Neurological Examination Research Articles

Effect of Fingolimod on Lymphocyte Subsets in Patients With Relapsing Multiple Sclerosis.

Background and aim Multiple sclerosis (MS) is the most common chronic inflammatory demyelinating disease of the central nervous system (CNS). This study aims to evaluate the effect of fingolimod on T and B lymphocytes in relapsing-remitting multiple sclerosis (RRMS) patients. Method Multiple sclerosis patients were selected from patients who were scheduled to start medication at the outpatient clinic of Kocaeli University, Kocaeli, Turkey, between February 2019 and February 2022. Venous blood samples were obtained before starting medication from the patients who agreed to participate in the study and who were to start treatment, simultaneous clinical and neurologic examinations were performed and the Expanded Disability Status Scale (EDSS) was calculated. After the six-month treatment, venous blood samples were taken again. Lymphocyte subgroup analyses were performed in the flow cytometry laboratory. Results The study included 48 patients in the fingolimod group and 33 patients as controls. Flow cytometry analyses showed there was no significant difference between the two groups in the numbers and percentages of CD19+, CD20+, and CD22+ cells at baseline, while a significant decrease was observed in all of these parameters in the fingolimod group after the six-month treatment. Discussion Our findings support that the fingolimod treatment has significant effects on both lymphocyte counts and lymphocyte subgroup ratios. The results show the mechanism of action of fingolimod is unaccountable only through T lymphocytes, and it is effective in both B lymphocyte subgroups and T lymphocytes.

Degraded oculomotor function and its implications on balance in pediatric strabismus

BackgroundChildren with visual impairment often exhibit poor postural control. However, the effects of strabismus on oculomotor system components and its impact on balance in children are not yet fully understood. This study aims to determine the potential effects of oculomotor functions on balance skills in children with strabismus.MethodsA total of 30 children aged between 6 and 10 years participated in this study. Fifteen children diagnosed with strabismus were included in the strabismus group (8.07 ± 1.33 years), and 15 healthy children without any vision problems were included in the control group (8.03 ± 1.49 years). All children underwent a comprehensive hearing evaluation, bedside neurological and balance examinations, the Pediatric Balance Scale (PBS) assessment to assess balance function, and Videonystagmography (VNG) tests to measure oculomotor function.ResultsIn the saccade test, no significant differences were found between the groups in terms of latency, accuracy, and speed (p > 0.05). The strabismus group showed significantly lower pursuit test gains (except the left eye at 0.4 Hz) (p < 0.05) and significantly higher asymmetries (except the right eye at 0.4 Hz) (p < 0.05). No significant difference was observed between the groups in optokinetic test gains (p > 0.05). The strabismus group had significantly lower scores on the 360-degree rotation task (10th item) (p = 0.027) and total PBS scores (p = 0.029). Correlation analysis revealed statistically significant negative correlations between strabismus angle and optokinetic test gains, pursuit test gains, and PBS total scores, with varying correlation strengths (p < 0.05 and − 0.639 < r < − 0.338).ConclusionsStrabismus adversely affects the optokinetic and pursuit systems, as well as balance in children. Furthermore, an increase in the strabismus angle is associated with greater adverse effects on these functions. The lower scores obtained in the PBS scores of the strabismus group indicate that strabismus may negatively affect balance skills in activities of daily living. Early intervention and targeted therapies should be considered to mitigate these effects and support the development of balance skills in children with strabismus.

Dyke-Davidoff-Masson Syndrome in a Tanzanian patient: a case report

BackgroundDyke-Davidoff-Masson Syndrome (DDMS) is a rare neurological disorder resulting from an insult to the developing brain in utero or during early life which is characterized by refractory seizures and a wide variety of deficits. Due to its rarity, the condition is often overlooked although a detailed history and imaging can help distinguish it from other similar conditions and provide early diagnosis.Case presentationA 30-year-old African female presented with a history of recurrent seizures and intellectual disability. She was born via vaginal delivery, and her post-natal history was unremarkable. Her developmental milestones were normal until the age of three, when she was hospitalized for two weeks due to a febrile illness accompanied by generalized seizures, from which she fully recovered. On cognitive assessment, she scored 14 out of 60 on the Ravens Standard Progressive Matrices (RSPM), indicating an intellectual disability. Neurological examination revealed constructional apraxia, an upper motor neuron lesion (UMNL) affecting the facial nerve, and left-sided spastic paresis. Additionally, a slow, sinuous writhing movement involving all the fingers of her left hand was observed. A computed tomography (CT) scan of her head confirmed a diagnosis of Dyke-Davidoff-Masson syndrome (DDMS). The scan showed significant volume loss in the right cerebral hemisphere, gross dilation of the right lateral ventricle with ex-vacuo dilatation, right calvarial thickening, and hyperpneumatization of the right frontal sinus. She was managed conservatively with anticonvulsants, which effectively controlled her seizures.ConclusionIn the setting of recurrent seizures, intellectual disability, hemiparesis, or facial asymmetry, a clinician should have a high index of suspicion for DDMS. Late diagnosis is often related to intractable seizures to anticonvulsants, necessitating hemispherectomy, which is not a readily available option in limited resource settings.

Is Intraoperative Muscle Motor Evoked Potential Variability due to Fluctuating Lower Motor Neuron Background Excitability?

This pilot study tests the contribution of fluctuating lower motor neuron excitability to motor evoked potential (MEP) variability. In six pediatric patients with idiopathic scoliosis and normal neurologic examination, cascades of 30 intraoperative H-reflexes (HRs) and MEPs were evoked in the soleus muscle using constant-current stimulators and recorded through surface electrodes with a 20-second interstimulus interval. First, HRs were obtained with an intensity capable of evoking the maximum response. Subsequently, MEPs were obtained with double trains and an intensity of 700 to 900 mA. Coefficients of variation (CVs) of amplitude and area under the curve from HRs and MEPs were compared using a paired two-tailed Student t test. Coefficients of correlation between the mean CVs of HR and MEP parameters were also assessed. Pooling the results from the six patients, the mean CV of amplitude from the MEP (24.6 ± 3) was significantly higher than that from the HR (3.5 ± 4.4) (P = 0.000091). The mean CV of the MEP area under the curve (21.8 ± 4.8) was also statistically significantly higher than that from the HR area under the curve (3.4 ± 4.5) (P = 0.00091). The coefficients of correlation of the mean CV of the HR amplitude and area under the curve compared with the corresponding values of the MEP were low (r = 0.29) and very low (r = 0.03), respectively. Our results suggest that fluctuations in lower motor neuron excitability may be less important than previously thought to explain the magnitude of MEP variability. The efficacy of corticospinal volleys to recruit a larger and more stable lower motor neuron population would be critical to obtain reproducible MEPs.

Case report on interesting cases of congenital ocular motor apraxia

Congenital ocular motor apraxia (COMA) is an uncommon disorder of ocular motility characterized by inability to initiate voluntary horizontal saccades with associated head thrusts during horizontal fixation shifts. In addition, when ocular movements typical of COMA are observed, detailed systemic and neurologic examination should be performed to rule out any associated congenital neurologic or metabolic disorder. We report two cases of COMA, a 14-year-old male with diminution of vision, esotropia, and his face turned to the right without any systemic disease, and a 9-year-old male with esotropia, no face turn, acute lymphocytic leukemia, and isolated complete agenesis of the corpus callosum. Both cases had abnormal saccadic initiation for horizontal gaze with head thrusts to take fixation. Both cases underwent Medial rectus (MR) recession, which improved face turn and strabismus, respectively.

Exonisation of an intronic L1 element in the dystrophin gene associated with X-linked muscular dystrophy in a Border Collie dog.

X-linked recessive dystrophinopathies are the most common muscular dystrophies (MDs) in humans and dogs. To date, 20 breed-specific MD-associated variants are described in the canine dystrophin gene (DMD), including one associated with dystrophin-deficient MD in the Border Collie mixed breed. Here, we report the diagnosis and follow-up of mild dystrophin-deficient MD in a 5-month-old male Border Collie, associated with a novel DMD variant. Diagnosis was based on neurological examination and laboratory evaluations including creatine kinase activity, electromyography and muscle biopsies with immunofluorescent staining. Inspection of the Sashimi plots of the RNA-seq data from the affected muscle biopsy led to the discovery of a 162-bp L1 pseudoexon in DMD intron 63, introducing a frameshift and a premature stop codon (NM_001003343.1: c.9271_9272insN[162] p.(Ala3091fs*21)). Reduced DMD mRNA levels were detected for both the non-pseudoexon (50× less) and pseudoexon (3× less) containing transcripts in the affected muscle, compared with the level of the non-pseudoexon containing transcript in a control muscle, resulting in very low dystrophin protein levels and the upregulation of utrophin. Because the variant was only found in the affected dog, not in the healthy mother and grandmother, or in 108 unrelated Border Collies from the Belgian population (46 males and 62 females), it was considered a de novo variant. Although the prognosis for dystrophinopathy is generally regarded as poor, the dog stabilised at the age of 6 months and is still clinically stable at the age of 2 years.

High Somatization Rates, Frequent Spontaneous Recovery, and a Lack of Organic Biomarkers in Post-Covid-19 Condition.

Many patients report neuropsychiatric symptoms after SARS-CoV-2 infection. Data on prevalence of post-COVID-19 condition (PCC) vary due to the lack of specific diagnostic criteria, the report of unspecific symptoms, and reliable biomarkers. PCC patients seen in a neurological outpatient department were followed for up to 18 months. Neurological examination, SARS-CoV-2 antibodies, Epstein-Barr virus antibodies, and cortisol levels as possible biomarkers, questionnaires to evaluate neuropsychiatric symptoms and somatization (Patient Health Questionnaires D [PHQ-D]), cognition deficits (Montreal Cognitive Assessment [MoCA]), sleep disorders (ISS, Epworth Sleepiness Scale [ESS]), and fatigue (FSS) were included. A total of 175 consecutive patients (78% females, median age 42 years) were seen between May 2021 and February 2023. Fatigue, subjective stress intolerance, and subjective cognitive deficits were the most common symptoms. Specific scores were positive for fatigue, insomnia, and sleepiness and were present in 95%, 62.1%, and 44.0%, respectively. Cognitive deficits were found in 2.3%. Signs of somatization were identified in 61%, who also had an average of two symptoms more than patients without somatization. Overall, 28% had a psychiatric disorder, including depression and anxiety. At the second visit (n=92), fatigue (67.3%) and insomnia (45.5%) had decreased. At visit three (n=43), symptom load had decreased in 76.8%; overall, 51.2% of patients were symptom-free. Biomarker testing did not confirm an anti-EBV response. SARS-CoV-2-specific immune reactions increased over time, and cortisol levels were within the physiological range. Despite high initial symptom load, 76.8% improved over time. The prevalence of somatization and psychiatric disorders was high. Our data do not confirm the role of previously suggested biomarkers in PCC patients.

Protocolo de exploración del pie diabético

The diabetic foot screening protocol recommends an annual assessment in all patients with diabetes starting at the time of diagnosis in those with type 2 diabetes mellitus (DM2). The examination focuses on three aspects: a visual inspection of the foot, a vascular evaluation by means of pedal pulses, and neurological examination using a 10g monofilament to detect sensory loss. It is essential to identify risk factors for ulcers, such as neuropathy, deformities, and peripheral arterial disease (PAD). If there are signs of risk, such as previous ulcers or sensory loss, patients should be referred to a diabetic foot specialist. Tests such as the ankle-brachial index (ABI) are used for vascular assessment and other tools such as a monofilament and tuning fork are used to measure neurological sensitivity. The patient's risk classification is used to plan follow-up and treatment.

Pharmacological Dissociation in Hemicrania Continua With Persistent Visual Aura Evolved From Episodic Migraine: A Case Report.

To report a case of hemicrania continua (HC) and persistent visual aura without infarction in a patient with previous episodic migraine with visual aura, whose persistent aura symptoms improved only after treatment with divalproex sodium. Once regarded as highly specific for migraine, visual aura has been associated with trigeminal autonomic cephalalgias, including HC. In previous descriptions of HC and episodes of typical visual aura, the aura occurred exclusively with severe headache exacerbations and, like the pain, resolved with indomethacin. Case report and literature review. A 54-year-old man with a history of episodic migraine with visual aura reported a gradual onset of HC with persistent visual aura of 15 months duration. General medical and neurological examinations were normal, including imaging studies. HC's headache responded to indomethacin, while the visual aura was recalcitrant, only improving with oral divalproex sodium treatment. As our patient experienced HC, which evolved from episodic migraine, we hypothesize that migraine and HC may share a common pathophysiology. However, the persistence of the visual aura, despite the abolition of pain and autonomic features with a therapeutic dose of indomethacin, and the subsequent successful treatment of the aura with divalproex sodium, suggest that aura and HC headache arise from distinct and dissociable mechanisms.

The effectiveness of various approaches in the treatment of peripheral neuropathies in people with type 2 diabetes mellitus

Introduction. Optimal therapeutic tactics for diabetic peripheral neuropathy (DPN) can reduce the risk of complications and improve the quality of life of patients with diabetes mellitus (DM).Aim: To evaluate the effectiveness of various approaches to the treatment of DPN.Materials and Methods. 67 patients were examined (36 men and 31 women, mean age 59.4 ± 9.7 years), duration of diabetes was at least 7 years. Patients underwent general clinical examinations, neurological examination and diagnosis of DPN with assessment of pain, tactile and vibration sensitivity. All patients underwent ultrasound of the peroneal nerve (PN): the structure and cross-sectional area (CSA) were assessed (≤ 11 mm2 was taken as the norm). Patients with symptoms of PN compression received mini-invasive treatment by perineural administration of 20 mg methylprednisolone under ultrasound control.Results. Clinical manifestations of DPN were identified in 33 (49.3%) cases. Changes in ultrasound PN occurred in 62 (92.5%) patients. 29 patients with echographic changes in PN and asymptomatic DPN received α-lipolic acid and benfotiamine: the CSA of the PN before treatment was 13,2 ± 2,4 mm2, after 6 months –10,4 ± 1,6 mm2; the proportion of people with CSA PN ≥ 12 mm2 before treatment was 82,7%, after 6 months –27,6% (all p &lt; 0.05). 19 patients with symptoms of DPN, but without signs of compression of the MBN, received additional drugs and techniques. The average pain intensity before treatment was 4,93 ± 1,07, after 6 months –2,47 ± 0,61; CSA PN before treatment –17,3 ± 3,8 mm2, after 6 months –13,2 ± 2,2 (all р &lt; 0,017). 14 patients with PN compression underwent mini-invasive treatment under ultrasound control. In the first 24–48 hours after manipulation, in all cases there was a moderate increase in local manifestations of compression. Then the pain intensity decreased (5.74 ± 1.19 points – before manipulation, 3.18 ± 0.97 – after 6 months, р &lt; 0,0125), CSA decreased (22.4 ± 4.3 mm2 – to 15.3 ± 3.6 mm2 – after 6 months, р &lt; 0,0125) and echographic characteristics improved.Conclusions. Ultrasound of the nerves can be a valuable method for the early diagnosis of DPN and a tool for choosing treatment tactics. The use of pathogenetic pharmacotherapy alone or in combination with other drugs was associated with satisfactory tolerability, favorable clinical and ultrasound dynamics. The use of mini-invasive treatment with perineural administration of drugs for compartment syndrome was characterized by a positive effect on compression symptoms and ultrasound characteristics of the nerve.

A hiatus in the rivalry between Pierre Marie and Jules Dejerine: a collaborative study on sensory disorders by Andre Pierre Marie and Gustave Roussy.

Personal and professional rivalries involving prominent neurologists mark the history of nineteenth-century French neurology. One of the great examples is the feud between Pierre Marie and Jules Dejerine. The dispute between the two, nevertheless, did not prevent Pierre Marie's son, André Marie, and Gustave Roussy - one of Dejerine's favorite pupils, from collaborating on significant research that led to the doctoral dissertation by Andre Marie regarding sensory disturbances associated with painful hemiagnosia found in thalamic lesions.

Idiopathic unilateral complete oculomotor nerve palsy: a case report of diagnostic quandary

Introduction and importance: When compared to other cranial nerve palsies idiopathic unilateral oculomotor nerve palsy with pupillary sparing is one of the least noted neurological conditions. Moreover, there lies a series of diagnostic dilemmas to come into a final diagnosis resulting in several array of clinical investigations. Hence, there is a delay in prompt management. Case summary: An elderly female without any known comorbidities presented with the complaint of headache, dizziness and dropping of left eyelid. Several arrays of diagnostic workups was done to come to a diagnosis, but even with rigorous laboratory investigations and radiological examinations, a common working diagnosis could not be made. Hence with a diagnosis of exclusion after proper neurological and neuro-ophthalmological examination, idiopathic unilateral common oculomotor nerve palsy was identified for which improvement with steroids was noted in the patient. Discussion: Idiopathic unilateral complete oculomotor nerve palsy is considered as a diagnosis of exclusion when all the diagnostic parameters fail to signify and positive results. The vague symptomatic presentation of the disease condition further compels the treating physician to carry out several panels of laboratory to radiological investigations. But if identified in time the treatment modality is straightforward. Conclusion: The diagnostic quandary in timely identification of such disease conditions needs a pertinent diagnostic guideline so as to avoid the unwanted panel of investigations.

Comparison of the Results of Combined Epidural Steroid Injection with Other Approaches in Lumbar Disc Herniation: A Retrospective Study

Background: Epidural steroid injection (ESI) is a minimally invasive treatment for lumbar disc herniation (LDH). It can be applied using a transforaminal (TFESI), interlaminar (ILESI), caudal (CESI), or combined (TFESI + CESI) approach. Aim: To compare the effectiveness of the three ESI approaches and the combined ESI application in reducing pain in patients with single or multi-level LDH. Methods: In this retrospective study, we included 239 patients diagnosed with LDH (who complained of low back pain for at least 3 months, had no neurological deficit or history of lumbar surgery, and were not contraindicated for ESI application) who received ESI and were followed up clinically for 2 years. Demographic (age, sex, body mass index (BMI)) and clinical data (duration of low back pain, visual analog scale (VAS) scores before and after ESI, and procedure-related information) were obtained from medical records. The VAS scores noted before treatment and at 3 months, 1 year, and 2 years after ESI were compared. Results: The post-treatment VAS scores of the combined ESI (TFESI + CESI) group were significantly lower than those of other approaches applied alone (P &lt; 0.05). Furthermore, VAS scores of the ILESI and CESI groups were significantly lower than those of the TFESI group at all three post-treatment time points (P &lt; 0.05). The patient’s age and BMI were weakly correlated with the post-treatment VAS scores. Conclusion: Combined ESI is more effective than any single-approach ESI in LDH and should be considered in suitable patients to increase treatment effectiveness.

Medical practice in classical Greece : The neurological and psychiatric case reports of the Hippocratic Corpus

Which theoretical and practical competences do the neurological and psychiatric case histories of the Hippocratic Corpus convey? The 431 Hippocratic case histories have been studied for reports and communication on the diagnostics, treatment and prognosis of single persons and groups of patients suffering from neurological and psychiatric diseases. In the 7books of the Hippocratic Epidemics, atotal of 128 patients with neurological and psychiatric symptoms are described. Epidemic fever and its variants were the leading predisposing conditions and the main symptoms were delirium, coma, insomnia, headache, speech disorders and convulsions. Anumber of patients with phrenitis and opisthotonos are also reported. The majority of the sick persons were male, were teenagers or adults and 47of them are mentioned by name. The patient's information about the course is often just as informative as the doctor's observations. Treatment was limited to physical and dietary measures. The Hippocratic physician diagnosed and attempted to treat alarge number of neurological and psychiatric diseases. The often almost continuous observations of the patients led to astonishingly precise predictions of the course and the prospects of recovery. Numerous symptoms described in the case studies, including carphologia and opisthotonus, have entered the neurological vocabulary. The retrospective etiological analysis of the reports leads to the almost explicit identification of neurosyphilis and encephalitis lethargica. The therapeutic measures described by the author were, as the changeable course of the diseases shows, only of limited effectiveness despite a very differentiated application over time, both against the underlying diseases and the neurological and psychiatric complications.

Outcomes of Traumatic Brain Injury Patients Managed in a Non–Intensive Care Unit Setting

IntroductionThe management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non–intensive care unit (ICU) setting after stratifying them using the mBIG criteria. MethodsA retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. ResultsOf the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. ConclusionsSelect patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

Vermian multinodular and vacuolating lesion of unknown significance discovered following syncope: a case report

Introduction and importance: Multinodular and Vacuolating Posterior Fossa Lesions of Unknown Significance (MV PLUS) are benign cystic lesions that, though typically asymptomatic, can present with neurological symptoms such as seizures, headaches, and syncope. These lesions are predominantly found in sub-tentorial brain structures but can also appear in supratentorial areas. MRI is crucial in detecting these lesions, characterized by small nodules with high intensity on T2-FLAIR sequences. Despite increasing awareness, the pathophysiology and classification of MV PLUS lesions remain unclear, necessitating further research and careful monitoring. Case presentation: A 52-year-old female presented with subjective dizziness and a recent syncope episode. Neurological examination showed ataxia and a positive Romberg sign. MRI revealed a multicystic and nodular lesion in the vermian and paravermian regions, with altered signal intensity on T1-weighted and FLAIR sequences. The lesion showed no pathological enhancement post-gadolinium administration, and spectroscopy revealed no significant metabolite peaks. Clinical improvement was observed following corticosteroid and antivertiginous therapy, and the patient was discharged with a recommendation for neuroradiological follow-up. Clinical discussion: MV PLUS lesions are a subset of multinodular and vacuolating lesions that present significant diagnostic challenges due to their complex radiological features. First described in 2013, these lesions have distinct MRI characteristics, including a nodular appearance with high T2-FLAIR intensity and occasional cystic components. Despite being benign and typically stable, the differential diagnosis includes various other intracranial lesions, requiring careful evaluation. The pathogenesis and optimal management strategies for MV PLUS lesions are still under investigation, emphasizing the need for continued research. Conclusion: MV PLUS lesions, although rare and benign, present unique diagnostic challenges due to their varied radiological features and potential neurological symptoms. Regular MRI monitoring is essential to track their stability, given the current lack of understanding regarding their pathophysiology and long-term implications. Further research is needed to elucidate the etiology, natural history, and optimal management of these intriguing lesions.

Testing the Validity and Reliability of a Standardized Virtual Examination for Concussion.

We determined inter-modality (in-person vs telemedicine examination) and inter-rater agreement for telemedicine assessments (2 different examiners) using the Telemedicine Buffalo Concussion Physical Examination (Tele-BCPE), a standardized concussion examination designed for remote use. Patients referred for an initial evaluation for concussion were invited to participate. Participants had a brief initial assessment by the treating neurologist. After a patient granted informed consent to participate in the study, the treating neurologist obtained a concussion-related history before leaving the examination room. Using the Tele-BCPE, 2 virtual examinations in no specific sequence were then performed from nearby rooms by the treating neurologist and another neurologist. After the 2 telemedicine examinations, the treating physician returned to the examination room to perform the in-person examination. Intraclass correlation coefficients (ICC) determined inter-modality validity (in-person vs remote examination by the same examiner) and inter-rater reliability (between remote examinations done by 2 examiners) of overall scores of the Tele-BCPE within the comparison datasets. Cohen's kappa, κ, measured levels of agreement of dichotomous ratings (abnormality present vs absent) on individual components of the Tele-BCPE to determine inter-modality and inter-rater agreement. For total scores of the Tele-BCPE, both inter-modality agreement (ICC = 0.95 [95% CI 0.86-0.98, p < 0.001]) and inter-rater agreement (ICC = 0.88 [95% CI 0.71-0.95, p < 0.001]) were reliable (ICC >0.70). There was at least substantial inter-modality agreement (κ ≥ 0.61) for 25 of 29 examination elements. For inter-rater agreement (2 telemedicine examinations), there was at least substantial agreement for 8 of 29 examination elements. Our study demonstrates that the Tele-BCPE yielded consistent clinical results, whether conducted in-person or virtually by the same examiner, or when performed virtually by 2 different examiners. The Tele-BCPE is a valid indicator of neurologic examination findings as determined by an in-person concussion assessment. The Tele-BCPE may also be performed with excellent levels of reliability by neurologists with different training and backgrounds in the virtual setting. These findings suggest that a combination of in-person and telemedicine modalities, or involvement of 2 telemedicine examiners for the same patient, can provide consistent concussion assessments across the continuum of care.

Subtle motor signs in children with ADHD and their white matter correlates.

Subtle motor signs are a common feature in children with attention-deficit/hyperactivity disorder (ADHD). It has long been suggested that white matter abnormalities may be involved in their presentation, though no study has directly probed this question. The aim of this study was to investigate the relationship between white matter organization and the severity of subtle motor signs in children with and without ADHD. Participants were 92 children with ADHD aged between 8 and 12 years, and 185 typically developing controls. Subtle motor signs were examined using the Physical and Neurological Examination for Soft Signs (PANESS). Children completed diffusion MRI, and fixel-based analysis was performed after preprocessing. Tracts of interest were delineated using TractSeg including the corpus callosum (CC), the bilateral corticospinal tracts (CST), superior longitudinal fasciculus, and fronto-pontine tracts (FPT). Fiber cross-section (FC) was calculated for each tract. Across all participants, lower FC in the CST was associated with higher PANESS Total score (greater motor deficits). Within the PANESS, similar effects were observed for Timed Left and Right maneuvers of the hands and feet, with lower FC of the CST, CC, and FPT associated with poorer performance. No significant group differences were observed in FC in white matter regions associated with PANESS performance. Our data are consistent with theoretical accounts implicating white matter organization in the expression of motor signs in childhood. However, rather than contributing uniquely to the increased severity of soft motor signs in those with ADHD, white matter appears to contribute to these symptoms in childhood in general.

An Unusual Paediatric Neck Mass: Cervical Lipoblastoma with Spinal Involvement.

Lipoblastoma is a benign tumour derived from embryonic white fat and is more commonly seen in children. Spinal involvement is rare, with only 14 cases reported to date. We report a case of a 7-year-old boy who was presented with an asymptomatic right neck swelling for 5 years. Clinical examination revealed a soft multilobulated mass causing tracheal deviation with normal neurological examination. Ultrasound, Computed tomography and Magnetic resonance imaging showed a lipomatous lesion with extension to spinal foramina at C3-C5 causing displacement of the spinal cord. Near total excision of the tumour was done with a small remnant left behind at C3-C4 as it was tightly adhered to the vertebral artery. Histopathological samples were consistent with lipoblastoma. The patient developed ipsilateral ptosis and pupillary myosis which improved on the second-month postoperative review; no other neurological deficit was noted, and a follow-up cervical MRI showed no recurrence.

Evaluating Physician Knowledge, Attitudes, and Practices in Screening and Supplementation for Vitamin B12 Deficiency in Type 2 Diabetes Patients Treated with Metformin.

Long-term metformin use in Type 2 Diabetes Mellitus (T2DM) patients is associated with Vitamin B12 deficiency. This study aims to evaluate physicians' knowledge, attitudes, and practices regarding Vitamin B12 screening and supplementation in this context. A survey was administered to physicians across various specialties in government hospitals and primary care centers in Riyadh, Saudi Arabia, from January 2019 to January 2020. The survey assessed their knowledge, attitudes, and practices concerning Vitamin B12 deficiency screening and supplementation. Of the 402 participating physicians, 94.0% (378 respondents) demonstrated sufficient knowledge about Vitamin B12 deficiency. However, 26.1% believed that Vitamin B12 supplementation does not necessitate screening. 55.7% did not prescribe Vitamin B12 prophylactically, 41.5% omitted neurological examinations in patients presenting with neuropathy, and 22.4% were unaware of the recommended Vitamin B12 supplement dose. Only 49.8% routinely screened for Vitamin B12 deficiency in symptomatic patients. Physicians with more extended years of experience showed significantly better knowledge about Vitamin B12 screening and supplementation (p<0.001). While most physicians were knowledgeable about Vitamin B12 deficiency and supplementation, a substantial gap in translating this knowledge into practice was observed. There is a critical need for institutional oversight to ensure adherence to American Diabetes Association (ADA) guidelines for Vitamin B12 screening and supplementation in T2DM patients on long-term metformin therapy.