Fit for Service: Preparing Residents for Neurointensive Care with Entrustable Professional Activities: A Delphi Study.

BACKGROUND: Although the relevance of neurointensive medicine and high-quality training of corresponding physicians is increasingly recognized, there is high heterogeneity in the nature, duration, and quality of neurointensive care curricula around the world. Thus, we aimed to identify, define, and establish validity evidence for entrustable professional activities (EPAs) for postgraduate training in neurointensive care to determine trainees' readiness for being on-call. METHODS: After defining EPAs through an iterative process by an expert group, we used a modified Delphi approach with a single-center development process followed by a national consensus and a single-center validation step. EPAs were evaluated by using the EQual rubric (Queen's EPA Quality Rubric). Interrater reliability was measured with Krippendorff's α. RESULTS: The expert group defined seven preliminary EPAs for neurointensive care. In two consecutive Delphi rounds, EPAs were adapted, and consensus was reached for level of entrustment and time of expiration. Ultimately, EPAs reached a high EQual score of 4.5 of 5 and above. Interrater reliability for the EQual scoring was 0.8. CONCLUSIONS: Using a multistep Delphi process, we defined and established validity evidence for seven EPAs for neurointensive medicine with a high degree of consensus to objectively describe readiness for on-call duty in neurointensive care. This operationalization of pivotal clinical tasks may help to better train clinical residents in neurointensive care across sites and health care systems and has the potential to serve as a blueprint for training in general intensive care medicine. It also represents a starting point for further research and development of medical curricula.

Germany-wide evaluation of residency in neurological intensive care medicine.

BACKGROUND: Neurointensive medicine is an important subspecialization of neurology. Its growing importance can be attributed to factors such as demographic change and the establishment of new therapeutic options. Part of the neurological residency in Germany is a six-month rotation on an intensive care unit (ICU), which has not yet been evaluated nationwide. The aim of this study was to evaluate kind and feasibility of neurointensive care training in Germany and to discover particularly successful training concepts. METHODS: In a preliminary study, ten residents and ten instructors were interviewed. Using content analysis, two questionnaires were created, which contained questions about specific teaching methods as well as individual satisfaction. The questionnaires were sent to 187 neurological clinics in Germany, and residents and instructors were asked to participate in the study. The data analysis was performed using SPSS and content analysis for the free-text data. RESULTS: Seventy of the 187 clinics contacted did not offer ICU-rotation. At 59,8% (n = 70) of the remaining hospitals, a total of 154 participants (84 residents, 70 educators) could be recruited. General satisfaction with the neurointensive medical training is high in both groups (residents: 3.34 ± 0.54; instructors: 3.79 ± 0.41, evaluated on the basis of a Likert scale from 1 = "not satisfied" to 5 = "fully satisfied"). Specific teaching methods (e.g. simulation trainings, feedback sessions) are perceived as very useful by residents, but rarely take place. Instructors are interested in educational opportunities such as didactic courses. CONCLUSION: This study provides an overview of the ICU-rotation as part of the five-year neurological residency. Neurointensive care rotations usually take place at maximum care hospitals and last at least seven months. Despite frequent time and personnel restrictions, motivation of trainers and residents is high. Nevertheless, teaching methods as simulation training and educational opportunities for instructors must be expanded.

Residents as teachers in Neurology: a Germany-wide survey on the involvement of neurological residents in clinical teaching.

BACKGROUND: Residents play an important role in the clinical training of medical students, spending up to 25% of their daily work teaching. In the US medical curriculum didactic courses for residents already exist and their role as a teacher is firmly anchored. In Germany, there are no fixed regulations or residents-as-teachers-programs. The aim of this study was to evaluate the activities of neurological residents in clinical teaching. METHODS: We conducted a prospective cross-sectional online survey among neurological residents in Germany. The evaluation was carried out descriptively and by means of text analysis. RESULTS: 138 residents from 39 German neurological university hospitals answered the survey. Nearly half of them needed the teaching activity as part of their career planning. The residents are mostly involved in practical courses. More than 80% stated, that they enjoy teaching. 64% stated that there were no preparatory courses for teaching at their hospital/university. 78.4% of the respondents received no or merely insufficient feedback for their own teaching and 62.5% had only little or even no knowledge about the university curriculum. CONCLUSIONS: By teaching medical students, residents play an outstanding role in recruiting students for neurology and, simultaneously, teaching leads an improvement in the residents' own learning. To encourage young neurologists as teachers and-at the same time as learners-Clinic directors and universities should promote residents-as-teachers programs in neurology and reward the residents' teaching activities.

Quantification of individual remyelination during short-term disease course by synthetic magnetic resonance imaging.

MRI is an important diagnostic tool for evaluation of myelin content in multiple sclerosis and other CNS diseases, being especially relevant for studies investigating remyelinating pharmacotherapies. In this study, we evaluated a new synthetic MRI-based myelin estimation in methylenetetrahydrofolate reductase deficiency as a treatable primary demyelinating disorder and compared this method with established diffusion tensor imaging in both methylenetetrahydrofolate reductase deficiency patients and healthy controls. This is the first synthetic MRI-based in vivo evaluation of treatment-associated remyelination. 1.5 T synthetic MRI and 3 T diffusion MRI were obtained from three methylenetetrahydrofolate reductase deficiency patients at baseline and 6 months after therapy initiation, as well as from age-matched healthy controls (diffusion tensor imaging: n = 14, synthetic MRI: n = 9). Global and regional synthetic MRI parameters (myelin volume fraction, proton density, and relaxation rates) were compared with diffusion metrics (fractional anisotropy, mean/radial/axial diffusivity) and related to healthy controls by calculating z-scores and z-deviation maps. Whole-brain myelin (% of intracranial volume) of the index patient was reduced to 6 versus 10% in healthy controls, which recovered to a nonetheless subnormal level of 6.6% following initiation of high-dosage betaine. Radial diffusivity was higher at baseline compared with healthy controls (1.34 versus 0.79 × 10-3 mm2/s), recovering at follow-up (1.19 × 10-3 mm2/s). The index patient's lesion volume diminished by 58% under treatment. Regional analysis within lesion area and atlas-based regions revealed lower mean myelin volume fraction (12.7Baseline/14.71Follow-up%) and relaxation rates, higher proton density, as well as lower fractional anisotropy and higher radial diffusivity (1.08 × 10-3 Baseline/0.94 × 10-3 Follow-up) compared with healthy controls. The highest z-scores were observed for myelin volume fraction in the posterior thalamic radiation, with greater deviation from controls at baseline and reduced deviation at follow-up. Z-deviations of diffusion metrics were less pronounced for radial and mean diffusivity than for myelin volume fraction. Z-maps for myelin volume fraction of the index patient demonstrated high deviation within and beyond lesion areas, among others in the precentral and postcentral gyrus, as well as in the cerebellum, and partial remission of these alterations at follow-up, while radial diffusivity demonstrated more widespread deviations in supra- and infratentorial regions. Concordant changes of myelin volume fraction and radial diffusivity after treatment initiation, accompanied by dramatic clinical and paraclinical improvement, indicate the consistency of the methods, while myelin volume fraction seems to characterize remyelinated regions more specifically. Synthetic MRI-based myelin volume fraction provides myelin estimation consistent with changes of diffusion metrics to monitor short-term myelin changes on individual patient level.

TDP-43 as structure-based biomarker in amyotrophic lateral sclerosis.

Pathologic alterations of Transactivation response DNA-binding protein 43 kilo Dalton (TDP-43) are a major hallmark of amyotrophic lateral sclerosis (ALS). In this pilot study, we analyzed the secondary structure distribution of TDP-43 in cerebrospinal fluid of ALS patients (n = 36) compared to Parkinson´s disease patients (PD; n = 30) and further controls (Ctrl; n = 24) using the immuno-infrared sensor technology. ALS patients could be discriminated from PD and Ctrl with a sensitivity/specificity of 89 %/77 % and 89 %/83 %, respectively. Our findings demonstrate that TDP-43 misfolding measured by the immuno-infrared sensor technology has the potential to serve as a biomarker candidate for ALS.

Neurological teaching in times of crisis.

Background/Objective: The changes to medical studies that became necessary as part of the Corona pandemic have also forced considerable adjustments in Neurology. Classroom teaching had to be converted almost entirely to digital formats within a short period of time. The present study provides an overview of the respective changes and associated complications as well as opportunities in teaching Neurology. Methodology: Lecturers in Neurology at all University hospitals in Germany were asked about their approach and the individual changes in their curriculum. Of a total of 39 locations, 23 answered the online questionnaire (see attachment 1). Results: While frontal teaching and lectures could be carried out digitally without any problems, difficulties arose especially in learning physical examination and bedside teaching. Most of the participants stated that they had not found satisfactory e-learning formats to replace teaching at the patients bed. Conclusion: The ad hoc changes in teaching Neurology resulted in significant additional effort for the part of lecturers, but were generally well accepted by students. The Corona pandemic thus ultimately offers an opportunity to enrich teaching in Neurology.

Correlates of polyneuropathy in Parkinson's disease.

OBJECTIVE: Previous studies in Parkinson's disease (PD) patients have demonstrated a high prevalence of polyneuropathy (PNP) and pronounced alpha-Synuclein pathology in dermal nerve fibers already at early disease stages. The aim of this study was to analyze associations between the prevalence and severity of PNP with nonmotor and motor symptoms in PD patients. METHODS: Fifty PD patients were characterized comprehensively for the presence of clinical symptoms (nonmotor and motor), electrophysiologic alterations and - for the first time - using high-resolution ultrasound of peripheral nerves. RESULTS: Sixty-two percent of PD patients showed electrophysiological pathology of PNP. The prevalence of patient-reported PNP symptoms was 86% and was particularly present in patients with longer disease duration, compromised scores of nonmotor and motor symptoms as well as with a negative evaluation of quality of life. Seventy-five percent of patients showed morphologic alterations similar to axonal PNP in high-resolution ultrasound compared to healthy controls. INTERPRETATION: The study demonstrates the high burden of peripheral nervous system disease in Parkinson's disease. It advocates further studies to delineate the underlying pathophysiological mechanisms in order to optimize treatment approaches for PD, including the associated PNP.