Approach to Common Sleep Disorders.

Sleep disorders are highly relevant in clinical practice given their prevalence as well as their impact on health outcomes and quality of life. The most common concerns are excessive daytime sleepiness, insomnia, disordered breathing, and abnormal movements or behaviors during sleep. A detailed but targeted history is vital, particularly from the sleep partner/witness. In-laboratory sleep testing (polysomnography and multiple sleep latency test) remains vital in the diagnosis of certain sleep disorders (such as sleep-disordered breathing and central hypersomnia) and in specific populations (such as in children and individuals with comorbid medical disorders). Advances in technology have allowed for a variety of methods in assessing a patient's sleep, from compact devices to evaluate for sleep apnea, wrist actigraphy, and mobile device-based applications. As the pathophysiology of various sleep disorders becomes better elucidated, disease-specific medications have been developed for these conditions. Nonetheless, a multidisciplinary approach to management is necessary, including improving sleep hygiene and cognitive behavioral therapy.

Assessing Sleep Concerns in Individuals With Acquired Brain Injury: The Feasibility of a Smartpad Sleep Tool.

OBJECTIVE: The investigators examined the presence of disrupted sleep in acquired brain injury (ABI) and the utility of a mobile health program, MySleepScript, as an effective clinical tool to detect sleep disturbances. METHODS: A cross-sectional pilot study of MySleepScript, a customizable electronic battery of validated sleep questionnaires, was conducted. Participants were recruited at the Acquired Brain Injury Clinic at Johns Hopkins Bayview Medical Center. RESULTS: Sixty-eight adults with ABI (mean age, 46.3 years [SD=14.8]) participated in the study, with a mean completion time of 16.6 minutes (SD=5.4). Time to completion did not differ on individual completion or staff assistance. The mean score on the Pittsburgh Sleep Quality Index was 9.2 (SD=4.7); 83.9% of individuals had poor sleep quality (defined as a score >5). Insomnia Severity Index scores indicated moderate to severe insomnia in 45% of participants; 36.5% of participants screened positive for symptoms concerning sleep apnea, while 39.3% of individuals screened positive for restless legs syndrome. CONCLUSIONS: Poor sleep quality was highly prevalent in this ABI cohort. MySleepScript may be an effective method of assessing for sleep disturbance in ABI. Further efforts to identify sleep disorders in this patient population should be pursued to optimize ABI management.

A scoping review of new implementations of interprofessional bedside rounding models to improve teamwork, care, and outcomes in hospitals.

Poor communication within healthcare teams occurs commonly, contributing to inefficiency, medical errors, conflict, and other adverse outcomes. Interprofessional bedside rounds (IBR) are a promising model that brings two or more health professions together with patients and families as part of a consistent, team-based routine to share information and collaboratively arrive at a daily plan of care. The purpose of this systematic scoping review was to investigate the breadth and quality of IBR literature to identify and describe gaps and opportunities for future research. We followed an adapted Arksey and O'Malley Framework and PRISMA scoping review guidelines. PubMed, CINAHL, PsycINFO, and Embase were systematically searched for key IBR words and concepts through June 2020. Seventy-nine articles met inclusion criteria and underwent data abstraction. Study quality was assessed using the Mixed Methods Assessment Tool. Publications in this field have increased since 2014, and the majority of studies reported positive impacts of IBR implementation across an array of team, patient, and care quality/delivery outcomes. Despite the preponderance of positive findings, great heterogeneity, and a reliance on quantitative non-randomized study designs remain in the extant research. A growing number of interventions to improve safety, quality, and care experiences in hospital settings focus on redesigning daily inpatient rounds. Limited information on IBR characteristics and implementation strategies coupled with widespread variation in terminology, study quality, and design create challenges in assessing the effectiveness of models of rounds and optimal implementation strategies. This scoping review highlights the need for additional studies of rounding models, implementation strategies, and outcomes that facilitate comparative research.

The utility and feasibility of assessing sleep disruption in a men's health clinic using a mobile health platform device: A pilot study.

INTRODUCTION: Evidence linking sleep disruption and sexual dysfunction in men is mounting; yet the characterisation of sleep patterns and complaints utilising a clinically feasible method within this patient population remain largely under-reported. AIM: A pilot study aiming to demonstrate a clinically feasible method to characterise the sleep patterns and complaints in a representative sample of patients treated in a men's health clinic. METHODS: Male patients (n = 48) completed a battery of validated sleep questionnaires using an mHealth mobile platform, MySleepScript, at the Johns Hopkins Men's Health and Vitality Center. Metrics related to clinical feasibility such as completion time, ease of use, preference of electronic format, and patient satisfaction were also collected. MAIN OUTCOME MEASURES: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Berlin Questionnaire, Patient Health Questionnaire (PHQ-9), and Primary Care PTSD Screen (PC-PTSD). RESULTS: Primary urological chief symptoms for this sample patient population were erectile dysfunction (ED; 80%), hypogonadism (40%), benign prostatic hyperplasia/lower urinary tract symptoms (BPH/LUTS; 40%) and Peyronie's disease (10%). Mean PSQI score was 7.8 [SD 4.2], with 67% of all patients falling within the "poor sleeper" range. At least mild symptoms of depression were noted in 40% and 43% were at risk for obstructive sleep apnea (OSA) on the Berlin Questionnaire. CONCLUSIONS: This pilot study demonstrated the feasibility and potential utility of an mHealth platform to assist clinicians, within a men's health clinic, in detecting sleep disturbances. Disrupted sleep was revealed in well over half of this sample of patients. As a result of the growing evidence linking poor sleep and sleep disorders (eg, OSA) to the conditions relevant to men's health (eg, erectile dysfunction, hypogonadism and BPH), further efforts beyond this pilot study are necessary to identify the aetiological processes underlying the association between specific disrupted sleep disorders and urological conditions.

Neurology Education in 2035: The Neurology Future Forecasting Series.

In the past decade, there have been dramatic changes in all aspects of neurologic care, and along with this, neurology education has transformed. These changes have affected all aspects of education across the educational continuum, including learners, teachers, educators, content, delivery methods, assessments, and outcomes. Health systems science, health humanities, diversity, equity, and inclusion and health disparities are becoming core components of neurology curricula, and, in the future, will be integrated into every aspect of our educational mission. The ways in which material is taught and learned have been influenced by technologic innovations and a growing understanding of the science of learning. We forecast that this trend will continue, with learners choosing from an array of electronic resources to engage with fundamental topics, allowing front-line clinical teachers to spend more time supporting critical reasoning and teaching students how to learn. There has been a growing differentiation of educational roles (i.e., teachers, educators, and scholars). We forecast that these roles will become more distinct, each with an individualized pattern of support and expectations. Assessment has become more aligned with the work of the learners, and there are growing calls to focus more on the impact of educational programs on patient care. We forecast that there will be an increased emphasis on educational outcomes and public accountability for training programs. In this article, we reflect on the history of medical education in neurology and explore the current state to forecast the future of neurology education and discuss ways in which we can prepare.

Insomnia: Personalized Diagnosis and Treatment Options.

Chronic insomnia is a clinical diagnosis fulfilled by criteria: (a) difficulty initiating or maintaining sleep, (b) inability to sleep despite having adequate opportunities, (c) having negative daytime effects due to lack of sleep, and (d) sleep difficulty not explained by other disorder-with symptoms at least three times per week during a period of 3 months. Cognitive behavioral therapy is considered a first-line treatment but can be supported with pharmacologic or digital therapeutics. When developing a patient's care plan, we should consider a "personomics" approach in which we personalize care plans as a form of sleep precision medicine.

The promotion of sleep wellness: Resilience as a protective factor.

Objectives: To evaluate the association between resilience, sleep quality, and health. Methods: This cross-sectional study included 190 patients (Mean age = 51, SD = 15.57) recruited from the Johns Hopkins Center for Sleep and Wellness. Patients completed a modified version of the brief resilience scale (BRS) to assess characteristics of resilience and questions to assess aspects of mental health, physical health, sleep quality, and daytime functioning. Results: Participants' average score on the BRS was 4.67 (SD = 1.32, range = 1.17-7), reflecting a high level of resilience. There was a significant gender difference in resilience levels for men (Mean = 5.04, SD = 1.14) and women (Mean = 4.30, SD = 1.38), such that men reported significantly higher levels of resilience compared to women (t (188) = 4.02, p < 0.001) [lower levels of resilience were significantly associated with higher levels of (current) fatigue and tiredness after adjusting for demographic, physical, and mental covariates. In those reporting between one and three mental health symptoms, high levels of resilience minimized the negative influence that these symptoms had on sleep quality. This minimizing effect was no longer evident in those experiencing >3 mental health symptoms, who also reported significantly higher symptoms of fatigue despite their high resilience scores. Conclusions: This study emphasizes how resilience may affect the relationship between mental health and sleep quality in sleep patients. Resilience may further our understanding of the inter-relationships between sleep and the manifestation of physical health symptoms, a relationship that will likely heighten in relevance during personal and global crisis. An awareness of this interaction could be used as a proactive prevention and treatment strategy. In other words, incorporating methods to evaluate resilience in patients with mental illnesses regularly can be useful for predicting the potential manifestation and severity of sleep disturbance. Therefore, strategies that focus on promoting resilience could improve health and wellness.

Comparative effectiveness study of flipped classroom versus online-only instruction of clinical reasoning for medical students.

CONTEXT: Bedside clinical teaching is the backbone of clerkship education. Data-driven methods for supplementing bedside encounters with standardized content from vetted resources are needed. OBJECTIVE: To compare a flipped-classroom versus an interactive online-only instruction for improving knowledge, skills, self-directed learning (SDL) behaviors, and satisfaction in a medical school clerkship. METHODS: An IRB-approved prospective study employing a peer-reviewed clinical reasoning curriculum in neurology was conducted; 2nd-4th year medical students rotating through a required clerkship were enrolled. Students were randomized to flipped-classroom (i.e., flipped) or interactive asynchronous online instruction (i.e., online-only), which supplemented existing bedside teaching. Baseline and end-of-course knowledge, skill development, SDL behaviors, satisfaction, and long-term retention were assessed by peer-reviewed clinical reasoning exam, NBME scores, faculty/resident clinical evaluations, non-compulsory assignment completion, end-of-clerkship surveys, and objective structured clinical exam (OSCE). RESULTS: 104 students (49 flipped, 55 online-only) were enrolled. Age, gender, and training level did not differ by group (all p > 0.43); baseline knowledge was higher in the flipped group (p = 0.003). Knowledge-based exam scores did not differ by group even after adjusting for differences in baseline knowledge (2.3-points higher in flipped group, 95%CI -0.4-4.8, p = 0.07). Clinical skills were significantly higher in the flipped group, including examination skills (4.2 ± 0.5 vs. 3.9 ± 0.7, p = 0.03) and future housestaff potential (4.8 ± 0.3 vs 4.5 ± 0.6, p = 0.03). Students in the online-only group were more likely to engage in SDL (42 vs. 12%, p = 0.001) and reported more hours studying (6.1 vs. 3.8 hours, p = 0.03). Satisfaction (p = 0.51) and OSCE scores (p = 0.28) were not different by group. CONCLUSIONS: In this comparative study of two evidence-based curricular delivery approaches, we observed no difference in knowledge acquired. Greater clinical skills were observed with flipped instruction, while more SDL was observed with online-only instruction. Supplementing bedside teaching with blended instruction that balances live skill development with vetted online resources is optimal for clerkship education.

It's a Win-Win: The Effect of Medical Students on Clinic Productivity.

Objective: We sought to explore whether obstetrics and gynecology (Ob-Gyn) ambulatory clinic preceptors can maintain their clinical productivity with a learner (medical student) present. Methods: We studied the productivity of five exemplary Ob-Gyn faculty over the 2016-2017 academic year. We used paired two-tailed t tests to compare physician productivity with and without a student. Faculty were interviewed and qualitative analyses were performed on faculty interview data to identify themes used to create sample best-practice workflows for student involvement in the clinic. Results: Three faculty had significant increases in relative value units (RVUs) per clinic half-day when a medical student was present (11%-31% increase, P<.05). Four faculty had average increases in net charges billed per clinic half-day ranging from $172.39 to $343.14. One faculty preceptor had a decrease in RVUs and charges billed when a student was present, which was not statistically significant. Themes derived from faculty interviews regarding their incorporation of medical students in the clinic included setting expectations, allowing students to assist with clinic workflow, note-writing, and efficient use of time and clinic space. In an iterative feedback process, we developed ideal workflow models for student involvement during clinic visits with and without a procedure. Conclusion: This mixed-methods pilot study suggests that medical students do not impede clinician productivity when utilized effectively in the outpatient setting. Further contemporary research is needed to assess the impact of learners on ambulatory clinician productivity in light of Medicare policy changes and modifications in medical education due to the COVID-19 pandemic.

Accelerated Implementation of a Virtual Neurology Clerkship Amid a Global Crisis.

The standard neurology clinical experience in medical school focuses primarily on bedside patient encounters; however, the limitations of the clinical environment due to the current COVID-19 pandemic have accelerated the need for virtual curriculum development. To provide guidance to Neurology clerkship directors during this unprecedented time, the American Academy of Neurology (AAN) Undergraduate Education Subcommittee (UES) formed a workgroup to develop an outline for a virtual curriculum, provide recommendations, and describe models of integrating virtual curricula into the neurology clerkship. In this overview, we discuss different methods of virtual instruction, hybrid models of clerkship training and the challenges to its implementation, professionalism issues, and modification of feedback and assessment techniques specific to the virtual learning environment. We also offer suggestions for implementation of a hybrid virtual curriculum into the neurology clerkship. The virtual curriculum is intended to supplement the core neurology in-person clinical experience and should not be used for shortening or replacing the required neurology clinical clerkship.

Practicing in a Pandemic: A Clinician's Guide to Remote Neurologic Care.

Neurologists around the country and the world are rapidly transitioning from traditional in-person visits to remote neurologic care because of the coronavirus disease 2019 pandemic. Given calls and mandates for social distancing, most clinics have shuttered or are only conducting urgent and emergent visits. As a result, many neurologists are turning to teleneurology with real-time remote video-based visits with patients to provide ongoing care. Although telemedicine utilization and comfort has grown for many acute and ambulatory neurologic conditions in the past decade, remote visits and workflows remain foreign to many patients and neurologists. Here, we provide a practical framework for clinicians to orient themselves to the remote neurologic assessment, offering suggestions for clinician and patient preparation before the visit; recommendations to manage common challenges with remote neurologic care; modifications to the neurologic examination for remote performance, including subspecialty-specific considerations for a variety of neurologic conditions; and a discussion of the key limitations of remote visits. These recommendations are intended to serve as a guide for immediate implementation as neurologists transition to remote care. These will be relevant not only for practice today but also for the likely sustained expansion of teleneurology following the pandemic.

Training in Neurology: Implementation and Evaluation of an Objective Structured Clinical-Examination Tool for Neurology Postgraduate Trainees in Lusaka, Zambia.

BACKGROUND: We established Zambia's first neurology residency program at the University of Zambia School of Medicine and the University Teaching Hospital in Lusaka. OBJECTIVE: To evaluate the feasibility and effectiveness of a modified objective structured clinical examination (OSCE) to assess clinical skills. METHODS: The neurology training program's 3 participants completed the OSCE exercise in February 2019. We used smartphones to videotape trainees performing a physical examination and oral presentation in the neurology clinic. Trainees and faculty reviewed the videos independently using a standardized rubric and then met for in-person feedback. RESULTS: Three trainees completed pre- and post-OSCE surveys rating their confidence in elements of the history and examination. Trainees' average self-confidence scores improved from the pre- to post-OSCE survey in every category (pre-OSCE: mean score 6.84, range 4.8-7.8, SD 0.92; post-OSCE: mean score 7.9, range 5.67-9.33, SD 0.86). Qualitative feedback showed trainees found the OSCE helpful, routinely applied feedback, and would appreciate repeating OSCEs. CONCLUSIONS: OSCEs improve trainees' self-confidence and can be modified and successfully implemented in a resource-limited neurology postgraduate training program. Important OSCE modifications involved using smartphones for videotaping and a real patient encounter rather than a standardized patient. Embedding the experience within a busy clinic day was practical, applicable, and efficient. Future work should expand use of OSCEs both within the Zambian neurology residency program and non-neurology training programs. Including additional video reviewers could add to the validity of clinical skills assessment. Videos could also be used for remote mentorship and teaching purposes.

Insomnia.

PURPOSE OF REVIEW: This article provides updated information regarding the diagnosis and treatment of chronic insomnia disorder. In addition to discussing the latest recommendations regarding pharmacotherapeutic options for insomnia, this article also discusses the increased use of nonpharmacologic treatment approaches, including cognitive-behavioral therapy intervention, integrative medicine, mindfulness and meditation, and other therapeutic options in clinical practice. RECENT FINDINGS: Insomnia is one of the most common sleep disorders in patients with other neurologic disorders. The definition and criteria for insomnia were updated with the release of the International Classification of Sleep Disorders, Third Edition. The American Academy of Sleep Medicine has updated clinical practice guidelines for the pharmacologic treatment of chronic insomnia in adults. New diagnostic and therapeutic options (eg, pharmacologic and behavioral therapies, at-home devices) have emerged to optimize and personalize the evaluation and management of sleep disorders such as insomnia. Although some of these devices and treatment options are still in the early stages of development, several are currently in clinical trials or will soon be available. SUMMARY: This article emphasizes complexities related to the evaluation and management of patients with chronic insomnia disorder and describes alternative therapeutic options for patients with this common sleep disorder.

Cross-Cultural Chronotypes: Educating Medical Students in America, Malaysia and the UAE.

This article was migrated. The article was marked as recommended. Background: Ample data demonstrates that sleep deprivation leads to impaired functioning including cognitive performance, memory and fine motor skills. Medical students represent a professional sector in which optimizing cognitive performance and functioning is critical from a personal, public health and safety perspective. Aims: To characterize chronotypes of an international cohort of medical students and determine if chronotype is affected by demographics or latitude. Samples: 328 students from medical schools in the United States (US), Malaysia and United Arab Emirates (UAE) were assessed for differences in chronotype and sleep habits. Methods: A cross-sectional, questionnaire-based study from medical schools in the US, Malaysia and UAE between 2013 and 2015. Results: There was a significant difference in mean waking times for Malaysian students who reported awakening earlier than US or UAE students. Malaysian students were most likely to feel their best earlier in the day and consider themselves a "morning type." UAE students were more likely to do "hard physical work" later in the day, followed by US and Malaysian. On average, US students were less likely to shift their bedtime later if they had no commitments the next day. Overall, mean chronotype score was "neither" type for all three groups however the Malaysian group showed a significant preference for morning hours in some individual questions. Conclusion: Medical student sleep patterns vary internationally but chronotype may not. Improving sleep education globally, with awareness of the effects of chronotype, could ultimately result in improved sleep awareness, potentially influencing physician wellbeing, patient care and safety.

Facets of personality related to sleep habits in Black adults.

OBJECTIVE: The objective of this study is to explore the relationship between personality traits and sleep in community-dwelling older Blacks, and to examine whether conscientiousness moderates relationships between neuroticism and sleep (quality and duration) within this cohort. METHOD: Black adults (age range: 55-86 years) residing in the Tampa Bay Area, Florida, completed the Big Five Inventory to examine broad personality traits (e.g., neuroticism) and specific facets (e.g., anxiety or depression) and the Pittsburgh Sleep Quality Index to evaluate sleep habits and quality. RESULTS: Ninety-three participants (Mean age: 66.6, standard deviation: 7.4) were included in the final sample. High neuroticism, low extraversion, low conscientiousness, and low openness were each significantly associated with worse overall sleep habits. Individuals high on the facets for neuroticism (e.g., anxiety, depression) and/or low for extraversion (e.g., assertiveness), conscientiousness (e.g., self-discipline and order), and openness (e.g., aesthetics and ideas) were more likely to report poorer sleep. However, only neuroticism and extraversion each remained significantly associated with worse sleep in our regression models adjusting for demographic and health covariates. Adults with both higher neuroticism and lower conscientiousness indicated a greater likelihood for experiencing daytime dysfunction within this population. CONCLUSIONS: Recognizing specific personality traits associated with disrupted sleep, particularly in those who self-identify as Black, may enhance the ability of sleep clinicians to diagnose and deliver more personalized treatments and interventions (e.g., cognitive behavioral therapy). The present study's findings further support existing literature, suggesting that clinicians should incorporate personality assessments to identify individuals most susceptible to severe sleep disturbances.

The PreDoc Program: Pipeline Healthcare Apprenticeship Program through the Lens of a Neurologist.

This article was migrated. The article was marked as recommended. Objective: The PreDoc program is a longitudinal apprenticeship aimed at increasing college student interest in pursuing a healthcare career. This program offers the continuity of clinical, research, and educational exposure in academic medicine utilizing a career immersion approach that allows a graduated level of responsibility, experience, and leadership opportunities. Methods: Students get an asynchronous/synchronous curriculum under the direction of academic physicians committed to boosting the pipeline. Training in critical career development skills including "goal setting," professionalism, communication, and time management are provided to Pre-Docs by their senior peers and program leaders. Results: Since the implementation of the PreDoc program in 2013, 28 students have enrolled in the program. Twenty-three students completed the survey; 100% ranked the program quality as good/excellent. Students reported more interest in academic medicine (n=19, 83%), neurology (n=18, 78%), and sleep medicine (n=18, 78%). A majority of the students reported that they were extremely likely to pursue a medical career (n=20, 87%). All students have completed or are in the process of completing at least one scholarly product. Conclusions: The PreDoc program has been successful in promoting college student scholarly productivity in healthcare and in garnering student interest in academic medicine, particularly in neurology.

Incorporating sleep medicine content into medical school through neuroscience core curricula.

OBJECTIVE: To present (1) justification for earmarking sleep medicine education as an essential component of all medical school curricula and (2) various avenues to incorporate sleep medicine exposure into medical school curricula through (primarily) neuroscience and neurology courses. METHODS: Per consensus of a team of leading neurology and sleep medicine educators, an evidence-based rationale for including sleep medicine across a 4-year medical school curriculum is presented along with suggested content, available/vetted resources, and formats for delivering sleep medicine education at various points and through various formats. RESULTS: Growing evidence has linked sleep disorders (e.g., sleep-disordered breathing, chronic insufficient sleep) as risk factors for several neurologic disorders. Medical educators in neurology/neuroscience are now strongly advocating for sleep medicine education in the context of neurology/neuroscience pre and post graduate medical education. Sleep medicine education is also a critical component of a proactive strategy to address physician wellness and burnout. The suggested curriculum proposes a sleep educational exposure time of 2-4 hours per year in the form of lectures, flipped-classroom sessions, clinical opportunities, and online educational tools that would result in a 200%-400% increase in the amount of sleep medicine exposure that US medical schools currently provide. The guidelines are accompanied by the recommendation for use of technological education, to facilitate more seamless curricular incorporation. CONCLUSION: Even in this era with limited flexibility to add content to an already packed medical school curriculum, incorporating sleep medicine exposure into the current medical school curriculum is both justified and feasible.

When a private community neurology practice executes home sleep apnea testing: benefits identified and lessons learned in a retrospective observational study.

OBJECTIVE: To investigate the feasibility and utility of a private community neurology practice-initiated home sleep apnea testing (HSAT) program. METHODS: A private community neurology practice conducted HSAT on patients clinically identified as high risk for obstructive sleep apnea (OSA). An academic board-certified sleep specialist performed all study interpretations. The presence and severity of OSA and its association with patient demographics (eg, sex, age) and comorbid health conditions relevant to OSA were evaluated. RESULTS: During 2011-2014, 147 consecutive patients clinically identified as highly "at risk for OSA" during their neurological visit underwent HSAT. Sixty-one percent (n=89) of patients had a "positive" study with evidence of an apnea-hypopnea index of greater than 5 events per hour. Of those, 37% (n=54) had mild OSA and 24% (n=35) had moderate-severe OSA. OSA was more common among men (54%, n=48) and in individuals with a previous documented history of depression (33%, n=48) and hypertension 44% (n=64). OSA treatment was ordered in 44% (n=39) of patients by the neurologists or by a sleep specialist. Twenty-four percent (n=21) of all patients studied were referred to a sleep specialist. CONCLUSION: Implementation of HSAT in a (nonsleep) private community neurology practice in collaboration with an academic sleep program is recommended. Based on this observational study, community-based neurological practices and board-certified sleep specialists should consider teaming up to develop HSAT collaborative programs to open new sleep care access pathways for neurological patients often at risk for sleep apnea.

Connecting clinical aspects to corticomotor excitability in restless legs syndrome: a TMS study.

We assessed corticomotor excitability in the primary motor cortex (M1) of participants with moderate-to-severe restless legs syndrome (RLS) symptoms using transcranial magnetic stimulation (TMS) in relation to the clinical and sleep aspects of the disease. Thirty-five participants (20 F; mean age: 59.23 ± 1.66 years; range: 42-78 years) affected by primary RLS (off medications) and 31 age-matched controls (19 F; mean age: 57.90 ± 1.50 years; range: 43-79 years) underwent TMS following two nights of polysomnography (PSG). Paired-pulse TMS measures [short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI), and intracortical facilitation (ICF)] of the dominant M1hand and M1leg muscles were collected and analyzed in relation to clinical features of RLS and PSG. We found decreased corticomotor excitability in M1hand, whereas it was increased in M1leg, which was greater in patients with more severe RLS. Participants with RLS with a history of dopamine-agonist-induced symptom augmentation showed decreased LICI (reduced inhibition) compared to nonaugmented participants with RLS for M1leg. None of the TMS measures (M1hand or M1leg) correlated with the PSG parameters. This study shows hyperexcitability in M1leg, and this appears related to RLS disease severity and decreased excitability in M1hand. The results provide new insight into the complex neurobiology of RLS, particularly in more advanced stages of the disease.

Education Research: Difficult conversations in neurology: Lessons learned from medical students.

OBJECTIVE: To characterize features of medical student exposure to difficult conversations during a neurology core clerkship. METHODS: This was a cross-sectional concurrent nested mixed methods study, and all students rotating through a required neurology clerkship between 2014 and 2015 were enrolled. Data collection included an electronic communication tracker, baseline and end-of-clerkship surveys, and 4 facilitated focus groups. Students were asked to log exposure to patient-clinician conversations about (1) new disability, (2) poor prognosis, (3) prognostic uncertainty (4), terminal diagnosis, and (5) end-of-life care. RESULTS: A total of 159 students were enrolled and 276 conversations were tracked. Most (70%) students observed at least 1 difficult conversation, and conversations about poor prognosis, new disability, and prognostic uncertainty were most commonly logged. At clerkship end, most students (87%) desired additional bedside training in communication skills. Exposure to one of the predefined conversation types did not improve student perceived preparedness to lead difficult conversations in the future. In focus groups, students noted that the educational value of observation of a difficult conversation could be optimized with preconversation planning and postconversation debriefing. CONCLUSIONS: Difficult conversations are common in neurology, and represent a valuable opportunity to provide communication skills training on the wards. Future curricula should consider ways to leverage these existing opportunities to enhance communication skills training.