Advanced Practice Clinician Training for Neurology.

BACKGROUND: The specialty of Neurology is faced with a fundamental problem of economics: supply and demand. The projected increase in provider supply is unlikely to keep up with projected increases in patient-care demand. Many large academic centers have used residents to meet this patient-care demand. However, the conflict between education of residents and patient-care needs has created a hindrance to both of those missions. Many specialties have been using advanced practice clinicians (APCs) to help address the need for patient care. In the setting of a residency program, this availability of APCs can help to alleviate patient-care demands for the resident and allow for better allocated educational time. Neurology has not historically been a popular choice for APCs and a standardized educational curriculum for a Neurology APC has not been established. METHODS: The authors share an example curriculum recently implemented for training new inpatient Neurology APCs. This curriculum includes a 12-week program complete with rotations through various subspecialties and proposes fundamental lecture topics for use in education. The authors share their expectations for clinical duties that evolve over the course of the 12-week program in conjunction with expectations for increasing clinical knowledge as well as efficiency in system utilization. CONCLUSION: The addition of APCs to support a busy inpatient Neurology practice has obvious beneficial implications but the integration and education of this new staff must be structured and well-designed to support the confidence of the APC in both their knowledge and their role as an indispensable member of the care team.

Urinary Tract Infections in Hospitalized Ischemic Stroke Patients: Source and Impact on Outcome.

BACKGROUND:  Urinary tract infections (UTIs) in ischemic stroke patients are a common occurrence and the frequent focus of quality improvement initiatives. However, many UTIs are community-acquired and the impact of such infections on patient outcomes remains controversial. METHODS:  We conducted a retrospective analysis of our Stroke Center Database and electronic medical records to determine the incidence of both community-acquired UTI (CA-UTI) and hospital-acquired UTI (HA-UTI) in hospitalized ischemic stroke patients. We assessed risk factors for UTI, as well as clinical outcome, the length of stay (LOS), and hospital charges. RESULTS:  In our study sample of 395 patients, UTIs were found in 11.7% and the majority of these (65%) were found on admission. Patients admitted from another hospital were more likely to be diagnosed with a UTI of any type compared to those arriving from home (odds ratio (OR) 2.42 95%, confidence interval (CI) 1.18, 4.95) and were considerably more likely to have an HA-UTI than a CA-UTI (OR 12.06 95% CI 2.14, 95.32). Those with a Foley catheter were also more likely to have a UTI (OR 2.65 95% CI 1.41, 4.98). In the multivariable analysis, we did not find a statistically significant relationship between any UTI or a specific UTI subtype and discharge modified Rankin Score (mRS), LOS, or hospital charges. Admission stroke severity remained associated with higher odds of discharge in poor condition (adjusted odds ratio (aOR) 6.23 95% CI2.33, 16.62), an extended LOS (6.84 vs 5.07, p = 0.006), and higher hospital charges ($18,305 vs $12,162, p = 0.001).  Conclusions: Urinary tract infections remain a common occurrence in stroke patients. However, the majority of UTIs are present on admission and may have little impact on discharge clinical condition, LOS, or hospital charges. These results may have implications for quality improvement (QI) initiatives that focus on the prevention and treatment of hospital-acquired UTIs.

Looks like a stroke, acts like a stroke, but it's more than a stroke: a case of cerebral mucormycosis.

Mucormycosis is a fungus that exhibits angiocentric growth and can cause a thrombotic arteritis. Infection with this organism is uncommon and cerebral involvement is most often secondary to direct invasion through the paranasal sinuses. Here, we present a case of mucormycosis with cerebral involvement without sinus disease, which resulted in ischemic stroke with rapid progression resulting in death.

Incorporating simulation technology into a neurology clerkship.

Simulation-based medical education is growing in use and popularity in various settings and specialties. A literature review yields scant information about the use of simulation-based medical education in neurology, however. The specialty of neurology presents an interesting challenge to the field of simulation-based medical education because of the inability of even the most advanced mannequins to mimic a focal neurologic deficit. The authors present simulator protocols for status epilepticus and acute stroke that use a high-fidelity mannequin despite its inability to mimic a focal neurologic deficit. These protocols are used in the training of third- and fourth-year medical students during their neurology clerkship at Penn State College of Medicine. The authors also provide a review of the pertinent literature.