Diagnostic Approach to the Patient with Altered Mental Status.

Acute encephalopathy is a common presenting symptom in the emergency room and complicates many hospital and intensive care unit admissions. The evaluation of patients with encephalopathy poses several challenges: limited history and examination due to the patient's mental status, broad differential diagnosis of systemic and neurologic etiologies, low yield of neurodiagnostic testing due to the high base rate of systemic causes, and the importance of identifying less common neurologic causes of encephalopathy that can be life-threatening if not identified and treated. This article discusses the differential diagnosis of acute encephalopathy, presents an approach to the history and examination in a patient with encephalopathy, reviews the literature on the yield of neurodiagnostic testing in this population, and provides a diagnostic framework for the evaluation of patients with altered mental status.

"A safe, non-judgmental space where I can really challenge myself:" learner experiences in a virtual, case-based diagnostic reasoning conference for students.

Case-based diagnostic reasoning conferences, like morning reports, allow undergraduate medical trainees to practice diagnostic reasoning alongside senior clinicians. However, trainees have reported discomfort doing so. Peer-assisted learning offers an alternative approach. We describe the design, implementation, and evaluation of a virtual, student-only diagnostic reasoning conference that leverages peer-assisted learning. Student virtual morning report's (VMR) design was informed by social and cognitive congruence and experience-based learning. We evaluated participant experiences using a survey focused on participant perceptions of Student VMR's value, their methods for participation, and their preferences for Student VMR compared with VMR with more senior clinicians. 110 participants (28.9%) completed the survey. 90 participants (81.2%) reported that Student VMR was educational. Compared to VMR, participants reported being more likely to participate in Student VMR by turning on their video (50.0%), presenting a case (43.6%), verbally participating (44.5%), or participating in the chat (70.0%). Strengths included a safe learning environment to practice DR and the opportunity to engage with an international learning community. When asked whether they preferred Student VMR or non-Student VMR, most respondents (64.5%, 71/110) identified that they did not have a preference between the two. A student-focused DR conference may offer a valuable complement to, but not a replacement of, apprenticeship-based DR case conferences.

Global impact of a virtual neurology morning report.

The global shortage and inequitable distribution of neurologists has led to significant gaps not only in neurology care, but also in neurology education. In order to increase access to neurology education, we developed neurology virtual morning report (NVMR), a virtual, open-access, case-based clinical reasoning conference available to learners worldwide. To evaluate NVMR's impact on participants' perception of, interest in, and confidence in neurology, we conducted a survey. Respondents represented 25 different countries of various income levels. The majority of respondents reported that NVMR decreased their perception of difficulty in understanding neurology and increased confidence in various clinical reasoning domains in neurology. Additionally, the majority of medical student participants showed an increased interest in pursuing neurology as a future specialty after participating in NVMR. NVMR represents a potential model for virtual educational conferences and highlights the opportunities digital education has to improve equitable access to neurology education.

Development and implementation of a case-based collaborative learning flipped classroom preclinical neurology course.

This paper describes the development, content, structure, and implementation of a case-based collaborative learning, flipped classroom, integrated preclinical neurology, neuroanatomy, and neuroscience course for first year medical students at Harvard Medical School. We report the methods for pre-class preparation, in-class instruction, and evaluation; student feedback with respect to content, teaching method, and learning environment; and several lessons learned regarding how to optimize preparatory and in-class learning in a case-based flipped classroom course.

Diagnostic reasoning in challenging cases.

Diagnostic reasoning relies on cognitive heuristics to recognise patterns of symptoms and signs in order to arrive at a diagnosis. These rules of thumb allow us to rapidly diagnose common conditions that present in typical ways. However, they may lead us astray when common conditions present atypically or when a patient has a rare condition or multiple conditions causing their constellation of symptoms, signs, and test results, rather than having a single diagnosis to explain them all. This article describes strategies to help counteract diagnostic pitfalls, to expand diagnostic possibilities and to make diagnostic progress with complex, multielement cases.

Metabolic and Toxic Myelopathies.

OBJECTIVE: This article reviews the clinical presentation, diagnostic evaluation, and treatment of metabolic and toxic myelopathies resulting from nutritional deficiencies, environmental and dietary toxins, drugs of abuse, systemic medical illnesses, and oncologic treatments. LATEST DEVELOPMENTS: Increased use of bariatric surgery for obesity has led to higher incidences of deficiencies in nutrients such as vitamin B12 and copper, which can cause subacute combined degeneration. Myelopathies secondary to dietary toxins including konzo and lathyrism are likely to become more prevalent in the setting of climate change leading to drought and flooding. Although modern advances in radiation therapy techniques have reduced the incidence of radiation myelopathy, patients with cancer are living longer due to improved treatments and may require reirradiation that can increase the risk of this condition. Immune checkpoint inhibitors are increasingly used for the treatment of cancer and are associated with a wide variety of immune-mediated neurologic syndromes including myelitis. ESSENTIAL POINTS: Metabolic and toxic causes should be considered in the diagnosis of myelopathy in patients with particular clinical syndromes, risk factors, and neuroimaging findings. Some of these conditions may be reversible if identified and treated early, requiring careful history, examination, and laboratory and radiologic evaluation for prompt diagnosis.

Clinical Features and Diagnosis of Intramedullary Spinal Cord Abscess in Adults: A Systematic Review.

BACKGROUND AND OBJECTIVES: Intramedullary spinal cord abscess (ISCA) was described 200 years ago but remains poorly understood and is often mistaken for immune-mediated or neoplastic processes. We present a systematic review of ISCA in adults, describing the clinical presentation, diagnostic features, treatment strategies, and outcomes. METHODS: Database searches for intramedullary abscess were performed on April 15, 2019, and repeated on February 9, 2022, using PubMed and EMBASE with 2 unpublished cases also included. Publications were independently reviewed for inclusion by 2 authors followed by adjudication. Data were abstracted using an online form and then analyzed for predictors of disability. RESULTS: A total of 202 cases were included (median age 45 years [interquartile range 31-58]; 70% male). Thirty-one percent of those affected had no identified predisposing condition. The most common symptom was weakness (97%), and the median symptom duration before presentation was 10 days (interquartile range 5-42). An MRI showed restricted diffusion in 100% of 8 cases where performed and enhancement in 99% of 153 cases where performed. The most common organisms were Mycobacterium tuberculosis (29%), Streptococcus sp. (13%), and Staphylococcus sp. (10%). All patients received antimicrobial therapy; surgical drainage was performed in 65%. At follow-up (median 6 months), 12% had died, 69% were ambulatory, and 77% had improved compared with clinical nadir. Of those who underwent operative intervention, surgery within 24 hours of diagnosis was associated with an increased likelihood of being ambulatory at follow-up compared with surgery after 24 hours (odds ratio 4.44; 95% CI 1.26-15.61; p = 0.020). DISCUSSION: ISCA is important to consider in any patient presenting with acute-to-subacute, progressive myelopathy. Immunocompromise and typical signs of infection (e.g., fever) are often absent. Diffusion restriction and gadolinium enhancement on MRI seem to be sensitive. Antimicrobial therapy with surgical drainage is the most common therapeutic approach, but morbidity remains substantial. If performed, urgent surgery may be more beneficial.

The case of a 49-year-old man with involuntary toe movements.

A 49-year-old man presented with 3 years of leg pain and involuntary toe movements. He described the pain as mild burning, radiating from the left foot upward to the leg. On examination, there were involuntary continuous flexion-extension movements of his left toes (video). Strength, sensation, and reflexes were normal. Lumbosacral MRI demonstrated diffuse degenerative disc disease with multi-level mild-to-moderate foraminal stenosis. Nerve conduction studies were normal. EMG showed neurogenic potentials and active denervation changes in the left anterior tibial and soleus muscles consistent with radiculopathy. The diagnosis of painful legs and moving toes is discussed.

Historical Perspectives on the Neurologic Manifestations of Viral Pandemics.

Neurologic symptoms have been reported in over 30% of hospitalized patients with coronavirus disease 2019 (COVID-19), but the pathogenesis of these symptoms remains under investigation. Here, we place the neurologic complications of COVID-19 within the context of three historical viral pandemics that have been associated with neurologic diseases: (1) the 1918 influenza pandemic, subsequent spread of encephalitis lethargica, and lessons for the study of COVID-19-related neuroinflammation; (2) the controversial link between the 1976 influenza vaccination campaign and Guillain-Barré Syndrome and its implications for the post- and parainfectious complications of COVID-19 and COVID-19 vaccination; and (3) potential applications of scientific techniques developed in the wake of the human immunodeficiency virus pandemic to the study of postacute sequelae of COVID-19.

Consensus Competencies for Postgraduate Fellowship Training in Global Neurology.

BACKGROUND AND OBJECTIVES: Use a modified Delphi approach to develop competencies for neurologists completing ≥1 year of advanced global neurology training. METHODS: An expert panel of 19 United States-based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, United States-based neurologists participated in 3 rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of 7 neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies. RESULTS: Three rounds of surveys, a conference call with United States-based experts, and a semistructured questionnaire and focus group discussion with LMIC experts were used to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across 8 domains: (1) cultural context, social determinants of health and access to care; (2) clinical and teaching skills and neurologic medical knowledge; (3) team-based practice; (4) developing global neurology partnerships; (5) ethics; (6) approach to clinical care; (7) community neurologic health; (8) health care systems and multinational health care organizations. DISCUSSION: These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.

A 47-Year-Old Man Presenting With Seizures and Prior Stroke.

A 47-year-old man presented to his local hospital in Peru after a generalized tonic-clonic seizure. His family reported a history of prior stroke of unclear etiology. This case report discusses the approach to a first seizure (including in tropical regions like Peru), the relationship between stroke and seizures, the approach to stroke in the young, and how to diagnose rare diseases in resource-limited settings.

Engaging teaching strategies in neurology: the flipped classroom and simulation training.

Just as neurology continues to expand its diagnostic and therapeutic modalities, so too does neurology education continue to expand in its pedagogical modalities. In this article, we describe two educational techniques-the flipped classroom and simulation-that we have incorporated in our teaching of neurology to students and doctors in training, with some practical tips for their successful implementation.

Clinical Problem-Solving: 72-Year-Old Woman With Multifocal Strokes and an Intracardiac Mass.

We present the case of a 72-year-old female with multifocal strokes found to have multiple, mobile intracardiac masses. We discuss the differential diagnosis and evaluation of intracardiac masses, and the challenges in management of the ultimately diagnosed etiology of stroke in this patient.

Approach to Neurologic Infections.

PURPOSE OF REVIEW: This article provides an overview of the clinical approach to the diagnosis of neurologic infections, focusing on the symptoms, signs, imaging features, and laboratory findings of the major categories of neuroinfectious diseases. RECENT FINDINGS: The increased use of immunosuppressive and immunomodulatory therapy to treat autoimmune diseases has led to an increase in opportunistic neurologic infections. The description of numerous causes of autoimmune antibody-mediated encephalitis over the past decade has expanded the differential diagnosis of encephalitis beyond infection. The emergence of metagenomic next-generation sequencing has led to diagnoses of rare or unexpected causes of neurologic infections and has the potential to enhance diagnostic precision in neuroinfectious diseases. SUMMARY: Infections of the nervous system can affect any level of the neuraxis and present over any time course. Neurologic infections may present atypically with respect to clinical, radiologic, and CSF analysis features in immunocompromised patients or older adults. A thorough evaluation including systemic features, past medical history, travel, exposures, detailed examination, neuroimaging, and CSF analysis is often necessary to make a definitive diagnosis. It is important to be aware of the test characteristics and limitations of microbiological tests on CSF for neurologic infections to avoid being misled by false positives or false negatives.

Meningitis.

PURPOSE OF REVIEW: This article reviews the diagnosis and treatment of infectious meningitis, including updates on newer molecular diagnostic techniques for microbiological diagnosis. RECENT FINDINGS: New polymerase chain reaction (PCR)-based molecular diagnostic techniques have improved the timeliness of microbiological diagnosis in meningitis, but clinicians must be aware of the limitations of such tests. Next-generation sequencing can now be applied to CSF, allowing for diagnosis of infections not identifiable by conventional means. SUMMARY: Infectious meningitis can be caused by a broad range of organisms. The clinician must be aware of the test characteristics of new molecular techniques for microbiological diagnosis as well as traditional techniques to tailor antimicrobial therapy appropriately in patients with meningitis.

Beyond electives: Rethinking training in global neurology.

Global health electives in neurology residencies provide opportunities for high-income country trainees, but have limited benefits-and may create burdens-for lower-income country hosts. Current suspension of global health electives for U.S. neurology residents due to the COVID-19 pandemic provides an opportunity to reflect on ways to reimagine global health education during this period and beyond. The framework proposed in this article underscores the need for equitable, bidirectional international partnerships and highlights global health educational innovations developed during the pandemic.