Teaming beyond the clinical environment - building collective commitment across graduate medical education.

This commentary provides evidence and expert opinion on effective relationships and communication strategies for trainee and graduate medical education leaders. The authors also argue that consistent communication and alignment of goals between trainee leadership and graduate medical education leadership are essential components of a successful collaboration that promotes trainee well-being.

Occipital neuralgia associates with high cervical spinal cord lesions in idiopathic inflammatory demyelinating disease.

BACKGROUND: The association of trigeminal neuralgia with pontine lesions has been well documented in multiple sclerosis, and we tested the hypothesis that occipital neuralgia in multiple sclerosis is associated with high cervical spinal cord lesions. METHODS: We retrospectively reviewed the records of 29 patients diagnosed with both occipital neuralgia and demyelinating disease by a neurologist from January 2001 to December 2014. We collected data on demographics, clinical findings, presence of C2-3 demyelinating lesions, and treatment responses. RESULTS: The patients with both occipital neuralgia and multiple sclerosis were typically female (76%) and had a later onset (age > 40) of occipital neuralgia (72%). Eighteen patients (64%) had the presence of C2-3 lesions and the majority had unilateral symptoms (83%) or episodic pain (78%). All patients with documented sensory loss (3/3) had C2-3 lesions. Most patients with progressive multiple sclerosis (6/8) had C2-3 lesions. Of the eight patients with C2-3 lesions and imaging at onset of occipital neuralgia, five (62.5%) had evidence of active demyelination. None of the patients with progressive multiple sclerosis (3/3) responded to occipital nerve blocks or high dose intravenous steroids, whereas all of the other phenotypes with long term follow-up (eight patients) had good responses. CONCLUSIONS: A cervical spine MRI should be considered in all patients presenting with occipital neuralgia. In patients with multiple sclerosis, clinical features in occipital neuralgia that were predictive of the presence of a C2-3 lesion were unilateral episodic symptoms, sensory loss, later onset of occipital neuralgia, and progressive multiple sclerosis phenotype. Clinical phenotype predicted response to treatment.

Carotid Cavernous Fistula Mimicking Hemicrania Continua: A Case Report.

BACKGROUND: Hemicrania continua is a primary headache disorder characterized by a continuous, unilateral headache associated with ipsilateral cranial autonomic features that responds to indomethacin. By definition, the symptoms are not referable to an underlying structural pathology. However, several cases of secondary hemicrania continua related to underlying structural lesions have been reported. CASE: We present a case of a 53-year-old male with a prolonged, right-sided headache associated with intermittent right-sided ptosis, conjunctival injection, tearing, and nasal congestion, suggestive of hemicrania continua, who was found to have an indirect carotid-cavernous fistula, and who, after endovascular treatment of the fistula, had resolution of his symptoms. CONCLUSION: Alternative, and perhaps less common, causes of headache should be considered when the clinical presentation is atypical or does not clearly fulfill diagnostic criteria for primary headache disorders. Carotid cavernous fistulas should be included within this differential, and represent a potentially treatable and reversible cause of otherwise refractory headache.

Renaut Corpuscles or Peripheral Nerve Infarcts? A Historical Overview.

Renaut corpuscles are cylindrical hyaline structures that arise from the peripheral nerve perineurium and project into the endoneurium. Despite their earlier accurate description in the French and German literature, Kernohan and Woltman (1938) reported very similar structures as "nerve infarcts" in a case series of vasculitic neuropathy. Krücke (1955) deserves credit for discovering this error and further explaining how peripheral nerves react differently (from brain parenchyma) to ischemia. We tried to elucidate the reason why Kernohan and Woltman, and others, made this scientific error by describing the historical evolution of our understanding of the structure and function of Renaut corpuscles.

Trigeminal Neuralgia and Multiple Sclerosis: A Historical Perspective.

Trigeminal neuralgia (TN) associated with multiple sclerosis (MS) was first described in Lehrbuch der Nervenkrankheiten für Ärzte und Studirende in 1894 by Hermann Oppenheim, including a pathologic description of trigeminal root entry zone demyelination. Early English-language translations in 1900 and 1904 did not so explicitly state this association compared with the German editions. The 1911 English-language translation described a more direct association. Other later descriptions were clinical with few pathologic reports, often referencing Oppenheim but citing the 1905 German or 1911 English editions of Lehrbuch. This discrepancy in part may be due to the translation differences of the original text.

An evidence-based review of oral magnesium supplementation in the preventive treatment of migraine.

BACKGROUND: Migraine is an incompletely understood, debilitating disorder that lacks a universally effective treatment. Magnesium participates in a variety of biochemical processes related to migraine pathophysiology, and a deficiency could contribute to migraine development. METHODS: A review of the literature from 1990 to the present on magnesium and migraine was conducted. REVIEW: The authors identified 16 studies aimed at magnesium status assessment in migraine, and four intervention trials assessing the efficacy of oral magnesium supplementation, independent of other therapies, in the prevention of migraine. CONCLUSION: The strength of evidence supporting oral magnesium supplementation is limited at this time. With such limited evidence, a more advantageous alternative to magnesium supplementation, in patients willing to make lifestyle changes, may be to focus on increasing dietary magnesium intake.

A tale of two systems: cardiac cephalalgia vs migrainous thoracalgia.

The practice of headache medicine is challenging, and excluding secondary causes of headaches is essential for proper diagnosis and treatment. The evaluation of secondary headaches often leads to investigations involving organ systems other than the nervous system. As such, headache, which is typically thought to be neurologic in origin, can be a manifestation of cardiac pathology in the form of cardiac cephalalgia. Conversely, chest pain, which is typically thought to be cardiac in origin, could be a manifestation of a neurologic disease process in the form of atypical migraine aura. In the presented cases, we demonstrate headaches that involve cardiac and neurologic pathology with atypical presentations.

Osler on migraine.

William Osler's 1892 textbook The Principles and Practice of Medicine became the dominant medical text in the English-speaking world. Osler was labeled a therapeutic nihilist by some. The topic of migraine, including treatment, was succinctly covered in his text. The objectives of this study were to review Osler's thoughts on migraine, and outline his therapeutic recommendations. Preventively Osler mentioned bromides, iron, arsenic, nitroglycerin, and cannabis. Acutely he recommended coffee, chloroform, cannabis, antipyrin, antifebrin, phenacetin, caffeine citrate, nux vomica, or ergot. He thought cannabis was the most satisfactory remedy. Osler was not a therapeutic nihilist when it came to migraine, and his treatment recommendations were similar to other writers of his time. Osler did not draw upon his personal experience to contribute new knowledge about migraine. Regardless, given the popularity and clarity of his text, Osler's well-summarized migraine chapter had a great influence on practicing physicians.

Silas Weir Mitchell on epilepsy therapy in the late 19th to early 20th centuries.

Silas Weir Mitchell (1829-1914), one of the fathers of American neurology, is well known for many contributions to neurology. However, his efforts in epilepsy are overshadowed by his other accomplishments. Mitchell introduced a new bromide preparation, lithium bromide, as a viable therapy. His most widely accepted contribution to the field was the introduction of inhaled amyl nitrite for early termination of seizures accompanied by an appropriate aura. Despite the prevalent views on lifestyle modification as a treatment for epilepsy during this time period, as well as Mitchell's own development of the "rest cure" for certain disease states, he was not a proponent of these types of interventions for epilepsy, nor did he support interventions focused on other organ systems, such as abdominal or gynecologic surgery. Mitchell had distinct opinions on the treatment of epilepsy, and helped to advance its therapeutics during his career.

Leonard Rowntree, Louis Wilson, Fielding Garrison, and the origins of teaching medical history at the Mayo Clinic.

A visiting surgeon described his disappointment with an aspect of the Mayo Clinic in 1914, stating that there was "the almost lack of anything that could be dignified by the term 'lecture.'" One year later, the Mayo Foundation for Medical Education and Research was founded. By 1917, the foundation declared history of medicine a graduate-level subject, and history of medicine questions were included in final oral examinations. In 1920 and 1921, lectures were given on historical topics; however, these lectures petered out, and there were no historical lectures in the official curriculum of 1923 or 1924. Enter Leonard Rowntree, who in 1926 proposed a lecture series on the history of medicine. Rowntree wrote to Fielding Garrison in early 1927 to ask for assistance selecting speakers. The two men corresponded and developed a list of eminent medical historians to invite, including Sir Charles Ballance, William Welch, and Garrison himself. These lectures served to enrich the greater Midwestern medical community as well thanks to Louis Wilson. Then head of the Mayo Foundation, Wilson wrote to nearby institutions to create a lecture circuit for speakers who traveled to the Mayo Clinic. Ultimately, the lectures were published as a book in 1933.

The Auxiliary to the American Academy of Neurology.

The American Academy of Neurology (AAN) was founded in 1948, and the Women's Auxiliary to the AAN was founded shortly thereafter. We reviewed historical archives of the AAN and Women's Auxiliary and interviewed past Auxiliary leaders to understand the perception and roles of neurologists' spouses. The Women's Auxiliary to the AAN was originally formed for the wives of neurologist Academy members with the intention of facilitating social and intragroup relationships. The first leaders and members of the organization included some of the spouses of the original Academy founders. With the original scope to provide socialization while the men were at meetings, the male neurologists initially planned much of the Auxiliary's activities. Over time, the Auxiliary's activities shifted and became women-led; engagement in community outreach grew, subcommittees expanded, and the group engaged in supporting the AAN in achieving its goals of improving neurology education and research. The change paralleled the women's movement with educational topics during the Auxiliary's meetings evolving from topics on homemaking to business and understanding neurologic diseases. The Auxiliary was intertwined with the Academy and initiated the S. Weir Mitchell Award and the Founders Award of the AAN in 1955 and 1994 to encourage basic and clinical research in neurology, respectively. In 1982, the Auxiliary requested increased involvement in the scientific programs at the annual meetings. Reflecting societal change, the name was changed to the "Auxiliary to the AAN" in the 1970s, and in the mid-1990s to the "Alliance to the AAN" to accommodate the increasing number of male partners of neurologists. Based on interviews, the Auxiliary provided engagement, empowerment, and connection between women. The Auxiliary's activities tapered in the late 1990s, in part due to changes in women's occupations, and to the rise of women's membership and leadership within the Academy.

History of migraine.

Migraine symptoms were described in ancient Babylonia, and supernatural forces were felt to play a role in etiology and treatment. This changed in the Greco-Roman period, when the (dis)balance of humors was considered in (patho)physiology and treatment based on this. Aretaeus distinguished between cephalalgia, cephalea, and heterocrania. The latter term was changed to hemicrania by Galen. Physicians in the 17th century attributed headache to the meninges, extracranial periost, and cranial blood vessels. As for the pathophysiology, Willis suggested intracranial vasoconstriction with subsequent dilatation. Tissot and Fothergill gave comprehensive descriptions of migraine, including visual symptoms. Symptomatic and idiopathic hemicrania were distinguished in the early 19th century. Vasomotor pathophysiology was scientifically studied in the 1860s, leading to sympathicotonic and angioparalytic theories. Latham combined them, stating the latter follows the first. Ergot was introduced in 1868; ergotamine was isolated in 1918. This led to the vasodilatation theory of migraine (Wolff), the discovery of 5-HT, and later the specific agonists. Aura and cortical spreading depression were studied in the early 1940s and related to spreading oligemia in the 1980s. Subsequently, hyperemia followed by oligemia after CSD was found. After the discovery of CGRP, a new a class of drugs became the subject of clinical studies.

Dr. Betty Clements: Breaking Gender Barriers in the Air Force and Neurology.

Women currently make up 45.9% of neurology residents and fellows, although little is known about the individual women who broke gender barriers to train as neurologists. Grace Elizabeth Betty Clements (1918-1965) was the first woman trainee at the Mayo Clinic to practice neurology and later became a founder of the Barrow Neurological Institute. Before paving the way for future women trainees in neurology, she served as a Women Airforce Service Pilot including flying atomic bomb planning missions during World War II. Following the war, her path to medicine included volunteering in the American Red Cross in the Philippines where she treated patients with Hansen disease (leprosy). Clements returned to her home state to complete medical school at the University of Nebraska before seeking neurologic training at the Mayo Clinic in 1954. Following additional training at Queen Square, she became a founder of the Barrow Neurological Institute in Phoenix, Arizona. Many early women in neurology have remarkable backgrounds that have equipped them for their career in medicine which Clements exemplifies.

Women in the Mayo Clinic Department of Neurology in its early years.

The stories of early women physicians in the field of neurology are seldom discussed. Understanding the history behind women in neurology can inform our current practice and uncover the possible origins of gender disparities in academic neurology. Utilizing annual section/department reports and other primary sources, we describe the first women trainees and staff who broke gender barriers to train and work in the Mayo Clinic Department of Neurology. The department was founded in 1913 when Walter Shelden became its first consultant. It was not until the 1950s that a woman completed her neurology training and went on to practice neurology. Throughout the early years of the training program, there were no women on staff, as it was not until the 1970s when the first women were hired as consultants.

Paroxysmal Panting: On Respiratory Crisis and Other Respiratory Curiosities in the Aftermath of Encephalitis Lethargica.

Pandemics in the early 20th century (and now with SARS-CoV-2) have been dominated by respiratory viruses damaging the lungs. Less is known about abnormal respiratory patterns from brain inflammation. One of the first descriptions of respiratory rhythm abnormalities was seen with an acute attack of epidemic encephalitis (encephalitis lethargica), and reports appeared soon after the original description in 1921. We reviewed these ill-remembered disorders of respiration rate, respiratory patterns, and respiratory tics. Most commonly, dysregulations occurred during the phase when ocular signs appeared. The early symptoms were an unrelenting tachypnea (panting) without air hunger and an inspiratory hold (fixés en inspiration forcée). Initially regarded as hysterical in nature, the later bizarre disorders of respiration were considered equally serious with attacks of gasping, panting, puffing, inspiratory breath holding, coughs, giggles, sighing, grunting, and moaning. These respiratory disorders were seen exclusively as part of a parkinsonian syndrome. Most remarkably, these attacks could be provoked by oxygen administration. These respiratory abnormalities with encephalitis lethargica are not well remembered. One purpose of recalling these episodes is to call attention to central causes of respiratory illness even in pandemics with respiratory viruses.

A case of sensory ataxia as the presenting manifestation of neurosarcoidosis.

Sarcoidosis rarely selectively affects the cauda equina with characteristic motor and sensory impairments.Using imaging, we report a case of cauda equina polyradiculopathy presenting with progressive sensory ataxia without clinical or electrophysiological evidence of motor involvement. Neurosarcoidosis was diagnosed pathologically by proximal dorsal root biopsy after systemic investigations for inflammatory, infectious, and neoplastic etiologies were found to be negative. There was clinical and radiographic improvement with corticosteroids. In addition, we review previously reported cases of cauda equina sarcoidosis.

A history of non-drug treatment in headache, particularly migraine.

Although new invasive procedures for the treatment of migraine have evolved during the past decades, the application of invasive procedures for this indication is not new. In this review, the history of non-drug treatments for migraine is discussed. Historical texts by physicians known to have written on headache and migraine (hemicrania), well-known books by physicians from the main historical periods up to 1900 and mainstream 20th century neurology handbooks were analysed. A large number of treatments have been tried, based on contemporaneous pathophysiological models that were not only applied to headache, but to medicine in general. Invasive procedures have been used for the more severe types of headache. Many treatments were based on ancient humoral theories up to the early 19th century. A new kind of invasive procedure appeared on the physician's palette in the 19th and 20th century, following the development of new ideas that were based on solid pathophysiology, after the introduction of scientific method into medicine. After its introduction in the mid-18th century, medical electricity became even more popular for the treatment of migraine following the discovery of vasomotor nerves in the mid-19th century, but at the end of that century a more critical attitude appeared. The discovery of the lumbar puncture (1892) and roentgenogram (1895) and increased knowledge of intracranial pressure led to a new series of invasive procedures for therapy-resistant migraine in the early 20th century. Vasospastic theories of migraine led to surgical procedures on the sympathetic nerves. Following the experiments by Graham and Wolff in the 1930s that emphasized the vasodilatation concept of migraine, sympathicolytic procedures again became popular, including vessel ligation of the carotid and middle meningeal arteries. The influence of suggestion and psychological phenomena recognized at the end of the 19th century probably played an important role in many of the procedures applied. These placebo effects, generally more powerful in invasive treatments, are discussed against the background of present-day invasive treatments for headache, where they are still a matter of concern.