[The new S2k AWMF guideline for the treatment of Bell's palsy in commented short form]. / Die neue S2k AWMF Leitlinie zur idiopathischen Fazialisparese in kommentierter Kurzform.

A new S2k AWMF guideline for the treatment of idiopathic facial palsy has been published. An accurate differential diagnosis is indispensable as 25-40% of all facial palsy cases are of non-idiopathic origin. It is explicitly recommended to treat patients with idiopathic facial palsy with steroids. Steroids favour a complete recovery, decrease the risk of synkinesis, autonomic sequelae and contractures. Adjuvant antiviral therapy cannot be recommended. On current data there is not sufficient evidence that the combination of steroids with antiviral drugs has a benefit for the patients. Even when not supported by randomized trials, adjuvant symptomatic therapy to protect the cornea and to avoid complications is recommended. There is no scientific evidence that physical therapy has any benefit but it should be taken into account because of psychological reasons. A benefit of acupuncture has not been proven. If eye closure remains incomplete as result of defective healing, one therapeutic option is lid loading of the upper eye lid. Moreover, in case of severe persistent palsy, several well-established microsurgical nerve and muscle plasty procedures are available.

Recurrent Miller Fisher syndrome: clinical and laboratory features.

To present two patients with Miller Fisher syndrome (MFS) recurrence after 35 and 44 years and review of the literature on recurring MFS. All identified cases with recurrent MFS were evaluated. Age, gender, clinical features of first and recurrent MFS, course of disease, laboratory findings, therapy and outcome were transformed into tables. Twenty-eight patients (16 men, 12 women; mean age at the first episode 34 years (range 13-57 years); mean age at the latest episode 47 years (range 21-66 years) with a total of 70 MFS episodes were identified. Twenty-one patients had a single recurrence, five patients had two recurrences, one patient had four recurrences and one patient had seven recurrences. The mean interval between attacks was 9.45 years (3 months to 44 years). In 76% of the initial episodes and in 81% of the recurrent episodes, an infectious disease preceded MFS. Additional facial and bulbar symptoms and autonomic disturbances were frequent findings. Cerebrospinal fluid (CSF) and electrodiagnostic findings were unspecific. If tested, autoantibodies against GQ1b had been positive in all episodes. In about half of the patients, immunotherapy was applied. The outcome was favourable in most patients. Recurrence of MFS is a rare quite uniform condition with a mostly favourable prognosis.

Smell and taste disorders in polyneuropathy: a prospective study of chemosensory disorders.

OBJECTIVE: The aim of the study was to assess the occurrence and the frequency of chemosensory dysfunction in patients with polyneuropathy (PNP). METHODS: We performed a prospective observational study. Olfactory function was assessed using the standardized 'Sniffin' Sticks' test to measure odor threshold for phenyl ethyl alcohol, odor discrimination, and odor identification. Gustatory function was assessed using the standardized 'taste strips' test. In addition, we assessed etiology, neurophysiology, and severity of the PNP, and the patients' comorbidities and medication. RESULTS: A total of 53 consecutive patients were enrolled (15 women, 38 men; mean age 61 years); 27 of them (51%) exhibited olfactory dysfunction and 23 of them (43%) gustatory dysfunction. Patients with diabetic PNP had significantly lower taste scores than patients with inflammatory, genetic, or idiopathic PNP. In addition, odor identification was negatively correlated with PNP severity. CONCLUSION: The applied bedside tests are useful to detect chemosensory dysfunction in patients with PNP. Chemosensory dysfunction is quite frequent in these patients.

[OSCE in the neurology clerkship. Experiences at the neurological department of the university hospital Erlangen]. / OSCE in der Neurologie. Erfahrungen an der neurologischen Universitätsklinik Erlangen.

BACKGROUND: In the German medical education program practical examinations at the end of the neurology clerkship are sparsely performed. By this way, motivation for practical learning and a method to assure quality of learning are not used. METHOD: The Anglo-Saxon concept of "objective structured clinical examination" (OSCE) is picked up and implemented as a practical examination at the end of the neurology clerkship of medical students in their 4th and 5th year. A catalogue of learning goals was defined and an OSCE of 5 stations was developed. A standard of a successful examination was defined. In two OSCE stations the competence in clinical decision making and reasoning were tested, in two stations the competence in practical examination skills and in one station the practical skill to perform a lumbar puncture at the phantom. The results of the OSCE stations were analysed for task difficulty, discriminatory power, normalized discrimination index and reliability. Using a questionnaire, the students evaluated the OSCE. RESULTS: N = 123 students (73 female, 50 male) with a mean age of 26.1 years (22 - 46 years) participated. The mean score was 40 +/- 3.6 of a total of 50 points (range 29 - 46). Female students (40.8 +/- 3.1) scored significantly higher than male ones (38.8 +/- 4; p = .002). One student (0.8 %) failed the examination. The difficulty of the stations ranged between 0.63 and 0.91, normalized discrimination index between 0.1 and 0.18 and the discriminatory power from r = 0.25 to r = 0.53. The reliability of the 5 stations was 0.65 (Cronbach's alpha). In the evaluation, the rating for innovation, organisation, length, clarity of the tasks, clinical reality and compatibility with general physician's competence, atmosphere during the examination and fairness was extremely positive. Most students would prefer an OSCE compared with a multiple-choice test. CONCLUSION: An OSCE at the end of the neurology clerkship is feasible. The quantitative analyses of the results are concordant with requirements of medical examinations. The OSCE is positively evaluated by the students.

Effects of peer-assisted training during the neurology clerkship: a randomized controlled study.

OBJECTIVE: To determine the efficacy of peer-assisted clinical skills training for students during their neurology clerkship. METHODS: Students (n = 122) were randomized to get clinical skills training from either student (peer) instructors (experimental group) or from experienced clinical staff (control group). The remaining schedule during the clerkship did not differ between both groups. Primary endpoint was students' practical skills and knowledge tested at the end of the course by a written test and objective structured clinical examination (OSCE). Secondary endpoints were evaluation of the practical training and self-estimated gain in theoretical and practical competence. RESULTS: In the written test, the peer-trained group (n = 66) scored 69.5 +/- 10.2 (95% CI 67-72) points of 100 and the postgraduates-trained group (n = 56) 66.7 +/- 11.4 (95% CI 63.6-69.8) (P = 0.15). In the OSCE the peer-trained group scored 93.7 +/- 6.3 (95% CI 92.1 to 95.2) points of 100 and the postgraduates-trained group 92 +/- 5.1 (95% CI 90.6 to 93.4) (P = 0.11). In the evaluation and self-assessment items, there was no significant difference between the two groups except for the postgraduates' higher competence (P = 0.004). CONCLUSION: Peer-trained students pass written exam and OSCE as efficient as postgraduates-trained students. Self-assessed learning success is equally rated in both groups.

[The Erlangen examination. An alternative to multiple choice testing for German neurology students]. / ERlanger Neurologisches Examen-STrukturiert (ERNEST). Alternative zur Multiple-Choice-Prüfung zum Abschluss des Blockpraktikums Neurologie.

BACKGROUND: With the latest revision of the German Medical Licensing Regulation in 2002, educating faculties gained more freedom in the organisation and assessment of trainees. The Erlangen Neurological Exam Structured (ERNEST) is an alternative for assessing competency in clinical knowledge at the end of the neurological general education. The answers must be given in written, short essay format. METHOD: The students (mostly 5th year of medical education) underwent the ERNEST including eight sections with ten to 15 questions each and the MC examination as had been applied earlier. The results were given in percentage scores. The examination was evaluated by a questionnaire using Likert scales. RESULTS: A total of 128 students (81 women, 47 men) with a mean age of 25.3 years (range 22-33) completed their initial training by the exam. The mean score was 69.6% in the ERNEST and 73.4% in the MC part (P<0.001). Of the students 12.5% in ERNEST and 11.7% in the MC (nonsignificant) failed to reach the projected score of 60% to pass the exam. Correlation between the ERNEST and MC results was significant, with r=0.784 (Pearson's coefficient, P<0.001). The students evaluated the aspects innovation, length, format, clarity of the tasks, closeness to reality, and compatibility with general physician's practice as predominantly positive. CONCLUSION: The ERNEST is a viable alternative form of assessment as compared to the conventional MC exam. The basic quantitative parameters of the assessment comply with the requirements of medical assessments. The students evaluated ERNEST as mainly positive.

Time course of VCAM-1 and ICAM-1 in CSF in patients with basal ganglia haemorrhage.

OBJECTIVES: In a pilot study we found a correlation of the clinical outcome with adhesion molecule (AM) concentrations in ventricular cerebrospinal fluid (CSF) but not in serum in patients with intracerebral haemorrhage. We now determined the time course of AM concentration in CSF and serum after basal ganglia haemorrhage (BGH) in order to further uncover pathogenetic mechanisms. MATERIALS AND METHODS: We included 11 patients with acute BGH and ventricular tamponade in which an extraventricular drainage had been applied to treat ventricular ballonade. Paired CSF and serum samples were obtained within 8 h after onset of BGH, as well as on the consecutive days 2, 4, 6, and 8, respectively. The concentrations of soluble ICAM-1 (sICAM-1) and VCAM-1 (sVCAM-1) in CSF and serum were measured by enzyme-linked immunosorbent assay. Moreover, we determined blood volume and perifocal oedema by a semi-automated planimetry technique from initial cranial computed tomography scans. RESULTS: sICAM-1 and sVCAM-1 levels in CSF were highest within the first hours after onset of BGH, then decreased significantly (P < 0.005 and <0.05, respectively) on day 2 and slightly increased thereafter. Furthermore, BGH volume was significantly correlated with the concentrations of sICAM-1 (r = 0.63, P < 0.05) and sVCAM-1 (r = 0.66, P < 0.05) in ventricular CSF but not in serum. CONCLUSIONS: Our results might indicate that the local inflammatory reaction is pronounced early after onset of BGH and appears to be restricted to the central nervous system. Moreover, AM concentrations measured early after BGH onset correlated stronger with radiological and clinical data than follow-up measurements.

[Retropharyngeal tendinitis. Differential diagnosis in the management of acute neck pain]. / Retropharyngeale Tendinitis. Differenzialdiagnose des akuten Zervikalsyndroms.

Neck pain is frequent and can be a symptom of numerous differential diagnoses with quite different diagnostic and therapeutic consequences. A 37-year-old woman reported acute neck pain aggravated by movements of the cervical spine and head and by swallowing. Clinical examination showed pronounced neck stiffness. T2-weighted MRI demonstrated high-intensity edema and effusion localized prevertebrally in the area of the superior part of the longus colli muscle. Computed tomography of this region demonstrated prevertebral calcification leading to the diagnosis of retropharyngeal tendinitis. Nonsteroidal antiphlogistic drugs led to rapid improvement of clinical signs and symptoms. Retropharyngeal tendinitis should be considered in patients with acute neck pain.

Taste in dementing diseases and parkinsonism.

Like with many sensory abilities a reduction of taste and smell occurs during aging. Since there are hints to an additional reduction in dementing diseases, we assessed 52 patients, 26 women and 26 men, who were presented to a memory clinic, using the Sniffin' Sticks, Whole Mouth and Taste Strip Tests. While smoking, alcohol consumption, intake of drugs and sex exerted only minor impact, age and the severity of cognitive impairment were of major importance. There was a moderate but significant correlation between the severity of dementia, taste and smell, even if the age effect was partialled out. Notably, patients with Parkinson syndrome showed worse taste and smell abilities than those without. Here the differences were indeed marked enough to play a possible role in making the diagnosis. This exploratory study confirms a mild reduction of gustatory function in dementing diseases over and beyond that of normal aging which--in addition to a reduction of smell--seems to be especially marked in Parkinson syndromes.