A national survey of Neurology Vice Chairs For Education.

OBJECTIVES: A growing number of Neurology Departments have appointed a Neurology Vice Chair for Education (NVCE), yet the roles and responsibilities of an NVCE have not been previously described in the literature. METHODS: A group of current NVCEs developed a survey that was sent to all NVCEs in the US via a secure, anonymous survey. Questions included roles and responsibilities, sources of support, metrics to determine success, faculty development, basic demographics and education scholarship engagement. RESULTS: Response rate was 27 of 45 NVCEs (60%). Among the respondents, 70% have been in the role 5 years or less and the NVCE role existed for 5 years or less in 60% of departments. Eighteen percent were provided with a written job description, and 63% never received any job description. Most common responsibilities included overseeing student (78%), resident (78%), and fellowship (74%) education, participation in education section of an annual report (67%) and oversight of education scholarship (59%). Fifty-two percent reported no specific funding for the NVCE role. Most were prior program directors (59%), male (61%) and White (85%). CONCLUSIONS: The NVCE role is new, and few have written job descriptions or specific funding for the role. They oversee education across the continuum of learners in their departments, communicate the education mission in an annual report and oversee educational scholarship. Most were not formally trained for the role and previously served in other education leadership roles. These data will be useful to programs in creating job descriptions and goals for the NVCE role.

You never forget your first? Impact of interview timing on institutional rank order.

OBJECTIVE: To analyze the impact of interview date on the applicant rank for Neurology residencies in the United States. METHODS: A multi-institutional retrospective review of interview dates and applicant rank list data for the National Resident Matching Program (NRMP) was conducted for five Neurology programs, totaling 1932 interviewed applicants over a combined total of 31 interview years. For each candidate, the interview date and applicant rank were abstracted along with the total number of interviews for that season. Statistical analyses were completed on the cumulative institution data set as well for each individual institution to assess for a possible relationship between interview date and applicant rank. RESULTS: The cumulative institutional analysis showed that the mean applicant rank decreased as the interview season progressed. Applicants who interviewed on the first day of the interview season were ranked 11.4% higher than those who interviewed on the last interview day. Additionally, applicants interviewed on the first interview day more likely to be ranked higher when compared to all other interview dates. Independent analysis of each program's data identified comparable, statistically significant, differences in mean applicant rank and interview position at three out of the five institutions. CONCLUSIONS: This study evaluated the impact of interview order on the ranking of applicants by Neurology residency programs, noting a temporal relationship with applicant rank and interview date. The primacy bias appreciated in our data merits further evaluation in other medical specialties. Strategies to minimize the impact of this bias should be employed by residency programs who use medical matching services.

Anti-myelin oligodendrocyte glycoprotein (MOG) associated disease masquerading as prolonged intractable nausea and vomiting.

The clinical and radiological spectrum of myelin oligodendrocyte glycoprotein (MOG) antibody associated disease continues to expand. Here, we describe a case of prolonged, relapsing, intractable nausea and vomiting misdiagnosed as a functional disorder for more than one year. The patient did not receive a neurological workup until clear neurological signs developed. This case exemplifies the delay in diagnosis when neurological disease presents with seemingly non-neurological symptoms and illustrates brainstem and upper spinal cord radiological findings that can help guide the treating physician to test for MOG antibodies and provide the appropriate treatment.

Treat the Patient, Not the Test When a Hospitalized Patient in Status Epilepticus Transitions to Comfort-Focused Goals of Care.

Status epilepticus is a common and under-recognized cause of unconsciousness among hospitalized patients. It can clinically mimic delirium and other causes of acute mental status change, especially when clinically relevant seizure activity is not appreciated on physical examination. While the successful treatment of status epilepticus may require anesthetic dosing of antiepileptics such as barbiturates, these seemingly drastic therapeutic measures are justified when goals of care are life prolonging as they may allow a patient to regain consciousness and meaningfully interact with loved ones. However, medical burden from electroencephalogram (EEG) monitoring and other care associated with its diagnosis and treatment can contribute to distress for patients who may be dying from a comorbid illness. Furthermore, when goals of care transition to comfort, care challenges can result regarding the ongoing management of barbiturates or other sedatives, previously prescribed to treat the status epilepticus. In this case study, the lack of clinically significant seizure activity led us to conclude that the discontinuation of a barbiturate infusion and the EEG monitoring was the clinically appropriate approach for a dying patient with comfort goals of care and nonconvulsive status epilepticus.

Hyperbaric oxygen treatment for post-radiation central nervous system injury: a retrospective case series.

Increased use of radiation therapy and increasing life spans following radiation treatment has led to an increase in the finding of post-radiation central nervous system injury in patients who have previously undergone radiation treatments. At this time, information regarding treatment for patients suffering from this serious side effect is limited and not readily available. It is imperative to examine possible treatment options, complications and success rates for these patients. This retrospective review will look at 10 patients who underwent hyperbaric oxygen therapy for post-radiation injury to the central nervous system. Review and investigation of the subjective, clinical and radiologic outcomes of these patients was conducted. It was determined that for patients with post-radiation central nervous system injury it is important to distinguish the exact diagnosis for each patient. For those patients with radiation necrosis, conclusion was made that hyperbaric oxygen (HBO2) therapy does lead to improvement in subjective, clinical and radiologic outcomes. However, the results were not consistent across all patients. For those patients with non-specific delayed radiation injury, findings showed that HBO2 does not lead to any improvement. Therefore, we conclude that for those patients who have been diagnosed with radiation necrosis of the central nervous system, we recommend HBO2 therapy as a potential treatment option for some patients.

One specialty at a time: achieving competency in geriatrics through an e-learning neurology clerkship module.

BACKGROUND: E-learning integrated into traditional clerkships may supplement gaps in medical student training, such as geriatrics competencies. METHOD: An e-module, "Neurology and Dementia: Psychosocial Aspects of Care," was offered during the M3 Neurology clerkship. OSCE scores were compared between students who did and did not complete the e-module with written examination scores as control. RESULTS: Students who completed the e-module had significantly higher scores on the standardized patient (SP) evaluation, written note, and attention to psychosocial aspects of care (P < .05 for all). Exam scores were unaffected (P = .24). Students delaying the OSCE by four weeks still showed retention of this learning. CONCLUSIONS: An e-module addressing geriatrics core competencies presented during a neurology rotation resulted in sustained learning of these vital concepts.

First trimester stroke prophylaxis in pregnant women with a history of stroke.

BACKGROUND AND PURPOSE: Current recommendations for stroke prevention during early pregnancy in women with a prior stroke history are based on limited evidence. In view of the uncertainty involved in balancing the fetal risk of medication against the maternal risk of recurrent stroke, a substantial variation in clinical decision making was anticipated. Thus, a survey was performed to describe the current practices of U.S. neurologists with a particular interest in stroke with regards to treatment of such patients. METHODS: A survey was sent to 384 actively practicing U.S. members of the American Academy of Neurology Stroke and Vascular Neurology section asking what antithrombotic, if any, they would use during first trimester pregnancy in women with a prior history of stroke, either unrelated or related to a previous pregnancy. RESULTS: 230 practitioners responded. Some form of antithrombotic therapy was selected by 75% of practitioners for women with a history of prior stroke not related to pregnancy and by 88% of practitioners for women with a history of prior stroke related to pregnancy. Aspirin and low molecular weight heparin were chosen by 51% and 7%, respectively, for stroke unrelated to pregnancy and by 41% and 25%, respectively, for stroke related to pregnancy. CONCLUSIONS: Most practitioners agree that women with a history of stroke should receive prophylaxis during the first trimester. However, much disagreement exists regarding which drug(s) to use. A national registry would be the most practical method of obtaining maternal and fetal outcome data to guide practice in this setting.

Clipping or coiling of ruptured cerebral aneurysms and shunt-dependent hydrocephalus.

BACKGROUND: Hydrocephalus may develop either early in the course of aneurysmal subarachnoid hemorrhage (SAH) or after the first 2 weeks. Because the amount of SAH is a predictor of hydrocephalus, the two available aneurysmal treatments, clipping or coiling, may lead to differences in the need for cerebrospinal fluid (CSF) diversion, as only surgery permits clot removal. METHODS: Hospital and University Hospitals Consortium (UHC) databases were used to retrieve data on all patients admitted to our hospital with aneurysmal SAH during the last 4 years. The incidence of permanent ventricular shunt (VS) according to treatment modality used was evaluated. RESULTS: One hundred eighty-eight patients were admitted with aneurysmal SAH. Coiling was performed on 48 (26%) and clipping on 135 (73.8%) patients. Fifty-six (31%) patients required CSF diversion. External ventricular drain was placed in 30 (22.2%) clipped and 13 (27.1%) coiled patients ( p = 0.5 ), and VS in 6 patients of the two treatment groups (4.4 versus 12.5%, respectively; p = 0.08). Patients requiring VS had longer UHC-expected hospital length of stay (LOS), as well as observed ICU and hospital LOS, compared to patients with temporary or no CSF diversion (24 +/- 14 versus 15 +/- 8, 20.5 +/- 9 versus 11 +/- 7, and 30 +/- 13 versus 16 +/- 11 days, respectively; p

Hyperbaric oxygen therapy of cerebral ischemia.

BACKGROUND: Hyperbaric oxygen (HBO) therapy of cerebral ischemia has been evaluated in a number of human and animal studies; however, there is presently no consensus on its efficacy. METHODS: We present a review of animal and human studies on HBO therapy of cerebral ischemia as well as present potential mechanisms of action of HBO. RESULTS: Animal studies of HBO have shown promise by reducing infarct size and improving neurologic outcome. HBO has also been shown to inhibit inflammation and apoptosis after cerebral ischemia. Early reports in humans also suggested benefit in stroke patients treated with HBO. Recent randomized, controlled human studies, however, have not shown benefit, although all were limited by small sample size. Important differences between animal and human studies suggest HBO might be more effective in stroke within the first few hours and at a pressure of 2-3 ATA. CONCLUSIONS: The clinical usefulness of HBO in the treatment of cerebral ischemia is not yet certain. Attention to emerging pathophysiologic data should be taken into consideration in design of any future clinical trials of HBO in acute ischemic stroke.

Pregnancy and stroke.

The risks of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage are not increased in the 9 months of gestation except for a high risk in the 2 days prior and 1 day postpartum. The remaining 6 weeks postpartum also have an increased risk of ischemic stroke and intracerebral hemorrhage, though less than the peripartum period. Although there are some rare causes of stroke specific to pregnancy and the postpartum period, eclampsia, cardiomyopathy, postpartum cerebral venous thrombosis, and, possibly, paradoxical embolism warrant special consideration. The diagnostic and therapeutic approaches to stroke during pregnancy and the postpartum period are similar to the approaches in the nonpregnant woman with some minor modifications based on consideration of the welfare of the fetus. There is a theoretical risk of magnetic resonance imaging exposure during the first and second trimester but the benefit to the mother of obtaining the information may outweigh the risk. Available evidence suggests that low-dose aspirin (<150 mg/day) during the second and third trimesters is safe for both mother and fetus. Postpartum use of low-dose aspirin by breast-feeding mother is also safe for infant. While proper counseling is imperative, a history of pregnancy-related stroke should not be a contraindication for subsequent pregnancy.

Determinants of mortality in stroke patients with right brain damage.

Stroke is the world's second leading cause of mortality and long-term disability. Damage to the nondominant right brain has distinct clinical characteristics. The resultant cardiovascular and autonomic dysfunction peculiar to right hemispheric stroke can adversely affect the short- and long-term outcome of stroke victims. Blood flow characteristics to the right hemisphere may also put the right brain at more risk for embolic and silent infarcts.