An observational study of an approach to accommodate a fourth-year to third-year neurology clerkship curricular transition.

Background: Curricular transformation can result in bulges in students' clinical placements.Objective: To report on learner outcomes associated with a competency-based opt-out approach for a required 4th-year neurology clerkship.Methods and Study Design: During Oregon Health & Science University's recent undergraduate medical education curricular transformation, a 4-week required neurology clerkship transitioned from the fourth-year to the third-year in academic year 2016-17. Because this would have resulted in the neurology clerkship accommodating double enrollment for an entire academic year, 4th year medical students from the prior curriculum (graduating class of 2017) were offered the option of opting-out of the required neurology clerkship if they demonstrated competency by passing the USA National Board of Medical Examiners (US-NBME) clinical neurology subject examination and completing a neurology faculty-observed history and complete neurological examination.Results: Fifty-seven of 133 fourth-year students (42.9%) chose to complete the required neurology clerkship with 77 (57.9%) choosing to opt-out. All opt-out students passed the neurological exam assessment and scored similarly to the students who took the clerkship (US-NBME Neurology Subject Exam mean raw score in the opt-out group 76.9 vs, 77.6; p = 0.61). Students grades did not differ. Students who opted-out tended to pursue surgical careers (e.g., general surgery -10.8% opted-out vs 0% clerkship, OB/GYN - 6.8% opted-out vs 0% clerkship, orthopedic surgery 5.4% opted-out vs 0% clerkship) where those who took the clerkship tended to choose medical residency training disciplines (family medicine -16.1% clerkship vs 10.8% opting-out; internal medicine - 32.1% clerkship vs 14.9% opting-out; psychiatry 10.7% clerkship vs 2.7% opting-out (p = 0.042)Conclusion: While undertaking the neurology clerkship would have been the desired approach, students appear not to have been harmed by the opt-out approach regarding performance on the US-NBME clinical neurology subject exam. Choices regarding opting-out versus taking the neurology clerkship appear to be associated with career choice.

Tumefactive Demyelinating Lesions in Multiple Sclerosis and Associated Disorders.

Tumefactive demyelinating lesions are rare consequences of central nervous system (CNS) idiopathic inflammatory demyelinating diseases. Tumefactive demyelinating lesions pose a diagnostic challenge because they can mimic tumors and abscesses and because they can be caused by a heterogeneous range of disorders. This article reviews the recent literature on the clinical presentation; radiographic features; prognosis; and management of tumefactive demyelinating lesions in multiple sclerosis, acute demyelinating encephalomyelitis, neuromyelitis optica, and the rare variants of multiple sclerosis including Schilder's disease, Marburg acute multiple sclerosis, and Balo's concentric sclerosis.

Immunopathology of Japanese macaque encephalomyelitis is similar to multiple sclerosis.

Japanese macaque encephalomyelitis (JME) is an inflammatory demyelinating disease that occurs spontaneously in a colony of Japanese macaques (JM) at the Oregon National Primate Research Center. Animals with JME display clinical signs resembling multiple sclerosis (MS), and magnetic resonance imaging reveals multiple T2-weighted hyperintensities and gadolinium-enhancing lesions in the central nervous system (CNS). Here we undertook studies to determine if JME possesses features of an immune-mediated disease in the CNS. Comparable to MS, the CNS of animals with JME contain active lesions positive for IL-17, CD4+ T cells with Th1 and Th17 phenotypes, CD8+ T cells, and positive CSF findings.

Botulinum toxin for symptomatic therapy in multiple sclerosis.

Botulinum toxin (BT) is a neurotoxin that paralyzes muscles by inhibiting release of acetylcholine from presynaptic vesicles at the neuromuscular junction. In people with multiple sclerosis (MS), clinical experience and research studies show that local injection of minute quantities of BT can temporarily control skeletal muscle spasticity, bladder detrusor hyperreflexia, and tremor. Specifically, BT injections have been shown to reduce muscle tone and improve passive function, and possibly improve active function, in patients with spasticity. Injection of BT into the bladder wall is a uniquely effective, safe, and durable treatment in patients with neurogenic detrusor hyperreflexia due to MS who have insufficient response or who do not tolerate oral antimuscarinic medications. This procedure has markedly reduced the need for indwelling catheters and bladder surgery. In addition, a recent study suggests BT may be effective for select patients with MS-associated upper extremity tremor. Appropriate use of BT can improve quality of life for many patients with MS.

Potential for misdiagnosis in community-acquired PET scans for dementia.

We reviewed records of patients seen in a tertiary Neurobehavior Clinic to identify those who had community-acquired PET scans as part of their dementia diagnostic evaluation with the goal of assessing factors influencing diagnostic accuracy. We compared outside radiologist PET diagnoses to our consensus clinical diagnosis and collected data regarding clinical variables, ordering reasons, and specialties of interpreting and ordering physicians. Among 1,580 total patients seen in our clinic, 46 met our inclusion criteria. There was disagreement between outside diagnosis based on PET and our consensus diagnosis in 65% (n = 30) of patients. Community-acquired PET scans may have lower diagnostic value in dementia evaluation than suggested by prior research and may be associated with significant risks including misdiagnosis with an incurable neurodegenerative disease.