The 2022 European postgraduate (residency) programme in neurology in a historical and international perspective.

BACKGROUND AND PURPOSE: Neurology residency programmes, which were first established at the beginning of the 20th century, have become mandatory all over Europe in the last 40-50 years. The first European Training Requirements in Neurology (ETRN) were published in 2005 and first updated in 2016. This paper reports the most recent revisions of the ETRN. METHODS: Members of the EAN board performed an in depth revision of the ETNR 2016-version, which was reviewed by members of the European Board and Section of Neurology of the UEMS, the Education and Scientific Panels, the Resident and Research Fellow Section and the Board of the EAN, as well as the presidents of the 47 European National Societies. RESULTS: The new (2022) ETRN suggest a 5-year training subdivided in three phases: a first phase (2 years) of general neurology training, a second phase (2 years) of training in neurophysiology/neurological subspecialties and a third phase (1 year) to expand clinical training (e.g., in other neurodisciplines) or for research (path for clinical neuroscientist). The necessary theoretical and clinical competences as well as learning objectives in diagnostic tests have been updated, are newly organized in four levels and include 19 neurological subspecialties. Finally, the new ETRN require, in addition to a programme director, a team of clinician-educators who regularly review the resident's progress. The 2022 update of the ETRN reflects emerging requirements for the practice of neurology and contributes to the international standardization of training necessary for the increasing needs of residents and specialists across Europe.

Continuing Medical Education (CME) in time of crisis: How medical societies face challenges and adapt to provide unbiased CME.

Healthcare professionals need to maintain their knowledge and skills to deliver the best possible care to patients. Medical societies play an important role as providers of continuing medical education (CME) and have actively continued this role during the COVID-19 pandemic adapting the delivery of education to virtual meetings and courses. The Biomedical Alliance in Europe CME Experts Committee conducted two surveys to collect information on the delivery of CME, generally, and during the COVID-19 pandemic from the member medical societies. In this article, we will present the most relevant data collected and share some reflections based on this analysis.

Assessment of sexual function in women with neurological disorders: A review.

BACKGROUND: Although the rehabilitation of sexual function has been identified as a top priority among women presenting neurological conditions, sexual function is rarely assessed in this clinical group. OBJECTIVES: To review published assessment tools of sexual dysfunction in women with neurological conditions including multiple sclerosis (MS), spinal cord injury (SCI), Parkinson disease, stroke, traumatic brain injury. METHODS: A systematic literature review was conducted with Medline via PubMed, PubMed Central, and Medline databases. RESULTS: There are three reliable methods to assess sexual dysfunctions in women with neurological conditions: physiological assessments of reflexes and perineal sensitivity testing, self-reporting questionnaires on sexual function and sexual satisfaction, and electrophysiological assessments. Physiological assessments of sacral and thoracolumbar reflexes have mainly been conducted among women with SCI. When performed, they reveal the existence of a psychogenic and/or reflex sexual potential in those women. Other forms of physiological assessments include vulvar sensitivity testing in women with SCI, quantitative sensory testing and pudendal somatosensory evoked potentials in MS populations. A few validated self-reporting measures are also available to assess sexual potential and sexual satisfaction, although mostly in women with SCI and MS. CONCLUSION: Despite high prevalence rates and important clinical implications, sexual dysfunction is not systematically assessed in women presenting various neurological conditions. Several well-validated tools exist for such assessments, which could be used for sexual rehabilitation in these patients. The implementation of systematic assessments of sexual potential is feasible and renewed efforts should be made to do so in clinical practice.

Dynamic Susceptibility Contrast Enhanced (DSC) MRI Perfusion and Plasma Cytokine Levels in Patients after Tonic-clonic Seizures.

BACKGROUND: Inflammatory events in brain parenchyma and glial tissue are involved in epileptogenesis. Blood concentration of cytokines is shown to be elevated after tonic-clonic seizures. As a result of inflammation, blood-brain barrier leakage occurs. This can be documented by imaging techniques, such is dynamic susceptibility contrast enhanced (DSC) MRI perfusion. Our aim was to check for postictal brain inflammation by studying DSC MRI perfusion and plasma level of cytokines. We looked for correlations between number and type of introducing seizures, postictal plasma level of cytokines and parameters of DSC MRI perfusion. Furthermore, we looked for correlation of those parameters and course of the disease over one year follow up. PATIENTS AND METHODS: We prospectively enrolled 30 patients, 8-24 hours after single or repeated tonic-clonic seizures. RESULTS: 25 of them had normal perfusion parameters, while 5 had hyperperfusion. Patients with hyperperfusion were tested again, 3 months later. Two of 5 had hyperperfusion also on control measurements. Number of index seizures negatively correlated with concentration of proinflammatory cytokines IL-10, IFN-ϒ and TNF-α in a whole cohort. In patients with hyperperfusion, there were significantly lower concentrations of antiinflammatory cytokine IL-4 and higher concentrations of proinflammatory TNF-a. CONCLUSIONS: Long lasting blood- brain barrier disruption may be crucial for epileptogenesis in selected patients.

Introduction.

This volume of the Handbook of Clinical Neurology deals with neurologic disorders of sex and bladder. Sexuality is for the large majority of humans a component of a fulfilled life, even though it is not "vital" in the usual sense of the word. However, dysfunctions of the lower urinary tract (LUT) are vital, as they may lead to chronic infection, dilatation of the upper urinary tract, renal insufficiency, and death. Sexual disorders and LUT are often mentioned in ancient literature, but most contemporary methods of diagnosis and treatment were only introduced in the 20th century. Despite the relatively high prevalence of these disorders, most physicians are ill prepared to discuss them with their patients, let alone to diagnose and treat them. It is the aim of this volume of the Handbook to try to reverse this attitude and convince neurologists that sexual and LUT function need to be addressed in their patients, for reasons of correct diagnosis and possible therapeutic consequences, as well as gaining overall trust from the patient.

Approach to the male patient with lower urinary tract dysfunction.

History and physical examination are the cornerstones of evaluation of the male patient with lower urinary tract (LUT) symptoms and (suspected) neurologic disorder, both to diagnose the nervous system lesion, and to get insight into the type of LUT dysfunction (LUTD). Non-neurologic LUTD needs to be ruled out. Laboratory testing is necessary to diagnose urinary infection. In those in whom neurogenic LUTD is probable, postvoid residual urine and urinary flow measurement generally rule out significant outflow obstruction and allow for basic symptomatic management. If symptomatology is complex or severe, or the pathophysiology uncertain, or invasive treatment planned, urodynamic or videourodynamic measurements should be performed to inform on bladder sensation, detrusor contractility, pressures generated in the bladder, as well as the behavior of bladder neck, the striated urethral sphincter, and urinary flow. This information is paramount to the clinician to plan management and consider prognosis. Assessment needs to be repeated, as chronic neurogenic LUTD is not a stable condition; in progressive neurologic diseases the nature of LUTD itself may change. The upper urinary tract needs to be checked and followed up regularly, particularly in patient groups in which high intravesical pressures may be generated.

Sexual dysfunction in patients with peripheral nervous system lesions.

Peripheral nervous system (PNS) disorders may cause sexual dysfunction (SD) in patients of both genders. These disorders include mainly polyneuropathies (particularly those affecting the autonomic nervous system (ANS)) and localized lesions affecting the innervation of genital organs. Impaired neural control may produce a malfunction of the genital response consisting of loss of genital sensitivity, erectile dysfunction, loss of vaginal lubrication, ejaculation disorder, and orgasmic disorder. In addition, there is often a loss of desire which actually has a complex pathogenesis, which goes beyond the mere loss of relevant nerve function. In patients who have no manifest health problems - particularly men with erectile dysfunction - one should always consider the possibility of an underlying polyneuropathy; in patients with SD after suspected denervation lesions of the innervation of genital organs within the lumbosacral spinal canal and in the pelvis, clinical neurophysiologic testing may clarify the PNS involvement. SD can alter self-esteem and lower patients' quality of life; opening up a discussion on sexual issues should be a part of the management of patients with PNS disorders. They may greatly benefit from counseling, education on coping strategies, and specific treatments.

Lower urinary tract dysfunction in patients with peripheral nervous system lesions.

The prevalence of lower urinary tract (LUT) dysfunction in peripheral nervous system (PNS) disorders is larger than in comparable control populations. This is particularly true for polyneuropathies with autonomic nervous system involvement, and for localized lesions with LUT innervation. LUT symptoms may be the guide to the diagnosis of processes localized in the lumbosacral spinal canal (as in cauda equina syndrome), and in the pelvis. Typical LUT dysfunctions (LUTD) caused by PNS involvement include bladder and sphincter hypoactivity with poor emptying, and incontinence. Paradoxically, bladder overactivity may also occur in pure PNS lesions. The acute cauda equina syndrome is an emergency requiring magnetic resonance imaging and surgery; in chronic neurogenic LUTD due to PNS involvement, the diagnosis of the lesion may be clarified by clinical neurophysiologic testing. Other important causes of neurogenic LUT dysfunction are perineoabdominal and pelvic surgeries. Surgeons are devising nerve-sparing techniques to prevent such major and often persistent complications in patients who are otherwise cured of the underlying disease. LUTD significantly affects the quality of life in patients and may lead to recurring urinary infections and upper urinary tract involvement. Thorough assessment of LUT function by urodynamics may be necessary in patients who are not improved by simple conservative measures.

Cognitive function in early clinical phase huntington disease after rivastigmine treatment.

BACKGROUND: In Huntington disease (HD) patients receiving rivastigmine treatment improvement of behavioral symptoms and of cognitive function (assessed with screening diagnostic instruments) has been reported. The aim of the present study was to verify such improvement in cognitive function by cognitive function assessment with a detailed neuropsychological battery covering all relevant cognitive systems expected to be impaired in early phase HD. SUBJECTS AND METHODS: Eighteen (18) HD patients entered the study and were randomly allocated to the rivastigmine and placebo group. All subjects underwent neuropsychological assessment at baseline. Follow-up neuropsychological assessment was applied after 6 months of rivastigmine or placebo treatment. Eighteen (18) healthy controls entered the study to control for practice effect and underwent neuropsychological assessment at baseline and after 6 months, without treatment. The neuropsychological battery consisted of assessment tools that are sensitive to cognitive impairment seen in early phase HD: CTMT, SDMT, Stroop (attention and information control), RFFT, TOL, Verbal fluency (executive functioning), CVLT-II, RCFT (learning and memory). Effect of rivastigmine and possible effect of practice was assessed using the mixed ANOVA model. RESULTS: No statistically significant effect of rivastigmine treatment on cognitive function in HD patients was detected. There was no evidence for practice or placebo effect. CONCLUSIONS: Detailed neuropsychological assessment did not confirm previously reported effect of rivastigmine treatment on cognitive function in HD patients. The limitations of our study are, in particular, small sample size and the lack of a single measure of relevant cognitive functioning in HD patients. Instead of focusing solely on statistical significance, a clinical relevance study is proposed to clarify the issue of rivastigmine effects in HD.

Intraoperative recording of the bulbocavernosus reflex.

: The bulbocavernosus reflex (BCR) is mediated by the sacral somatic afferent/efferent periphery as well as the sacral cord. Unfortunately, the reflex has suffered from a partly deserved reputation as difficult to implement. However, recent stratagems have improved the test's reliability. Multipulse stimulation (enhanced by double trains as required) and exacting recording technique can yield positive and remarkably reproducible results in patients of all ages and either sex. In this review, we document a 94% baseline BCR acquisition rate among 100 consecutive cases in one institution. Acceptance and routine use of the BCR is needed to help assure optimal post-operative low sacral function in intradural and extradural surgeries at the level of conus medullaris, cauda equina, sacral plexus, and the pudendal nerve. Case studies within this review illustrate the power of the BCR to predict patient outcome or, much more importantly, reverse incipient patient injury in real time.

Lower urinary tract and sexual dysfunction in neurological patients.

BACKGROUND: Lower urinary tract dysfunction (LUTD) and sexual dysfunction (SD) are common in neurological patients due to a combination of lesions affecting relevant neural control, constraints imposed by sensorimotor and cognitive deficits and--particularly for SD--psychosocial consequences of chronic neurological disease. SUMMARY: This review summarizes the etiology, diagnosis and treatment of LUTD and SD in neurological patients. KEY MESSAGES: LUTD may lead to serious health problems; both LUTD and SD significantly affect quality of life. Management of patients with spinal cord injury and dysraphism is undertaken in specialized centers according to established guidelines. Treatment of neurological patients with noncomplicated neurogenic LUTD or SD should preferentially be guided by a neurologist. CLINICAL IMPACT: For rational treatment of urinary symptoms, an accurate assessment is mandatory; the bladder and the sphincter need to be defined as normal, over- or underactive. Urodynamic testing is the gold standard for functional diagnosis; assessment of residual urine and uroflow are the minimal requirements before considering management. Dysfunction of desire, arousal and orgasm (ejaculation) may be diagnosed by medical history and are amenable to counselling and treatment, which is--in the case of erectile dysfunction--evidence based. Further high-quality studies are necessary to test the best approaches for diagnosing and managing particular types of neurogenic LUTD and SD in the different neurological patient populations.

Recommendations for the use of prolonged-release fampridine in patients with multiple sclerosis (MS).

Prolonged-release fampridine (fampridine PR) is a potassium channel blocker that improves conductivity of signal on demyelinated axons in central nervous system. Fampridine PR has been approved to improve speed of walking in patients with multiple sclerosis. This statement provides a brief summary of data on fampridine PR and recommendations on practical use of the medication in clinical practice, prediction, and evaluation of response to treatment and patient management.

Management of sexual dysfunction in Parkinson's disease.

Nonmotor symptoms, among them sexual dysfunction, are common and underrecognized in patients with Parkinson disease; they play a major role in the deterioration of quality of life of patients and their partners. Loss of desire and dissatisfaction with their sexual life is encountered in both genders. Hypersexuality (HS), erectile dysfunction and problems with ejaculation are found in male patients, and loss of lubrication and involuntary urination during sex are found in female patients. Tremor, hypomimia, muscle rigidity, bradykinesia, 'clumsiness' in fine motor control, dyskinesias, hypersalivation and sweating may interfere with sexual function. Optimal dopaminergic treatment should facilitate sexual encounters of the couple. Appropriate counselling diminishes some of the problems (reluctance to engage in sex, problems with ejaculation, lubrication and urinary incontinence). Treatment of erectile dysfunction with sildenafil and apomorphine is evidence based. HS or compulsive sexual behaviour are side effects of dopaminergic therapy, particularly by dopaminergic agonists, and should be treated primarily by diminishing their dose. Neurologists should actively investigate sexual dysfunction in their Parkinsonian patients and offer treatment, optimally within a multidisciplinary team, where a dedicated professional would deal with sexual counselling.

The role of clinical neurophysiology in urogynecology.

INTRODUCTION: Clinical neurophysiological methods remain interesting research tools in urogynecology; their diagnostic role in the individual "pelvic floor" patient is, however, minor. CONCLUSION: The methods are diagnostically useful particularly in patients suspected to have a lesion involving the sphincters or the peripheral sacral nervous system, the diagnosis of which will influence management decisions or have prognostic or medicolegal relevance. Most helpful tests are the concentric needle EMG and bulbocavernosus reflex testing.

Stroke patients who regain urinary continence in the first week after acute first-ever stroke have better prognosis than patients with persistent lower urinary tract dysfunction.

AIMS: Urinary incontinence (UI) is a predictor of greater mortality and poor functional recovery; however published studies failed to evaluate lower urinary tract (LUT) function immediately after stroke. The aim of our study was to evaluate the course of LUT function in the first week after stroke, and its impact on prognosis. METHODS: We included 100 consecutively admitted patients suffering first-ever stroke and evaluated them within 72 hours after stroke, after 7 days, 6 months, and 12 months. For LUT function assessment we used ultrasound measurement. The patients were divided into three groups: (i) patients who remained continent after stroke, (ii) patients who had LUT dysfunction in the acute phase but regained continence in the first week, and (iii) patients who did not regain normal LUT control in the first week. We assessed the influence of variables on death using the multiple logistic regression model. RESULTS: Immediately after stroke 58 patients had LUT dysfunction. The odds of dying in group with LUT dysfunction were significantly larger than odds in group without LUT dysfunction. Odds for death for patients who regained LUT function in 1 week after stroke were comparable to patients without LUT dysfunction. CONCLUSIONS: We confirmed that post-stroke UI is a predictor of greater mortality at 1 week, 6 months and 12 months after stroke. However, patients who regain normal bladder control in the first week have a comparable prognosis as the patients who do not have micturition disturbances following stroke.

Raising awareness about fecal incontinence.

There is a lack of awareness about fecal incontinence despite its prevalence and adverse impact on quality of life. Inadequate knowledge about fecal incontinence deters help-seeking, therapeutic consultation, and clinical research about effective prevention and management strategies. A systematic, evidenced-based approach to raise awareness of fecal incontinence is essential to forward progress and overcome multiple barriers. In this manuscript, strategies of this approach are prioritized and focus on increasing continence literacy and communication, emphasizing prevention and screening, disseminating evidenced-based management interventions, and promoting larger scale impact through effective partnerships.

Correlations between the ICIQ-UI short form and urodynamic diagnosis.

AIMS: Urinary incontinence is a common symptom in many diseases as well as in general population. To measure the impact of urinary incontinence (UI) on individual's quality of life the English short form International Consultation on Incontinence questionnaire (ICIQ-UI Short Form) has been developed, which consists of three scored and one self-diagnostic question. Our aim was to translate the ICIQ-UI Short Form into Slovene, re-validate it, and test the diagnostic value of the questionnaire in determining the type of UI. METHODS: ICIQ-UI Short Form was translated into Slovene and re-validated. In the validation process we included urology and gynecology outpatient clinics attendants, elderly institutionalized patients, and a community sample. One group of patients underwent urodynamic testing and the results were compared to their responses to question six of the ICIQ-UI Short Form. Both sets of answers were compared using the Kappa (kappa) statistics. RESULTS: The Slovene version of the ICIQ-UI Short Form was found to be valid (excellent test-retest reliability, good internal consistency, good responsiveness to change, and reflected well underlying theories). The questionnaire correlated well with urodynamic findings. The perceived cause of leakage (Question 6) was a good indicator of objectively proven cause of incontinence (Kappa value 0.77). CONCLUSIONS: We found that the Slovene version of the ICIQ-UI Short Form is a valid and reliable questionnaire for assessment of UI. In addition to its ability to assess the impact of UI on individual's quality of life it also has a diagnostic value of the cause of incontinence.