Toward a more efficient and effective neurologic examination for the 21st century.

Practice pressures and quality improvement require greater efficiency and effectiveness in the neurologic examination. I hypothesized that certain 'marginal' elements of the examination rarely add value and that 'core' elements, exemplified by the plantar response (Babinski), are too often poorly performed or interpreted. I analyzed 100 published, neurologic clinicopathologic conferences (CPCs) and 180 ambulatory neurologic consultations regarding 13 hypothetically 'marginal' examination components (including 'frontal' reflexes, olfaction, jaw strength, corneal reflex, etc.); also, 120 exams on medical inpatients with neurologic problems, recording definitive errors. I surveyed the recalled practices of 24 non-neurologists and reviewed the literature for relevant data or guidance. In the CPCs the 'marginal' elements of the examination were rarely provided, requested, or used diagnostically, nor did they contribute in the 180 ambulatory consultations. In the chart review errors and omissions dominated testing of plantar responses, with missed Babinski signs in 14% of all cases and 77% of patients with Babinski signs. House officers harbored unrealistic expectations for performance of 'marginal' examination elements. Most textbooks omit detailed guidance (and none cite evidence) on achieving greater efficiency. Exams should be streamlined, while improving 'core' skills. Neurologists should apply evidence to update the exam taught to students and non-neurologists.

Time to learn: the outlook for renewal of patient-centred education in the digital age.

BACKGROUND: Major forces in society and within health systems are fragmenting patient care and clinical learning. The distancing of physician and trainee from the patient undermines learning about the patient-doctor relationship. The disconnection of care and learning from one successive venue to another impedes the ability of trainees to learn about illness longitudinally. METHODS: As a conceptual piece, our methods have been those of witnessing the experiences of patients, practitioners, and students over time and observing the impact of fragmented systems and changing expectations on care and learning. We have reflected on the opportunities created by digital information systems and interactive telemedicine to help renew essential relationships. RESULTS: Although there is, as yet, little in the literature on educational or health outcomes of this kind of technological enablement, we anticipate opportunities for a renewed focus on the patient in that patient's own space and time. Multimedia applications can achieve not only real-time connections, but can help construct a "virtual patient" as a platform for supervision and assessment, permitting preceptors to evaluate trainee-patient interactions, utilization of Web-based data and human resources, and on-line professionalism. CONCLUSIONS: Just as diverse elements in society are capitalizing upon digital technology to create advantageous relationships, all of the elements in the complex systems of health care and medical training can be better connected, so as to put the patient back in the centre of care and the trainee's ongoing relationship to the patient back in the centre of education.

Malpractice claims: outcome evidence to guide neurologic education?

The choice of objectives and content in neurologic education should be informed by evidence from patient outcomes and errors. Malpractice claims are proposed as one data source, although they only partially reflect health outcomes. Epidemiologic, statewide data suggest some provisional priorities for key topics and training targets, but require further research to assess their value for guiding neurologic education.

Suspected conversion disorder: foreseeable risks and avoidable errors.

The authors reviewed the occurrence in their emergency department of cases of serious neurologic problems initially thought to be conversion disorders or similar psychogenic conditions. Their aim is to indicate the significance of this issue for emergency physicians (EPs) because of its contribution to the incidence of medical errors. Although there are no national statistics, the authors estimate by extrapolation that thousands of such cases probably have occurred and large numbers may still occur each year in the United States, sometimes resulting in patient injury. They have identified ways of anticipating and attempting to prevent such occurrences. Proposed interventions focus on education regarding the difficulty of diagnosis, patient-based risk factors, and physician-based attitudes and thought processes. The authors also include suggestions for systemic "safety nets" that will help to ensure quality of care, such as appropriate imaging and consultation. Review of texts and journals readily accessible to EPs revealed little attention to this subject.

A prospective study of fever and bacteremia after flexible fiberoptic bronchoscopy in children.

STUDY OBJECTIVES: To assess the incidence of fever and bacteremia after fiberoptic bronchoscopy in immunocompetent children. DESIGN: Prospective study. PATIENTS: Immunocompetent children undergoing fiberoptic bronchoscopy between January 1997 and June 1998. MEASUREMENTS AND RESULTS: Ninety-one children were included in the study. Forty-four children (48%) developed fever within 24 h following bronchoscopy. Bacteremia was not detected in any of the cases at the time of the fever. Children who developed fever were younger than those who remained afebrile (mean age, 2.4 +/- 3.6 years vs 4.2 +/- 3.7 years; p = 0.025). In the fever group, 66% of the bronchoscopies were considered abnormal, compared to 45% in the nonfever group (p = 0.04). Of the fever group, 40.5% of BAL fluid cultures had significant bacterial growth, significantly higher compared to the nonfever group (13.2%; p = 0.006). Of the 80 patients in whom BAL was performed, fever occurred in 52.5% compared to only 18.2% in those who did not have BAL (p = 0.03). BAL fluid content of cell count, lipid-laden macrophages, and interleukin-8 were not significantly different in both groups. In a logistic regression analysis, the significant predictors for developing fever were positive bacterial culture (relative risk, 5.1; 95% confidence interval, 1.6 to 16.4; p = 0.007) and abnormal bronchoscopic findings (relative risk, 3.1, 95% confidence interval, 1.2 to 8.3; p = 0.02). When age < 2 years was included in the model, this factor became highly significant (relative risk, 5.01; 95% confidence interval, 1.83 to 13.75; p < 0.002). CONCLUSIONS: Fever following fiberoptic bronchoscopy is a common event in immunocompetent children and is not associated with bacteremia. Risks to develop this complication are age < 2 years, positive bacterial cultures in BAL fluid, and abnormal bronchoscopic findings.

Spinal cord emergencies: false reassurance from reflexes.

Emergency physicians need to understand the potential for false reassurance in the interpretation of reflex examination data. Neurologic consultation should be sought when classic signs are lacking, but other evidence causes suspicion. Changes in teaching emphasis and acute practice are needed, since the stakes may be high and time is of the essence. We have responded to the insights gained from this study by augmenting in-service and continuing medical education teaching and by implementing guidelines to assist EPs. We have emphasized the importance of spotlighting high-risk patients, as exemplified above, and of taking advantage of neurologic or neurosurgical consultation. Where in-person consultation is less available, the use of guidelines and remote consultation should be able to help direct further examination, diagnostic formulation, and the need for imaging decisions. Given the potential for severe negative outcome if spinal emergencies are not optimally managed, we must give the teaching of these issues high priority.

Use of CD34 and factor VIII to diagnose hepatocellular carcinoma on fine needle aspirates.

OBJECTIVE: The immunohistochemical staining patterns characteristic of hepatocellular carcinoma (HCC) using CD34 and factor VIII antibodies were compared with those of other hepatic lesions to determine if these stainings can be used as a diagnostic criterion. STUDY DESIGN: We reviewed 44 fine needle aspirates from the liver to evaluate the immunoperoxidase staining patterns on cell block preparations using CD34 and factor VIII and to determine whether this could distinguish HCC from the other lesions. These included HCC (14 cases), metastatic tumor (14 cases) and nonneoplastic liver lesions (16 cases). RESULTS: This retrospective study showed that in the nine documented cases of HCC, staining for CD34 and/or factor VIII was positive. The pattern of staining was either peripheral, around small clusters of tumor cells, or linear, diffuse and sinusoidal. In all the documented cases (27) of metastatic carcinoma and nonneoplastic lesions staining for CD34 and factor VIII was negative. In addition, there were eight problematic cases. In 7 cases the cytologic diagnosis on Papanicolaou-stained smears was inconclusive about HCC or metastatic carcinoma. CD34 and factor VIII confirmed the final diagnosis on the cell blocks. Based on this staining, 4 were HCC, 2 were metastatic carcinoma and 1 was equivocal, most probably HCC. In one case the differential diagnosis between well-differentiated HCC and a nonneoplastic liver lesion could not be made on cytologic smears, and here, also, CD34 and factor VIII aided in the correct diagnosis of a nonneoplastic liver lesion. CONCLUSION: We suggest immunoperoxidase staining with CD34 and factor VIII be performed on the cell block sections from FNAs in any problematic hepatic case.

The problematic interpretation of foamy cells in breast fine needle aspirates. A report of two cases.

BACKGROUND: Lipid-rich carcinoma and primary malignant fibrous histiocytoma (MFH) of the breast are rare tumors. Cytologically the presence of cells with foamy cytoplasm can cause diagnostic difficulties in both tumors. CASES: Fine needle aspiration was performed on two females with breast masses. The lipid-rich carcinoma showed cells with fine, variably sized vacuoles in the cytoplasm. The MFH smears showed large, histiocytelike cells with foamy cytoplasm, both mononucleated and multinucleated. CONCLUSION: When presented with cytologic smears showing foamy cells, in addition to the nature of the nucleus one must pay attention to the size and character of the cytoplasmic vacuoles to differentiate between sarcoma versus carcinoma.

Neurologic education for the future: a decade of curricular reform at Harvard Medical School.

The field of neurology is undergoing significant changes to which curricular reform is both responding and contributing. We reflect on a decade of experience at Harvard Medical School with integration of neuroscience, behaviour, pathophysiology and introductory clinical skills. As part of Harvard's "New Pathway" curriculum, this coordinated, pre-clerkship program embraces a "hybrid" form of problem-based learning. A variety of methods are employed synergistically to meet the two broad goals of preparing for competency in neurologic clerkships and for career-long learning in clinically relevant neuroscience. We articulate specific ways of elevating the level of intellectual inquiry, involving multi-disciplinary faculty more productively, and vertically integrating the learning experience through the years of medical school.

An integrated preclerkship curriculum in neuroscience, psychiatry, and neurology.

The study's objective was to promote understanding of the integration of preclerkship learning in neuroscience, psychiatry, and neurology and to share the authors' experience with such a program. A dualism, which may have survived in the past for lack of robust evidence of mind-brain relationships, is now increasingly outmoded. Medical school education should reflect the increasing coherence to be found in these fields. The authors describe curricular and course innovations and revisions at Harvard Medical School that have been implemented in successive iterations over the past decade. These changes have depended upon multidisciplinary leadership, planning, and faculty participation, as well as faculty development and closer coordination between classroom- and hospital-based activity. A hybrid, problem-based block course in the second year integrates basic science with neurologic and psychiatric topics that are aligned with practice of relevant clinical skills. The authors have achieved a high level of integration and coordination of these subjects at preclerkship levels in the domains of both knowledge and skills. The students, as well as the faculty, strongly endorse an intellectually coherent and clinically relevant program of integrated preclerkship learning in neuroscience, psychiatry, and neurology.

Fine-needle aspiration of nodular hidradenoma: a case report.

A case of nodular hidradenoma presenting on the forearm of a 36 year old woman is reported. The diagnosis was made on fine-needle aspiration biopsy (FNAB). The cytologic features of the lesion are described. This is the first case to be diagnosed cytologically.

Merkel cell carcinoma diagnosed by fine-needle aspiration.

Merkel cell carcinoma is a relatively rare neoplasm of the skin. The present study describes three cases of Merkel cell carcinoma diagnosed by fine-needle aspiration cytology and reviews their histologic, cytologic, and ultrastructural features. The advantages of using fine-needle aspiration to diagnose Merkel cell carcinoma (and other cutaneous neoplasms) are emphasized.

Assessment of testicular spermatozoa morphology by image analysis.

OBJECTIVE: We objectively evaluated the testicular sperm cell morphology. METHODS: The spermatozoa head morphology was evaluated by image analysis as presented on testicular fine-needle aspiration cytology smears. RESULTS: 2,356 spermatozoa heads were classified into six groups, according to different morphology parameters. CONCLUSIONS: This objective method of morphologic assessment of testicular spermatozoa provides an important tool for the evaluation of testicular spermatozoa and can serve as a guide for therapy in male infertility.

Crafting cases for problem-based learning: experience in a neuroscience course.

Clinical cases for problem-based learning should capture the relevance of patient encounters, and not serve merely as a 'take-off' point for scientific study. As a vehicle of learning, the case should drive the science and the science should drive the case. Decision points elicit intellectual commitment, and help to raise the level of inquiry. Our cases are focused, avoiding clinical complexity and reliance on pattern recognition. We emphasize formulation of evidence-based mechanistic hypotheses. The case does not stand alone, but must suit its position in the course and curriculum.

Necrosis of parotid pleomorphic adenoma following fine needle aspiration. A case report.

Fine needle aspiration of parotid tumors is used worldwide and usually is well tolerated by the patient, with no complications. We report a case of pleomorphic adenoma diagnosed by fine needle aspiration that underwent necrosis following the aspiration procedure.