Matthew McCoyd

Why neurology? Factors which influence career choice in neurology.

Objective: To evaluate the factors which influence the decision to pursue a career in neurology. Methods: An anonymous survey was developed using a Likert scale to rate responses. The survey was sent to adult and child neurology faculty, residents and fellows, as well as medical students applying for neurology. Descriptive statistics were used to analyse the factors of influence. Respondents were subsequently categorized into pre-neurology trainees, neurology trainees, child neurologists and adult neurologists, and differences between the groups were analysed using Pearson’s chi-square test. Results: One hundred and thirty-three anonymous responses were received. The respondents were neurologists across all levels of training and practice. Across all respondents, the most common factor of high importance was intellectual content of specialty, challenging diagnostic problems, type of patient encountered and interest in helping people. Responses were similar across the groups; however, the earliest trainees cited interest in helping people as most important, while those in neurology training and beyond cite intellectual content of the specialty as most important. Discussion: As trainees transition from their earliest levels of clinical experience into working as residents and faculty, there is a shift in the cited important factors. Lifestyle and financial factors seem to be the least motivating across all groups. Encouragement from peers, mentors, faculty and practicing physicians is considered high influences in a smaller number of neurologists. This may present an opportunity for practicing neurologists to make connections with medical students early in their education in an effort to encourage and mentor candidates.

Update on Therapeutic Options for Multiple Sclerosis

Multiple sclerosis (MS) is one of the most common neurologic disorders that affects young people. The disorder has long been associated with clinical relapses and a disabling course. However, there has been a rapid expansion in the available treatment options for MS, and new insights into existing therapies, as decades of research has begun to produce tangible treatment results leading to newly approved an emerging therapies.

Biopsy Proven Tumefactive Multiple Sclerosis with Concomitant Glioma: Case Report and Review of the Literature

We report a case of pathologically confirmed tumefactive multiple sclerosis (MS) followed shortly thereafter by the diagnosis of an oligoastrocytoma. The complexity of diagnosis and management of concomitant presence of tumefactive MS and glial cell tumors is discussed.

Neurologic aspects of lymphoma and leukemias.

The leukemias and lymphomas represent a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized almost since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders has evolved along with our knowledge of the malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize the heralding features. This review focuses on the relevant clinical neurologic features and diagnostic studies to identify leukemias and lymphomas affecting the nervous system.

Neurocutaneous Disorders for the Practicing Neurologist: a Focused Review

The neurocutaneous disorders (NCDs) embrace an extensive group of developmental disorders associated with involvement of the skin, central nervous system (CNS), and/or the peripheral nervous system (PNS). The neurocutaneous manifestations relate to the common ectodermal origin of these organs. This review intended for the practicing clinical neurologist focuses on selected aspects of the NCDs primarily those associated with cerebrovascular disease. Our emphasis is primarily on those NCDs with genetic heterogeneity and their neurological manifestations.

Frequency of Direct Funduscopy Upon Initial Encounters for Patients with Headaches, Altered Mental Status, and Visual Changes: A Pilot Study.

Objective To determine the performance of direct funduscopy (DF) as part of the initial clinical assessment among different faculty physicians and residents from internal medicine, emergency medicine, and neurology (N). Methods Retrospective study of 163 randomly reviewed charts of patients (>18 years) presenting either to the ED, inpatient units, or outpatient clinics from January 2001 to July 2013, with corresponding ICD-9 codes for headaches, altered mental status, and visual changes. Results Although the Neurology Service was the one who performed most DF upon initial evaluation, DF is infrequently done throughout services independent of inpatient or outpatient location. Two thirds of the patients (66%) presenting with visual symptoms had evaluation done by Ophthalmology, which in some instances contributed to the final diagnosis. Conclusion A more robust teaching of DF should be included among the basic clinical competencies during Medical School and Neurology Residency training.

Chapter 69 – Neurologic aspects of lymphoma and leukemias

The lymphomas and leukemias are a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders evolved along with our knowledge of malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize their heralding features. This reviews focus is the relevant clinical neurologic features and diagnostic studies that identify leukemias and lymphomas affecting the nervous system.

Surgical Results of Common Peroneal Nerve Neuroplasty at Lateral Fibular Neck

BACKGROUND Common peroneal nerve (CPN) compressive neuropathy is the most common lower-extremity entrapment neuropathy. MATERIALS AND METHODS A retrospective review of a prospectively maintained single-institution database of all patients with CPN palsy who underwent decompression and neuroplasty over a 5-year period was performed. RESULTS Thirty patients underwent a neuroplasty of the CPN over a 5-year period (2010-2015) at our institution. The median age was 45 years, and there was a male preponderance. The average time between first onset of symptoms to surgery was 122.9 weeks and between first clinic visit and surgery was 21 weeks. The etiology of the CPN neuropathy was as follows: in 12 patients, it followed a surgical procedure and in 14 patients, it occurred after a trauma to the lower extremity. In 2 patients, it occurred as a result of a mass lesion compromising the nerve and in 1 patient, a local infection predisposed to CPN palsy. Right and left lower extremities were equally involved. The median body mass index was 28.6. The most common presentation was weakness of the tibialis anterior (TA) and extensor hallucis longus (EHL) and loss of sensation in the distribution of the CPN or one of its major branches. Pain was a presenting symptom in 16 patients. Only 12 of the 30 patients had a positive Tinels sign at the site of compression over the lateral fibular neck. Preoperative electrophysiologic confirmation of CPN neuropathy was available in all patients. Mean follow-up was 52 weeks. Prone positioning and selective use of the operating microscope provided excellent visualization and surgical exposure of the CPN from the lower popliteal region to the peroneal tunnel. Average operating room time was 170 minutes and average skin-to-skin time 91 minutes. Clinical improvement after surgery in terms of motor function was noted in 24 of the 26 patients who presented with a motor deficit. The most consistent improvement was noted in the TA and EHL; a trend toward greater improvement with shorter time to surgery was noted. No complications related to the surgical site or CPN were encountered, and no patient had a decline in their neurologic examination as a consequence of the surgery. One patient developed a positioning-related right upper-extremity brachial plexus neuropraxic injury after surgery that recovered completely. CONCLUSIONS Common peroneal neuropathy usually presents with weakness of the TA and EHL and decreased sensation or pain in the distribution of the CPN. Microscope-assisted surgical neuroplasty of the CPN at the lateral fibular neck with the patient in a prone position allows decompression of the nerve from the lower popliteal region to the peroneal tunnel. Significant improvement in motor strength after surgery, particularly of the TA and EHL, was observed in this series.

Simulation-Based Training in Brain Death Determination Incorporating Family Discussion

Background Good medical care relies on communication as much as technical expertise, yet physicians often overestimate the efficacy of their patient communication skills. Teaching communication skills can be cost- and time-intensive, and efforts have rarely focused on challenging situations, such as conveying the news of a patients brain death to a family member. Objective We developed a resource-sensitive simulation program to teach residents how to diagnose brain death and how to show empathy in discussing the diagnosis with the patients family. Methods From 2015 to 2017, 3 cohorts of incoming neurology residents participated in the 3-day training exercise. The 2-hour preintervention assessment involved making the diagnosis of brain death and sharing the news with an actor portraying the patients family member. The scoring via checklists consisted of 15 clinical skills, 9 apnea test-related skills, and 37 verbal skills related to family discussion. The 5-hour didactic intervention focused on technical aspects of the brain death examination and lessons in communication with role-playing. The 2-hour postintervention assessment repeated the brain death examination and family discussion simulations. Data were analyzed using the Wilcoxon signed rank test. Results A total of 18 residents (100%) were assessed, with significant differences between preintervention and postintervention testing across all areas, including clinical assessment (45%-76%, P < .001), apnea testing (57%-92%, P < .001), and verbal communication (46%-73%, P < .001). Conclusions The findings suggest a benefit in simulation training for brain death examination, apnea testing, and the subsequent family discussion regarding the patients diagnosis.

Neurologic complications of cardiac arrest

Cardiac arrest is a common and serious medical emergency affecting upwards of 450000 Americans on an annual basis. It causes a substantial strain on the physical and financial resources of the medical system. The optimal management of patients requires the close collaboration of multiple specialists, including first responders, intensivists, cardiologists, and neurologists. The role of the neurologist for the post-arrest patient is to assist in management to minimize brain injury as well as to prognosticate long-term outcomes to help guide therapy decisions of families and physicians. This review focuses on epidemiologic data, current management recommendations, clinical and ancillary testing to suggest long-term prognosis, and common complications of cardiac arrest. Particular attention has been paid to updates, including therapeutic hypothermia, since this topic was last reviewed in 1993.