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Between December 1965 and December 1971, the United States maintained armed forces in Vietnam never less than 180,000 men and women in support of the war. At one time, this commitment exceeded half a million soldiers, sailors, and airmen from both the United States and its allies. Such forces required an extensive medical presence, including 19 neurologists. All but two of the neurologists had been drafted for a 2-year tour of duty after deferment for residency training. They were assigned to Vietnam for one of those 2 years in two Army Medical Units and one Air Force facility providing neurological care for American and allied forces, as well as many civilians. Their practice included exposure to unfamiliar disorders including cerebral malaria, Japanese B encephalitis, sleep deprivation seizures, and toxic encephalitis caused by injection or inhalation of C-4 explosive. They and neurologists at facilities in the United States published studies on all of these entities both during and after the war. These publications spawned the Defense and Veterans Head Injury Study, which was conceived during the Korean War and continues today as the Defense and Veterans Head Injury Center. It initially focused on post-traumatic epilepsy and later on all effects of brain injury. The Agent Orange controversy arose after the war; during the war, it was not perceived as a threat by medical personnel. Although soldiers in previous wars had developed serious psychological impairments, post-traumatic stress disorder was formally recognized in the servicemen returning from Vietnam.

Between December 1965 and December 1971, the United States maintained armed forces in Vietnam never less than 180,000 men and women in support of the war. At one time, this commitment exceeded half a million soldiers, sailors, and airmen from both the United States and its allies. Such forces required an extensive medical presence, including 19 neurologists. All but two of the neurologists had been drafted for a 2-year tour of duty after deferment for residency training. They were assigned to Vietnam for one of those 2 years in two Army Medical Units and one Air Force facility providing neurological care for American and allied forces, as well as many civilians. Their practice included exposure to unfamiliar disorders including cerebral malaria, Japanese B encephalitis, sleep deprivation seizures, and toxic encephalitis caused by injection or inhalation of C-4 explosive. They and neurologists at facilities in the United States published studies on all of these entities both during and after the war. These publications spawned the Defense and Veterans Head Injury Study, which was conceived during the Korean War and continues today as the Defense and Veterans Head Injury Center. It initially focused on post-traumatic epilepsy and later on all effects of brain injury. The Agent Orange controversy arose after the war; during the war, it was not perceived as a threat by medical personnel. Although soldiers in previous wars had developed serious psychological impairments, post-traumatic stress disorder was formally recognized in the servicemen returning from Vietnam.

CPT Andrew C. Carr was the second neurologist to be assigned to Vietnam during the early years of the war. Soon after his return, he prepared a commentary on the practice of neurology under field conditions, providing a vivid account of the practice of good neurology under bad conditions.

Objective: Changes in health care delivery required substitution of a number of alternatives for the traditional inpatient clerkship used in the neurology education of fourth-year medical students at the Uniformed Services University of the Health Sciences and for third-year medical students from Georgetown University. Methods: We retrospectively analyzed grades on a locally generated multiple-choice examination based on a student objective list. Scores from students rotating on ambulatory neurology, neurosurgery, child neurology, neurorehabilitation, and rotations at other military hospitals over a 2-year period were compared with those achieved by students in a traditional clerkship at Walter Reed Army Medical Center. Results: There were no significant differences in the grades between any of the groups. Conclusions: Student acquisition of factual material was not influenced by the type of clinical experience or by whether the student is in the third or fourth year of medical school.

Neurologic symptoms are common in all practice settings, and neurologic diseases comprise a large and increasing proportion of health care expenditures and global disease burden. Consequently, the training of all physicians should prepare them to recognize patients who may have neurologic disease, and to take the initial steps in evaluating and managing those patients. We present a core curriculum outlining the clinical neurology skills and knowledge necessary to achieve that degree of preparation. The curriculum emphasizes general principles and a systematic approach to patients with neurologic symptoms and signs. The ability to perform and interpret the neurologic examination is fundamental to that approach, so the curriculum delineates the essential components of the examination in three different clinical settings. The focus of the curriculum is on symptom-based rather than disease-based learning. The only specific diseases selected for inclusion are conditions that are common or require urgent management. This curriculum has been approved by the national organization of neurology clerkship directors and endorsed by the major national professional organizations of neurologists. It is intended as a template for planning a neurology clerkship and as a benchmark for evaluating existing clerkships. It should be especially helpful to clerkship directors, neurology chairs, deans of medical education, and members of external accreditation groups.

We were privileged to know Jonathan Pincus for over 50 years, beginning when we were all Yale Neurology residents in the early 1960s. We followed his career with great interest and admired his droll sense of humor. Years later, when he was Chairman of Neurology at Georgetown University School of Medicine, he regularly invited one of us (C.H.G.) to his faculty meetings, which were object lessons in how to manage a busy clinical department.

Article abstract-Since the emergence of the specialty, neurologists have worked with a rather restricted list of relatively inexpensive pharmacologic agents. This is rapidly changing with the development of new agents for the treatment of migraine, multiple sclerosis, Parkinson's disease, Alzheimer's disease, and epilepsy, accelerated in part by designation of the 1990s as the "Decade of the Brain". Exciting as these developments are, they are very costly when applied to the large number of patients who may benefit, perhaps exceeding $6.4 billion. Since this cost exceeds the $1.5 billion income of all practicing neurologists, it enhances the value of the neurologic consultation, which can provide more accurate diagnosis and more expertly directed therapy. Our relationships with the drug manufacturers are changing as our prescribing habits become a more likely determinant of profits.NEUROLOGY 1995;45: 569-572

We have studied cortical localization provided by surface and sphenoidal electroencephalograms (EEGs) and that of computed tomography (CT), magnetic resonance imaging (MR) and single photon emission tomography (SPECT) in 58 patients with partial epilepsy. Each patient had EEG, MR and SPECT during a hospitalization period of 1-2 weeks. CT scans were obtained either during the same period or had been performed in the preceding year. EEG evaluation consisted of 3-5 days of continuous monitoring including video-telemetry and ambulatory recording as well as conventional EEGs with special electrode placements. Additionally 33 of 58 patients (55%) who were potential surgical candidates had sphenoidal recordings. All patients had an abnormal EEG which showed evidence of epileptic hyperexcitability. EEG abnormality was localized in 43 patients (74%). Neuroimaging studies were focally abnormal in 38 patients (66%); 12 CT (21%), 29 MR (50%) and 24 SPECT (41%). Thirty four of 43 patients with localized EEG had at least 1 focally abnormal neuroimaging study (79%), whereas 4 of 15 (27%) patients with non-localized EEG did so. Twenty-eight of 29 patients with focal MR (97%), 11 of 12 patients with focal CT (92%) and 20 of 24 patients with focal SPECT (83%) had a concordant focal EEG. EEG and neuroimaging localization agreed in all 15 patients in whom both MR and SPECT disclosed a concordant focal abnormality. This study demonstrates a significant (P less than 0.005) correlation between surface/sphenoid EEG and neuroimaging localization in partial epilepsy.

Somatosensory evoked potentials (SEPs) to median and posterior tibial stimulation were obtained in 22 patients with syringomyelia. All patients had magnetic resonance imaging (MR) which defined the maximum transverse diameter of the syrinx as well as its longitudinal extension. SEP was abnormal in 16 (72%) patients. Median and posterior tibial SEPs were abnormal in 11 and 15 patients respectively. Both tests were abnormal in 10 patients. Ten patients showed absence of one or more central potentials (P/N13, N20, N22) and 7 patients demonstrated increased conduction times (N9-N20, P/N13-N20, N22-P40). The mean maximum transverse diameter of the syrinx was 7.5 mm in patients with normal SEPs and 16.2 mm in patients with abnormal SEPs. Abnormal SEP was observed in all 5 patients with loss of position sense, in 9 of 13 (69%) with loss of superficial pain and temperature, and 1 of 2 patients with motor deficit only. Central SEP abnormalities were observed in 3 of 5 patients with sensory deficits indistinguishable from a peripheral neuropathy and in 2 patients in the asymptomatic extremity. Three of 4 patients with syringomyelia and Chiari malformation had a normal SEP.

Changes in health care delivery required substitution of a number of alternatives for the traditional inpatient clerkship used in the neurology education of fourth-year medical students at the Uniformed Services University of the Health Sciences and for third-year medical students from Georgetown University.We retrospectively analyzed grades on a locally generated multiple-choice examination based on a student objective list. Scores from students rotating on ambulatory neurology, neurosurgery, child neurology, neurorehabilitation, and rotations at other military hospitals over a 2-year period were compared with those achieved by students in a traditional clerkship at Walter Reed Army Medical Center.There were no significant differences in the grades between any of the groups.Student acquisition of factual material was not influenced by the type of clinical experience or by whether the student is in the third or fourth year of medical school.

Based on improvement in our understanding of the prognosis of young adults with new onset seizures, and cumulative experience with the rules in effect for the last 30 years, a substantial change in the regulations affecting the fitness and profiling of these soldiers has been made. In general, these liberalize retention and profiling, set limits on the duration of trials of duty, provide for fitness determinations in soldiers with pseudo-seizures, and specify when neurologic consultation is required.

In 1983, a new regulation was prepared, based on clinical reports published at that time, redefining the fitness standards for those applicants to the military who had experienced one or more seizures during childhood or early adult life. The most important change admitted those who had been free of seizures and off medications for 5 years or more and who had normal EEGs. Only 2 of 155 soldiers enlisted in 1986 and 1987 meeting these criteria were separated for seizure-related complaints. Both had problems during basic training and the diagnosis of recurrent epilepsy was tenuous in both. We conclude that the regulation change has given many young adults a chance to serve effectively in the Army without appreciable increase in medical or training costs.

Nerve agents produce neuromuscular blockade and convulsions in exposed humans. Military personnel in areas of potential exposure take prophylactic pyridostigmine. They are instructed to self-administer atropine and pralidoxime at the first sign of nerve agent toxicity. The key to treatment of nerve agent poisoning is the administration of atropine in doses larger than is customary in most other disorders, repeated as often as needed. Mechanical ventilation may be required. Convulsions are treated with diazepam, but only after atropine has been administered.

Median and posterior tibial somatosensory evoked potentials (SEPs) were studied on 25 patients with pathologically proven intraspinal neoplasms, and the results were compared and correlated with the details of clinical examination and the information derived from magnetic resonance imaging (MR). MR was abnormal in all cases and in 23 of 25 (92%) demonstrated an intraspinal expansile lesion. SEP was abnormal in 19 of 25 patients (76%). Abnormal SEPs were found in 18 of 19 patients (94%) with cervical or thoracic neoplasms but only in 1 of 6 patients (16%) with the tumor in the thoracolumbar or lumbar region. SEP-MR correlation was significant (P less than 0.05) for thoracic intraspinal neoplasms where all 9 had an abnormal SEP showing a similar pattern of normal median and abnormal posterior tibial study. Clinically, all 7 patients with posterior column sensory deficits had abnormal SEP (100%). Abnormal SEPs were seen in 7 of 11 (63%) patients with spinothalamic deficits and in 4 of 8 (50%) of those with normal sensory examinations. Four of 9 patients (44%) with a normal neurological examination or an examination disclosing ambiguous results indistinguishable from a peripheral pathology had an abnormal SEP strongly suggesting a central sensory disorder. Comparison of preoperative and postoperative SEPs did not disclose useful prognostic information pertaining to the functional recovery.

The clinical efficacy of the trihexyphenidyl was investigated in 100 patients with movement disorders. The study group consisted of 54 women and 46 men. Their ages ranged from 18 to 70 years, and their duration of illness varied from a few months to 36 years. Each patient had a videotape of the movements and a neurological examination, before administration of the drug, at the time of maximum or effective dosage, and one week after withdrawal from trihexyphenidyl. The drug was administered at an initial total daily dose of 2 mg and gradually increased to a total daily dose of 60 mg over a period of 4-6 weeks. Improvements were rated both clinically and from the videotapes. Three groups of movement disorders demonstrated a significant response to trihexyphenidyl: (1) dystonia 37%; tonic torticollis demonstrated a significantly better response than the clonic variant (80% vs. 22%). (2) rhythmic-oscillatory movements of brainstem-cerebellar origin (palatal myoclonus, pendular nystagmus, facial myokymia) 90%; (3) cerebellar tremor 75%. Among 32 responders, 17 (56%) continued taking trihexyphenidyl beyond 24 months. Side effects consisted of dryness of the mouth, jitteriness, stomatitis, blurred vision, and forgetfulness.

Two patients with multiple sclerosis experienced acute unilateral deafness during an exacerbation. The brain stem auditory evoked potential test (BAEP) of both patients revealed absence of all waves after wave I, on the side of the hearing loss. These findings strongly suggest that acute hearing loss in multiple sclerosis results from involvement of the eighth nerve close to the ponto-medullary junction.

✓ Five patients are described with cerebral microglioma or reticulum cell sarcoma. The tumors varied from local neoplasms to multicentric or miliary foci. One of these patients is the second case reported of a microglioma associated with Waldenström's macroglobulinemia. Serum electrophoresis on the other four patients did not reveal any consistent abnormality or pattern. Immunoglobulin studies performed on three of the five patients confirmed Waldenström's syndrome in one, revealed an elevated IgA globulin in a second, and was normal in a third. Cerebrospinal fluid findings included elevated spinal fluid protein in all five patients. The brain scan was abnormal in all four cases so tested. Arteriograms in four patients demonstrated tumor blushes indicative of increased numbers of enlarged vessels. The relationship between reticulum cell sarcomas originating in the central nervous system and those originating elsewhere is discussed.

• Pattern reversal visual evoked potential (VEP) test was performed in 30 asymptomatic patients with neurofibromatosis (NF). All patients had normal visual acuity, visual fields, and ophthalmoscopic examination results. Pattern reversal VEP was abnormal in eight patients (26%). Seven of these patients had computed tomographic scans with reformated orbital views. Orbital computed tomographic scans were abnormal in six patients and in each case showed enlargement of the optic nerve on the side of VEP abnormality. Our data indicate that pattern reversal VEP is a valuable screening test in asymptomatic patients with NF. Because of the high incidence of VEP abnormality in such patients, VEP abnormality must be interpreted cautiously when a patient with NF is suspected of having other diseases or disorders that potentially affect the visual pathways.

• The yield of magnetic resonance (MR) imaging was investigated in 30 patients with partial complex epilepsy, and the results were compared with those of computed tomography (CT). Magnetic resonance imaging and CT disclosed focal cerebral abnormalities in 13 (43%) and eight (26%) patients, respectively. Two additional focal temporal lesions were identified by double-dose CT scanning, increasing the yield of CT to 33%. Magnetic resonance images were abnormal in all patients with focally abnormal CT scans, and in four patients (50%) they defined the extent of the temporolimbic lesions better than did the CT scans. Two of these patients had gliomas. In addition, MR images were focally abnormal in 85% of the patients in whom scalp electroencephalograms showed focal ictal discharges. These data indicate that MR imaging is more informative than CT in partial complex epilepsy.

Medical students at two teaching institutions were given an objective list containing information thought to be of maximum neurological teaching value. The usefulness of the objective list was assessed by giving the students pre- and post-tests containing questions that were derived from the objective list. Irrespective of the disparity in the clinical teaching programme, there was no significant difference between test scores of students who rotated at the two institutions. Comparison of pre- and post-test scores showed a highly significant improvement (P less than 0.005) in test scores. An objective list should be part of an effective undergraduate teaching programme in neurology.

Palatal myoclonus and acquired pendular nystagmus result from lesions in dentatorubroolivary pathways. We have investigated the effect of high doses of the anticholinergic drug trihexyphenidyl in four patients with palatal myoclonus and in four patients with acquired pendular nystagmus. The movements of each patients were videotaped three times: before administration of trihexyphenidyl, at the time of maximum or effective dosage, and after withdrawal from trihexyphenidyl. In five patients the movements were also electrographically recorded. A neurologist not familiar with the patients reviewed the tapes and rated the changes. In seven of eight patients, administration of the trihexyphenidyl resulted in marked improvement of both movements and complaints by patients. This observation indicates that disturbance of cholinergic mechanisms plays an important role in the pathophysiology of these two movement disorders.

Quantitative perimetric studies in two patients with involvement of a lateral geniculate nucleus (caused by astrocytoma in one and a small arteriovenous malformation in the other) revealed strikingly incongruous defects in the contralateral homonymous fields of vision. The patterns of these hemianopias were analysed and correlated anatomically in terms of established patterns of retinal projections within the six cellular laminae of the geniculate nucleus. Incongruous wedge-shaped field defects recorded in the patient with the astrocytoma are unique and appear to be pathognomonic of focal geniculate disease in the dorsal crest of the nucleus.

• One hundred eighty-six depressed psychiatric inpatients were seen at our institution during 1982. Forty-five of these patients were treated with tricyclic antidepressants, 32 received maprotiline hydrochloride, a tetracyclic compound, 20 received other medications, and 82 received no drug treatment. One patient in the tricyclic group (2.2%) and five patients in the maprotiline group (15.6%) developed seizures. In four patients the seizure followed the institution of maprotiline therapy by less than three weeks. These data indicate that depressed patients taking the tetracyclic drug maprotiline are at risk for developing epileptic seizures.

Extrapyramidal syndromes have been described after administration of phenytoin and primidone. 1-4 Although asterixis, dystonia, and tremor have been described with carbamazepine (Tegretol) 1,5-7 there is no report of orofacial dyskinesia. We report a case in which a dose-related lingual-facial-buccal extrapyramidal reaction occurred in association with carbamazepine intoxication.

A study of 343 Active members and Fellows of the American Academy of Neurology revealed that among 285 responders who spent over 10 hours per week in direct patient care, 198 were in private practice, 69 worked exclusively for institutions, and 18 worked part time in each setting. Eighty-three (29%) used extenders in their practice. Institutionally based neurologists were significantly more likely to use extenders than those in private practice.

In a patient with the syndrome of crural paresis and homolateral ataxia, administration of trihexyphenidyl resulted in improvement of disabling unilateral ataxia and gross intention tremor. Symptoms returned when drug therapy was interrupted. CT showed a radiolucent lesion deep in the parietal white matter close to the internal capsule.