The "Neurological Hat Game": A fun way to learn the neurological semiology.

INTRODUCTION: In-class courses are deserted by medical students who tend to find it more beneficial to study in books and through online material. New interactive teaching methods, such as serious games increase both performance and motivation. We developed and assessed a new teaching method for neurological semiology using the "Hat Game" as a basis. METHODS: In this game, two teams of second-year medical students are playing against one another. The game is played with a deck of cards. A neurological symptom or sign is written on each card. Each team gets a predefined period of time to guess as many words as possible. One member is the clue-giver and the others are the guessers. There are three rounds: during the first round, the clue-giver uses any descriptive term he wants and as many as he wants to make his team guess the maximum number of words within the allocated time. During the second round, the clue-giver can only choose one clue-word and, during the third round, he mimes the symptom or sign. The team that has guessed the most cards wins the game. To assess the efficacy of this learning procedure, multiple choices questions (MCQs) were asked before and after the game. Exam results of second-year students on their final university Neurology exam were analyzed. A satisfaction survey was proposed to all participating students. RESULTS: Among 373 students, 121 volunteers (32.4%) were enrolled in the "Neurology Hat Game" and 112 attended the game. One hundred and seven of the 112 students completed the MCQs with a significant improvement in their responses after the game (P<0.001). The 112 students who completed the satisfaction self-administered questionnaire were very satisfied with this funny new teaching method. CONCLUSIONS: Teaching neurological semiology via the "Hat Game" is an interesting method because it is student-centered, playful and complementary to the lecturer-centered courses. A randomized controlled study would be necessary to confirm these preliminary results.

'The Move', an innovative simulation-based medical education program using roleplay to teach neurological semiology: Students' and teachers' perceptions.

INTRODUCTION: Neurological disorders are frequently being managed by general practitioners. It is therefore critical that future physicians become comfortable with neurological examination and physical diagnosis. Graduating medical students often consider neurological examination as one of the clinical skills they are least comfortable with, and they even tend to be neurophobic. One way to improve the learning of neurological semiology is to design innovative learner-friendly educational methods, including simulation training. METHODS: The feasibility of mime-based roleplaying was tested by a simulation training program in neurological semiology called 'The Move'. The program was proposed to third-year medical students at Pierre and Marie Curie University in Paris during their neurology rotation. Students were trained to roleplay patients by miming various neurological syndromes (pyramidal, vestibular, cerebellar, parkinsonian) as well as distal axonopathy, chorea and tonic-clonic seizures. Using an anonymous self-administered questionnaire, the students' and teachers' emotional experience and views on the impact of the program were then investigated. RESULTS: A total of 223/365 students (61%) chose to participate in the study. Both students and teachers felt their participation was pleasant. Students stated that The Move increased their motivation to learn neurological semiology (78%), and improved both their understanding of the subject (77%) and their long-term memorization of the teaching content (86%). Although only a minority thought The Move was likely to improve their performance on their final medical examination (32%), a clear majority (77%) thought it would be useful for their future clinical practice. Both students (87%) and teachers (95%) thought The Move should be included in the medical curriculum. CONCLUSION: Mime-based roleplaying simulation may be a valuable tool for training medical students in neurological semiology, and may also help them to overcome neurophobia.

[Association between students' clinical performance and their success in the computerized national ranking tests: A single-center retrospective cohort study]. / Association entre les performances cliniques des étudiants et leur réussite aux Épreuves classantes nationales informatisées : une étude de cohorte rétrospective monocentrique.

INTRODUCTION: Before attending residency, 6th-year French medical students must validate a final examination including a practical clinical test in their faculty. However, the national ranking that determines their future specialty and region solely relies on a computerized knowledge test. Our goal was to investigate the association between the final faculty test and the national ranking test. METHODS: In our faculty, the final examination includes a computerized theoretical test (similar to the national one) and a practical test: a standardized evaluation of semiology skills at the bedside and a standardized assessment of relational skills with role plays. The agreements between the national test and faculty computerized and practical tests were analyzed by intraclass correlation coefficients (ICC). RESULTS: Data from 1806 students who underwent the three examinations from 2017 to 2021 were analyzed. There was a good agreement between the ranks in the faculty and national computerized tests: ICC 0.83 (95% CI 0.81-0.85). By contrast, the agreement between the ranks in the faculty practical test and the national computerized test was poor: ICC 0.13 (95% CI 0.08-0.17). Results were stable over the years. CONCLUSION: The agreement between the ranking of the current national test and the clinical skills assessed by a specific faculty test is poor. This could relate to a true independence or to different levels of motivation to perform well. Indeed, the result of the national test is the most important one as it determines their career. Incorporating a clinical assessment into the national ranking test will motivate students to acquire clinical skills and value those who perform well this practical dimension.

A case of recurrent vulvar carcinoma treated with erlotinib, an EGFR inhibitor.

BACKGROUND: There is no effective therapy for patients with regional and/or distant recurrence of vulvar carcinoma. Recently two case reports about the use of erlotinib, an EGFR (epithelial growth factor receptor) inhibitor, in the context of recurrent vulvar cancer were published with a good clinical response reported. CASE: We report a case where erlotinib was used in a 67-year-old patient with recurrent and multi-treated vulvar carcinoma. Utilization of erlotinib was started with rapid clinical improvement. The treatment was well tolerated with palliation of symptoms. A CT scan also showed cutoff "net" improvement, with regression of size and number of hilar and pulmonary metastases. After one month of improvement, despite continuous treatment with erlotinib, dyspnea returned. A new CT scan showed an increased number of hilar nodes, a new hepatic lesion and increase in the size of the known pelvic lesion. CONCLUSION: EGFR inhibitors appear to be promising agents for this devastating and fatal disease. As with other studies with these agents, our patient showed a rapid response with important palliation of symptoms, however of short duration.

Are script concordance tests suitable for the assessment of undergraduate students? A multicenter comparative study.

INTRODUCTION: Script concordance tests (SCTs) have been developed to assess clinical reasoning in uncertain situations. Their reliability for the evaluation of undergraduate medical students has not been evaluated. METHODS: Twenty internal medicine SCT cases were implemented in undergraduate students of two programs. The results obtained on the SCTs were compared to those obtained by the same students on clinical-based classical multiple-choice questions (MCQs). RESULTS: A total of 551/883 students (62%) answered the SCTs. The mean aggregate score (based on a total 20 points) was 11.54 (3.29). The success rate and mean score for each question did not differ depending on the modal response but the discrimination rate did. The results obtained by the students on the SCT test correlated with their scores on the MCQ tests. Among students, 446/517 (86%) considered the SCTs to be more difficult than classical MCQs, although the mean score did not differ between the SCT and MCQ tests. CONCLUSION: The use of SCTs is a feasible option for the evaluation of undergraduate students. The SCT scores correlated with those obtained on classical MCQ tests.

Progressive clinical case-based multiple-choice questions: An innovative way to evaluate and rank undergraduate medical students.

INTRODUCTION: In France, at the end of the sixth year of medical studies, students take a national ranking examination including progressive clinical case-based multiple-choice questions (MCQs). We aimed to evaluate the ability of these MCQs for testing higher-order thinking more than knowledge recall, and to identify their characteristics associated with success and discrimination. METHODS: We analysed the 72 progressive clinical cases taken by the students in the years 2016-2019, through an online platform. RESULTS: A total of 72 progressive clinical cases (18 for each of the 4 studied years), corresponding to 1059 questions, were analysed. Most of the clinical cases (n=43, 60%) had 15 questions. Clinical questions represented 89% of all questions, whereas basic sciences questions accounted for 9%. The most frequent medical subspecialties were internal medicine (n=90, 8%) and infectious diseases (n=88, 8%). The most frequent question types concerned therapeutics (26%), exams (19%), diagnosis (14%), and semiology (13%). Level 2 questions ("understand and apply") accounted for 59% of all questions according to the Bloom's taxonomy. The level of Bloom's taxonomy significantly changed over time with a decreasing number of level 1 questions ("remember") (P=0.04). We also analysed the results of the students among 853 questions of training ECNi. Success and discrimination significantly decreased when the number of correct answers increased (P<0.0001 both). The success, discrimination, mean score, and mean number of discrepancies did not differ according to the diagnosis, exam, imaging, semiology, or therapeutic type of questions. CONCLUSION: Progressive clinical case-based MCQs represent an innovative way to evaluate undergraduate students.

Preservation of ovarian function by ovarian transposition prior to concurrent chemotherapy and pelvic radiation for cervical cancer. A case report and review of the literature.

BACKGROUND: For over 45 years, ovarian transposition has been proposed for patients with cervical cancer to preserve ovarian function prior to pelvic radiation. We report a case of preservation of ovarian function and regular normal menstrual cycles after pelvic cisplatin-based chemoradiation and perform a literature review. CASE: A 29-year-old female with cervical cancer underwent laparoscopic ovarian transposition prior to cisplatin-based chemoradiation. At 3-year follow-up after completion of her chemoradiation treatment indicated that she was still free of any disease. She is experiencing normal menstrual cycles at regular monthly intervals. CONCLUSION: The present case shows that it is possible to retain ovarian function and menstrual cycles by ovarian transposition prior to pelvic chemoradiation. This provides an option for cervical cancer patients who desire preservation of ovarian function.

[Münchausen syndrome with forgery on biologic results. A case report]. / Pseudoleucémie par falsification d'examens biologiques: genèse d'un syndrome de Münchausen.

Münchausen syndrome is a disorder defined by the following: acute factitious symptoms leading to inappropriate investigation and therapy, a restless journey from hospital to hospital and autobiographical falsification. We report here a 20-year-old woman who presented at our hospital consultation of internal medicine with laboratory-test results suggesting the diagnosis of leukemia. A new complete blood cells count and a medullogram by sternal puncture did not show any abnormality. Comparative examination of laboratory-test sheets lead to the diagnosis of Münchausen syndrome as some results had been falsified. With unlimited access to information through internet and word or image processing softwares, laboratory results have become easy to falsify nowadays, particularly for patients with Münchausen syndrome, who may then be quite difficult to diagnose accurately in the context of medical consultation.

Lymph node metastases in low-grade endometrial stromal sarcoma.

OBJECTIVES: The objective of this study was to review our experience on lymphatic dissemination in patients with low-grade endometrial stromal sarcoma. METHODS: All cases diagnosed as low-grade endometrial stromal sarcoma or endolymphatic stromal myosis before October 2003 and who had lymph node sampling at some point in their evolution were retrieved from the files of the pathology and gynecologic oncology departments of l'Hotel-Dieu de Quebec University Hospital (HDQ). RESULTS: Fifteen patients with either limited lymph node biopsies or a complete lymph node dissection at some point in the course of their disease were found. Five of these patients (33%) presented lymph node metastases either at the initial hysterectomy, during a subsequent staging procedure, or at the time of a recurrence. CONCLUSION: These findings suggest that the incidence of lymph node involvement in low-grade endometrial stromal sarcoma is higher than expected. More extensive sampling of lymph nodes in a larger number of patients may allow a better understanding of the frequency and prognostic significance of these metastases.

Combined laparoscopic and vaginal radical surgery in cervical cancer.

OBJECTIVE: The purpose of our study was to review our experience with laparoscopic staging and vaginal radical surgery in the treatment of early stage cervical cancer. STUDY DESIGN: We reviewed the charts of 102 patients who had a laparoscopic pelvic lymphadenectomy followed by vaginal radical hysterectomy (VRH) or vaginal radical trachelectomy (VRT). RESULTS: Patients' age ranged from 25 to 68 years (median: 36). Squamous and adenocarcinoma histology occurred in 68 and 32%, respectively. Stage Ib1 occurred in 77% of cases and the rest were stage Ia1 (1%), 1a2 (16%), and IIa (6%). Patients were divided into three groups: VRH (57), VRT (34), and node only (NO) (11), when positive nodes were identified on frozen section. Median operative time for VRH and VRT were 270 and 260 min compared to 200 min in the NO group (half also had bilateral paraaortic node dissection, which lengthened the OR time). Hospital stay was shorter in the NO group (2 days). For each group (VRH, VRT, and NO) the median pelvic node count was 27, 26, and 23 and the median paraaortic node count was 3, 4, and 9. Two VRH were converted to an abdominal procedure because of technical difficulties and one VRT was converted to a VRH because of positive endocervical margins. Intraoperative complications related to laparoscopy included two iliac and one epigastric vessel injuries. Complications related to the radical surgeries included three cystostomies, managed vaginally, and a laparotomy for parametrial bleeding after VRT. Postoperative complications occurred in 6% of patients and only one was considered major (an abscess which required surgical drainage). Overall, there were only four recurrences in the vaginal surgery groups and one in the NO group. There were no ureteral or intestinal injuries and there have been no trocar site recurrences. CONCLUSION: Our data show that approaching cervical cancer with a combined laparoscopic and vaginal surgery is feasible. The overall morbidity and complication rate are low and the lymph node count is satisfactory. Staging the nodes laparoscopically first to identify positive nodes is advantageous, particularly since we favor the use of chemoradiation therapy in those cases. The laparoscopic node staging thus avoids an unnecessary laparotomy in patients with positive nodes, reduces morbidity, and allows for early radiation therapy.

Nitrous oxide concentration during cryotherapy.

OBJECTIVE: The purpose of this study was to record room air concentrations of nitrous oxide during sessions of cryotherapy and to compare them with available norms. Complementary objectives were to determine the knowledge of Canadian colposcopists and to evaluate the need for education regarding nitrous oxide toxicities. MATERIAL AND METHODS: Air concentrations of nitrous oxide during cryotherapy sessions were measured with an infrared gas analyzer. A survey was sent to colposcopists throughout Canada to evaluate their knowledge of toxicities of nitrous oxide. RESULTS: The mean air concentrations of nitrous oxide measured were 169, 91, 99, and 103 ppm, respectively. Adding a tube to the cryotherapy scavenging outlet to dispose of the gas diminished the concentration to 17 ppm. The survey showed that 74% of the gynecologists surveyed use nitrous oxide as a refrigerant and only 18% know about the toxicities of nitrous oxide. CONCLUSION: Without a device to dispose of nitrous oxide securely during cryotherapy, the air concentration exceeds safe levels. Education of clinicians on the toxicities of nitrous oxide should be a goal in the future.

Vaginal radical hysterectomy versus abdominal radical hysterectomy in the treatment of early-stage cervical cancer.

The purpose of this study is to compare the safety, efficacy, and potential benefits of vaginal radical hysterectomy (VRH) versus abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer. We reviewed the charts of our first 52 patients with cervical cancer. We reviewed the charts of our first 52 patients with cervical cancer who underwent a laparoscopic pelvic lymphadenectomy (LPL), followed either by a VRH (Schauta) in 25 cases or ARH in 27 cases. For the 52 patients, the mean lymph nodes count obtained by LPL was 27 (range 8-59), and the only complication was an external iliac vein trauma requiring laparotomy. Both VRH and ARH groups were comparable in terms of age, weight, parity, stage, histology, and tumor volume. The mean blood loss was 400 cc for VRH vs 450 cc for ARH, operating time was 270 min vs 280 min, blood transfusion in 5 vs 4 women, and postoperative stay was 7 days for both groups. The only intraoperative complication in addition to the vein trauma was a cystotomy which occurred in 2 VRH patients. Febrile morbidity was noted in 4 VRH patients vs 9 ARH patients. There were one preperitoneal abscess and one hematoma in the VRH group vs 4 wound infections and 1 hematoma after ARH. Ileus occurred in 1 VRH vs 4 ARH patients. The current mean follow-up time is 27 months (8-52) and there has been one recurrence so far in the ARH group. Even though this is a retrospective study, our data indicate that VRH and ARH are comparable, except for the absence of an abdominal scar and less febrile morbidity with the vaginal approach. However, in our opinion, the main advantage in learning the Schauta operation is that the experience gained allows one to offer radical trachelectomy to selected young patients who wish to preserve their fertility.