and motivation. We developed and assessed a new teaching method for neurological semiology using the "Hat Game" as a basis. METHODS: In this game, two teams of second-year medical students are playing against one another. The game is played with a deck of cards. A neurological symptom or sign is written on each card. Each team gets a predefined period of time to guess as many words as possible. One member is the clue-giver and the others are the guessers. There are three rounds: during the first round, the clue-giver uses any descriptive term he wants and as many as he wants to make his team guess the maximum number of words within the allocated time. During the second round, the clue-giver can only choose one clue-word and, during the third round, he mimes the symptom or sign. The team that has guessed the most cards wins the game. To assess the efficacy of this learning procedure, multiple choices questions (MCQs) were asked before and after the game. Exam results of second-year students on their final university Neurology exam were analyzed. A satisfaction survey was proposed to all participating students. RESULTS: Among 373 students, 121 volunteers (32.4%) were enrolled in the "Neurology Hat Game" and 112 attended the game. One hundred and seven of the 112 students completed the MCQs with a significant improvement in their responses after the game (P<0.001). The 112 students who completed the satisfaction self-administered questionnaire were very satisfied with this funny new teaching method. CONCLUSIONS: Teaching neurological semiology via the "Hat Game" is an interesting method because it is student-centered, playful and complementary to the lecturer-centered courses. A randomized controlled study would be necessary to confirm these preliminary results.

Motor functional neurological disorders: An update.

Motor functional neurological disorders (FNDs) are motor symptoms not explained by a lesion or related to a known dysfunction of the central nervous system, yet functional imaging studies suggest the presence of a genuine brain dysfunction. With this common disabling condition, there is a particular need for collaboration between neurologists and psychiatrists. Neurologists can search for positive clinical signs to make the diagnosis, which can then be followed by an explanation of the disease, whereas psychiatrists can look for psychological factors and psychiatric comorbidities in order to deliver appropriate treatment. Such a multidisciplinary approach is important, particularly with the participation of neurologists, psychiatrists, physiotherapists and psychologists. If necessary, additional treatments such as transcranial magnetic stimulation (TMS), hypnosis and sedation may be proposed.

Epileptic seizures at initial presentation in patients with brain arteriovenous malformation.

OBJECTIVES: Brain arteriovenous malformations (AVMs) often present with epileptic seizures, but prospective data on the risk of seizures with respect to morphologic AVM characteristics are scarce. METHODS: We studied 155 consecutive patients with AVMs from a prospective, single-center database using demographic and morphologic factors based on prospectively coded MRI and digital subtraction angiography (DSA) data. Univariate analysis and multivariate logistic regression models were used to test the effect of demographic (age and sex) and morphologic characteristics (AVM size, anatomic and arterial location, and venous drainage pattern) on seizures as initial presentation in patients with unruptured brain AVMs. RESULTS: Overall, 45 patients with AVMs initially presented with seizures (29%). By univariate comparison, male sex (p = 0.02), increasing AVM size (p < 0,006), frontal lobe localization (p < 0.0001), arterial borderzone location (p < 0.0006), superficial venous drainage (p = 0.0002), and presence of venous ectasia (p = 0.003) were statistically associated with seizures. The multivariate analysis confirmed an independent effect of male sex, frontal lobe AVMs, and arterial borderzone location on seizure occurrence. All patients with seizures showed the presence of a superficial venous drainage component. CONCLUSIONS: Our study suggests that seizures mainly occur in AVMs with superficial drainage. Other predisposing factors include male sex, increasing AVM size, and frontal lobe and arterial borderzone location. Whether or not interventional treatment has an effect on the long-term risk of epilepsy remains to be determined.

Determinants of survival in behavioral variant frontotemporal dementia.

BACKGROUND: Behavioral variant frontotemporal dementia (bvFTD) is a common cause of younger onset dementia. Little is known about its rate of progression but a recently identified subgroup seems to have an excellent prognosis. Other determinants of survival are unclear. METHODS: We analyzed survival in a large group of clinically diagnosed bvFTD patients (n = 91) with particular attention to demographic and clinical features at presentation. Of the 91 cases, 50 have died, with pathologic confirmation in 28. RESULTS: Median survival in the whole group was 9.0 years from symptom onset, and 5.4 years from diagnosis. After the exclusion of 24 "phenocopy" cases, the analysis was repeated in a subgroup of 67 patients. The mean age at symptom onset of the pathologic group was 58.5 years and 16% had a positive family history. Their median survival was 7.6 years (95% confidence interval [CI] 6.6-8.6) from symptom onset and 4.2 years (95% CI 3.4-5.0) from diagnosis. The only factor associated with shorter survival was the presence of language impairment at diagnosis. CONCLUSIONS: Patients with definite frontotemporal dementia have a poor prognosis which is worse if language deficits are also present. This contrasts with the extremely good outcome in those with the phenocopy syndrome: of our 24 patients only 1 has died (of coincident pathology) despite, in some cases, many years of follow-up.

[Acute bilateral deafness and facial diplegia as a presentation of occlusion of the basilar artery]. / Surdité bilatérale suivie d'une diplégie faciale révélatrice d'une occlusion du tronc basilaire.

INTRODUCTION: Sudden bilateral deafness and facial weakness are unusual presentations of brain stem stroke. OBSERVATION: We report the case of a patient who presented successively sudden bilateral deafness and facial diplegia in correlation with a brain stem stroke but without any ischemic pontine lesion. DISCUSSION: Unlike our case, all of the earlier publications, have reported the presence of ischemic pontine lesions in patients with bilateral deafness and facial diplegia. Selective vulnerability of inner ear to ischemia has been hypothesized but cannot explain the facial diplegia. CONCLUSION: Our case would suggest extra-neuraxis failure by ischemia of the acoustico-facial nerve.