"Building Your Neurology Acumen": A Flipped Classroom Approach for Internal Medicine Residents.

Globally, internal medicine (IM) residents often feel they lack the knowledge and skills to approach patients presenting with neurologic issues. We conducted a multiple method needs assessment to determine the feasibility of a novel neurology flipped classroom (FC) curriculum for internal medicine residents. Our primary findings include participants: (1) finding neurology a useful rotation; (2) feeling uncomfortable with the neurological examination; and (3) endorsing flipped classroom as a potential alternative but with significant barriers. Our findings elucidate upon the various extrinsic/intrinsic motivators for resident education and illustrate the need to re-examine the way in which neurology is being taught to off-service residents.

Patient preference for virtual versus in-person visits in neuromuscular clinical practice.

INTRODUCTION/AIMS: It is unknown if patients with neuromuscular diseases prefer in-person or virtual telemedicine visits. We studied patient opinions and preference on virtual versus in-person visits, and the factors influencing such preferences. METHODS: Telephone surveys, consisting of 11 questions, of patients from 10 neuromuscular centers were completed. RESULTS: Five hundred and twenty surveys were completed. Twenty-six percent of respondents preferred virtual visits, while 50% preferred in-person visits. Sixty-four percent reported physical interaction as "very important." For receiving a new diagnosis, 55% preferred in-person vs 35% reporting no preference. Forty percent were concerned about a lack of physical examination vs 20% who were concerned about evaluating vital signs. Eighty four percent reported virtual visits were sufficiently private. Sixty eight percent did not consider expenses a factor in their preference. Although 92% were comfortable with virtual communication technology, 55% preferred video communications, and 19% preferred phone calls. Visit preference was not significantly associated with gender, diagnosis, disease severity, or symptom management. Patients who were concerned about a lack of physical exam or assessment of vitals had significantly higher odds of selecting in-person visits than no preference. DISCUSSION: Although neither technology, privacy, nor finance burdened patients in our study, more patients preferred in-person visits than virtual visits and 40% were concerned about a lack of physical examination. Interactions that occur with in-person encounters had high importance for patients, reflecting differences in the perception of the patient-physician relationship between virtual and in-person visits.

Autonomic involvement in Guillain-Barré syndrome: an update.

BACKGROUND: Guillain-Barré syndrome (GBS), an inflammatory, usually demyelinating polyradiculopathy, is characterized by ascending symmetrical limb weakness, sensory disturbances, and absent or reduced deep tendon reflexes. There is extensive literature suggesting that GBS is associated with autonomic dysfunction in up to two-thirds of patients. However, it is interesting that there is still no consensus amongst medical professionals regarding whether GBS patients should be routinely screened for autonomic nervous system (ANS) neuropathy. This is an important issue, as the mortality rate from presumed ANS abnormalities now exceeds that of respiratory failure. Given the long interval since this literature was last comprehensively reviewed, an update on this topic is warranted. METHODS: A PubMed search yielded 193 results with the terms "GBS or Guillain-Barré syndrome and autonomic symptoms" and 127 results with the terms "GBS or Guillain-Barré syndrome and dysautonomia." RESULTS: This review will summarize the current literature involving GBS and autonomic dysfunction in terms of presentation, management, and a brief discussion of prognosis. We also examine prospective approaches that may be helpful and update a proposed management plan.

Headaches: a Review of the Role of Dietary Factors.

Dietary triggers are commonly reported by patients with a variety of headaches, particularly those with migraines. The presence of any specific dietary trigger in migraine patients varies from 10 to 64 % depending on study population and methodology. Some foods trigger headache within an hour while others develop within 12 h post ingestion. Alcohol (especially red wine and beer), chocolate, caffeine, dairy products such as aged cheese, food preservatives with nitrates and nitrites, monosodium glutamate (MSG), and artificial sweeteners such as aspartame have all been studied as migraine triggers in the past. This review focuses the evidence linking these compounds to headache and examines the prevalence of these triggers from prior population-based studies. Recent literature surrounding headache related to fasting and weight loss as well as elimination diets based on serum food antibody testing will also be summarized to help physicians recommend low-risk, non-pharmacological adjunctive therapies for patients with debilitating headaches.

Maternal circulating leukocytes display early chemotactic responsiveness during late gestation.

BACKGROUND: Parturition has been widely described as an immunological response; however, it is unknown how this is triggered. We hypothesized that an early event in parturition is an increased responsiveness of peripheral leukocytes to chemotactic stimuli expressed by reproductive tissues, and this precedes expression of tissue chemotactic activity, uterine activation and the systemic progesterone/estradiol shift. METHODS: Tissues and blood were collected from pregnant Long-Evans rats on gestational days (GD) 17, 20 and 22 (term gestation). We employed a validated Boyden chamber assay, flow cytometry, quantitative real time-polymerase chain reaction, and enzyme-linked immunosorbent assays. RESULTS: We found that GD20 maternal peripheral leukocytes migrated more than those from GD17 when these were tested with GD22 uterus and cervix extracts. Leukocytes on GD20 also displayed a significant increase in chemokine (C-C motif) ligand 2 (Ccl2) gene expression and this correlated with an increase in peripheral granulocyte proportions and a decrease in B cell and monocyte proportions. Tissue chemotactic activity and specific chemokines (CCL2, chemokine (C-X-C motif) ligand 1/CXCL1, and CXCL10) were mostly unchanged from GD17 to GD20 and increased only on GD22. CXCL10 peaked on GD20 in cervical tissues. As expected, prostaglandin F2α receptor and oxytocin receptor gene expression increased dramatically between GD20 and 22. Progesterone concentrations fell and estradiol-17ß concentrations increased in peripheral serum, cervical and uterine tissue extracts between GD20 and 22. CONCLUSION: Maternal circulating leukocytes display early chemotactic responsiveness, which leads to their infiltration into the uterus where they may participate in the process of parturition.

Residency training experiences of residents with children: A phenomenological study.

Parenthood during postgraduate medical training has become an increasingly relevant topic in recent years. While previous research has attempted to explore the experiences of residents in a parenting role through surveys and limited qualitative studies, an in depth understanding of the postgraduate training experience of these parent residents has not been clearly described. The optimal means of supporting trainees completing residency while parenting remains unclear. The study aim was to develop a rich understanding of the residency training experience of residents in a parenting role. We conducted 15 semi-structured telephone interviews. Our study population included postgraduate trainees from 9 different programs from a large research-intensive university who were parents upon entry to residency or who became parents during residency training. Transcendental phenomenology was used as a qualitative research methodology, guided by life course theory. Thematic analysis of residents' training experiences revealed the following themes: 1) challenges of being a parent with residency responsibilities; 2) work-life balance; 3) support systems; 4) impact on patient interactions; 5) impact on other interactions; and 6) unspoken expectations. Participants suggested actionable solutions to improve the training experience for residents in a parenting role, which included: 1) family-inclusive events; 2) scheduling flexibility; 3) support for fathers; and 4) optimizing support for breastfeeding mothers. Residents in a parenting role represent a unique postgraduate trainee population. Despite focus on resident wellness, challenges remain for individuals trying to navigate parenthood and residency. This data may be utilized to inform support and strategies to optimize the training experiences of these residents.