Prospective study on a fast-track training in psychiatry for medical students: the psychiatric hat game

Abstract: Background: While medical students are losing interest in lectures in favor of other educational materials, many studies suggest the benefit of active learning, combined with gamified educational tools. The authors developed a psychiatric adaptation of the « Hat Game ». It was hypothesised that this game would increase both knowledge and motivation in medical students toward psychiatric semiology. The aim of the study was to assess the benefit of a Psychiatric Hat Game session for learning psychiatric symptoms in third-year medical students. Student performance was also evaluated at 3 months. Methods: This gamified fast-track training consists of two teams and each team has to guess as many psychiatric semiology terms as possible using different techniques (i.e. speech, mime). The study involved a pre- and post-evaluation of knowledge (Multiple Choice Questions) and a satisfaction survey. Baseline, post-immediate, and three-months scores were compared by using Friedman analysis for paired samples. Comparisons of mean scores at two different times were performed by using Wilcoxon test for paired samples. Results: One hundred and sixty-six students were proposed to take part in the study. Among them 129 completed the whole program (response rate = 77.7%). Mean scores measured at the three points in time were significantly different (p < 0.001, N = 129). Knowledge mean scores were significantly higher after the game than before (+ 28.6%, p < 0.001). Improvement was maintained 3 months after the game (+ 18.9%, p < 0.001). Satisfaction survey items highlighted that students enjoyed and would recommend this type of gamified training. Conclusions: The Psychiatric Hat Game improved knowledge of psychiatric semiology in medical students. Results suggest that it is a promising and efficient tool to playfully teach medical semiology, with transferable features, utility and acceptability from one medical field to another. This study contributes to the growing body of knowledge advocating for serious games and gamified training in medical education.Version of Recor

Mort subite et inattendue épileptique (revue de la littérature et étude de cas alsaciens.)

STRASBOURG-Medecine (674822101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Impact de l'interruption de la transmission dopaminergique sur l'activité des ganglions de la base et du cortex moteur, et mécanismes d'action de la stimulation haute fréquence du noyau subthalamique

Les symptômes moteurs de la maladie de Parkinson sont principalement liés à la dégénérescence de la voie nigro-striatale. D un point de vue électrophysiologique, chez les patients et dans des modèles animaux de la maladie, des changements d activité ont été décrits principalement au niveau des ganglions de la base (GGB) et dans le réseau thalamo-cortical. Il s agit d altérations de fréquence et de patron de décharge des neurones, de synchronisation excessive d activité dans les basses fréquences, notamment dans la bande de fréquence bêta, et de perte de sélectivité de réponse à une stimulation périphérique. A un stade avancé de la maladie, la stimulation haute fréquence (SHF) du noyau subthalamique (NST) permet l amendement des symptômes moteurs mais également des divers changements électrophysiologiques observés dans la situation parkinsonienne.L utilisation d injections systémiques de neuroleptiques, antagonistes des récepteurs dopaminergiques nous a permis d étudier sur un même neurone de la substance noire réticulée (SNr), structure de sortie des GGB, les effets induits par l interruption pharmacologique aiguë de la transmission dopaminergique puis de la SHF du NST. La SHF du NST restaure l activité spontanée des neurones de la SNr ainsi que leur réponse évoquée par une stimulation corticale traduisant un rétablissement du transfert des informations corticales dans le réseau des GGB. Au cours de cette dernière étude, le bon positionnement de l électrode de stimulation dans le NST nous a amené à mettre en évidence l existence d une voie subthalamo-corticale activée antidromiquement par une stimulation du cortex moteur. Nous avons caractérisé anatomiquement et électrophysiologiquement cette voie qui avec la voie cortico-subthalamique dite hyperdirecte constitue une boucle partiellement ouverte. Les projections réciproques de cette boucle se situent principalement dans le territoire moteur oro-facial.Nous avons ensuite étudié les délais de survenue de l activité excessive dans la bande de fréquence bêta par rapport à l akinésie chez des rats ayant subi une interruption de la transmission dopaminergique pharmacologique, aiguë et chronique, ou lésionnelle, unilatérale et bilatérale (6-OHDA au niveau de la substance noire compacte). Des enregistrements électroencéphalographiques des cortex moteur et pariétal ont été effectués pendant un mois chez des rats vigiles ainsi traités. Chez les rats présentant une interruption chronique de la transmission dopaminergique, la synchronisation excessive bêta survient progressivement et elle est précédée par l akinésie. La présence de cette activité excessive bêta est dépendante de l état de vigilance puisqu uniquement présente durant l éveil et le sommeil paradoxal, lorsque l activité corticale est dans état désynchronisé. Conformément à l influence prédominante des GGB sur le cortex moteur, l intensité de l activité bêta pathologique est plus importante dans cette région corticale qu au niveau du cortex pariétal. De plus, la cohérence d activité entre ces deux aires corticales se majore traduisant une perte de ségrégation fonctionnelle.Enfin, nous avons réalisé des enregistrements unitaires intracellulaires de neurones pyramidaux du cortex moteur chez des rats contrôles et unilésés à la 6-OHDA avant et après SHF du NST. La lésion dopaminergique induit une hyperexcitabilité des neurones avec une dépolarisation du potentiel de membrane au repos et une augmentation de la résistance membranaire s accompagnant d une augmentation d amplitude des événements synaptiques. Il existe également une altération du patron de décharge avec de nombreuses bouffées de potentiels d action. La SHF du NST corrige partiellement les changements induits par la lésion dopaminergique probablement par la mise en jeu des interneurones GABAergiques du cortex.PARIS-BIUSJ-Thèses (751052125) / SudocPARIS-BIUSJ-Physique recherche (751052113) / SudocSudocFranceF

From anticipation to impulsivity in Parkinson's disease

Anticipatory actions require to keep track of elapsed time and inhibitory control. These cognitive functions could be impacted in Parkinson's disease (iPD). To test this hypothesis, a saccadic reaction time task was used where a visual warning stimulus (WS) predicted the occurrence of an imperative one (IS) appearing after a short delay. In the implicit condition, subjects were not informed about the duration of the delay, disfavoring anticipatory behavior but leaving inhibitory control unaltered. In the explicit condition, delay duration was cued. This should favor anticipatory behavior and perhaps alter inhibitory control. This hypothesis was tested in controls (N = 18) and age-matched iPD patients (N = 20; ON and OFF L-DOPA). We found that the latency distribution of saccades before the IS was bimodal. The 1st mode weakly depended on temporal information and was more prominent in iPD. Saccades in this mode were premature and could result of a lack of inhibition. The 2nd mode covaried with cued duration suggesting that these movements were genuine anticipatory saccades. The explicit condition increased the probability of anticipatory saccades before the IS in controls and iPDON but not iPDOFF patients. Furthermore, in iPD patients the probability of sequences of 1st mode premature responses increased. In conclusion, the triggering of a premature saccade or the initiation of a controlled anticipatory one could be conceptualized as the output of two independent stochastic processes. Altered time perception and increased motor impulsivity could alter the balance between these two processes in favor of the latter in iPD, particularly OFF L-Dopa

Etude l activité bêta corticale durant le trouble comportemental en sommeil paradoxal chez les patients parkinsoniens

Un des marqueurs électrophysiologiques de la maladie de Parkinson (MPI) est une hyperactivité dans la bande de fréquence bêta au niveau des ganglions de la base et du cortex cérébral au repos et sans traitement anti-parkinsonien. Lors d un mouvement et sous traitement dopaminergique ou chirurgical, cette hyperactivité bêta diminue et une hyperactivité gamma apparaît, suggérant un rôle anti-kinétique à l'activité excessive bêta et un rôle pro-kinétique de l'activité gamma. L association d un trouble comportemental en sommeil paradoxal (TCSP) à la MPI est fréquente. Le but de cette thèse fut d analyser les changements d activité bêta durant les TCSP pour mieux comprendre pourquoi ces patients recouvrent une meilleure motricité durant ces épisodes.On a analysé les données cliniques, polysomnographiques et l'activité corticale en EEG pendant le sommeil paradoxal (SP) chez des patients parkinsoniens avec et sans TCSP, en les comparant à des sujets témoins. Nos résultats n'étaient pas significatifs probablement suite au nombre faible de patients par groupe (N=5). Il existe toutefois une augmentation du spectre de puissance et de la cohérence corticale dans la bande bêta chez les patients avec TCSP avec une prédominance pendant le TCSP. Les patients parkinsoniens sans TCSP avaient une diminution du spectre de puissance et de la cohérence par rapport aux sujets témoins sans explication claire. Une étude plus complète semble indispensable.Ces résultats témoignent probablement d une atteinte neurodégénérative plus évoluée chez les patients avec TCSP. Une extension des lésions à d autres systèmes non dopaminergiques pourrait participer au changement de niveau d activité bêta.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Subthalamic nucleus high-frequency stimulation restores altered electrophysiological properties of cortical neurons in parkinsonian rat.

Electrophysiological recordings performed in parkinsonian patients and animal models have confirmed the occurrence of alterations in firing rate and pattern of basal ganglia neurons, but the outcome of these changes in thalamo-cortical networks remains unclear. Using rats rendered parkinsonian, we investigated, at a cellular level in vivo, the electrophysiological changes induced in the pyramidal cells of the motor cortex by the dopaminergic transmission interruption and further characterized the impact of high-frequency electrical stimulation of the subthalamic nucleus, a procedure alleviating parkinsonian symptoms. We provided evidence that a lesion restricted to the substantia nigra pars compacta resulted in a marked increase in the mean firing rate and bursting pattern of pyramidal neurons of the motor cortex. These alterations were underlain by changes of the electrical membranes properties of pyramidal cells including depolarized resting membrane potential and increased input resistance. The modifications induced by the dopaminergic loss were more pronounced in cortico-striatal than in cortico-subthalamic neurons. Furthermore, subthalamic nucleus high-frequency stimulation applied at parameters alleviating parkinsonian signs regularized the firing pattern of pyramidal cells and restored their electrical membrane properties

Invalidation of Parkinson's disease diagnosis after years of follow-up based on clinical, radiological and neurophysiological examination

International audienceIntroduction : Diagnosis of Parkinson's disease (PD) is mainly based on clinical features. Accurate neurological examination is required but dopamine transporter (DaT) single photon emission computed tomography (SPECT) could be perfomed to support the diagnosis in ambiguous cases. The aim of this work is to describe the characteristics of patients with a prolonged PD misdiagnosis.Methods : We collected data from 24 patients initially diagnosed with PD who had an atypical long-term evolution. We analyzed demographic and clinical characteristics and antiparkinsonian drugs medication. Brain MRI, DaT-SPECT and/or accelerometry/electromyography (EMG) recording were performed in a subgroup of patients. We analyzed the causes of erroneous PD diagnosis as well as the final diagnoses.Results : Mean age at PD diagnosis was 60.4 ± 14.8 years. Symptoms at onset were rest tremor (n = 19), gait instability (n = 7) and micrographia (n = 4). Mean duration before diagnosis correction was 8.4 ± 5.3 years. All patients were treated by antiparkinsonian drugs with a mean daily levodopa equivalent dose (LED) of 508.1 ± 528.4 mg. All 18 patients who underwent DaT-SPECT had a normal result. The most frequent final diagnoses were essential tremor (n = 11) and functional movement disorders (n = 9).Conclusion : Cases that have been initially diagnosed as PD and then progress in an atypical long-duration fashion may have been misdiagnosed. Absence of genuine bradykinesia, non-sustained response to antiparkinsonian drugs, or absence of levodopa-related side effects should prompt the clinician to reappraise the diagnosis and to consider performing a DaT-SPECT

The Role of Magnetic Resonance Imaging for the Diagnosis of Atypical Parkinsonism

International audienceThe diagnosis of Parkinson's disease and atypical Parkinsonism remains clinically difficult, especially at the early stage of the disease, since there is a significant overlap of symptoms. Multimodal MRI has significantly improved diagnostic accuracy and understanding of the pathophysiology of Parkinsonian disorders. Structural and quantitative MRI sequences provide biomarkers sensitive to different tissue properties that detect abnormalities specific to each disease and contribute to the diagnosis. Machine learning techniques using these MRI biomarkers can effectively differentiate atypical Parkinsonian syndromes. Such approaches could be implemented in a clinical environment and improve the management of Parkinsonian patients. This review presents different structural and quantitative MRI techniques, their contribution to the differential diagnosis of atypical Parkinsonian disorders and their interest for individual-level diagnosis

Short-term temporal memory in idiopathic and Parkin-associated Parkinson's disease.

In a rapidly changing environment, we often know when to do something before we have to do it. This preparation in the temporal domain is based on a 'perception' of elapsed time and short-term memory of previous stimulation in a similar context. These functions could be perturbed in Parkinson's disease. Therefore, we investigated their role in eye movement preparation in sporadic Parkinson's disease and in a very infrequent variant affecting the Parkin gene. We used a simple oculomotor task where subjects had to orient to a visual target and movement latency was measured. We found that in spite of an increased average reaction time, the influence of elapsed time on movement preparation was similar in controls and the two groups of PD patients. However, short-term temporal memory of previous stimulation was severely affected in sporadic PD patients either ON or OFF dopaminergic therapy. We conclude that the two different contributions to temporal preparation could be dissociated. Moreover, a short-term temporal memory deficit might underlie temporal cognition deficits previously observed in PD

A single-center series of 482 patients with functional motor disorders

International audienceFunctional motor disorders (FMD) are common and disabling. They are known to predominantly affect women and young to middle-aged patients, although they also occur during childhood or in the elderly. Demographic and clinical characteristics of patients with FMD are poorly known, since large series of consecutive patients are scarce.MethodsIn a chart review study, we retrospectively abstracted data from consecutive FMD patients who were referred to the Neurophysiology Department of the Salpêtrière University Hospital between 2008 and 2016 for treatment with repeated transcranial magnetic stimulation.Results482 patients were included. Most patients were women (73.7%). Median age at symptoms onset was 35.5 years and symptoms were mostly characterized by acute (47.3%) or subacute (46%) onset. Only 23% of patients were active workers, while 58.3% were unemployed because of FMD. Half of the patients had functional motor weakness (n = 241) whereas the other half had movement disorders (n = 241), mainly with tremor (21.1%) or dystonia (20.5%). Among all patients, 66.4% had psychiatric comorbidity and 82.6% reported a history of trauma in the 6 months before symptoms onset. No difference was found in age or gender according to clinical phenotypes.ConclusionThis large series will contribute to better characterize FMDs