Inpatient Neurology Deaths and Factors Associated With Discharge to Hospice.

Background and Purpose: The Neurology Mortality Review Committee at our institution identified variability in location of death for patients on our inpatient neurology services. Hospice may increase the number of patients dying in their preferred locations. This study aimed to characterize patients who die on inpatient neurology services and explore barriers to discharge to hospice. Methods: This retrospective study was completed at a single, quaternary care medical center that is a Level I Trauma Center and Comprehensive Stroke Center. Patients discharged by an inpatient neurology service between 6/2019-1/2021 were identified and electronic medical record review was performed on patients who died in the hospital and who were discharged to hospice. Results: 69 inpatient deaths and 74 discharges to hospice occurred during the study period. Of the 69 deaths, 54 occurred following withdrawal of life sustaining treatment (WLST), of which 14 had a referral to hospice placed. There were 88 "hospice-referred" patients and 40 "hospice-eligible" patients. Hospice-referred patients were less likely to require the intensive care unit than hospice-eligible patients. Hospice-referred patients had their code status changed to Do Not Intubate earlier and were more likely to have advanced directives available. Conclusion: Our data highlight opportunities for further research to improve discharge to hospice including interhospital transfers, advanced directives, earlier goals of care discussions, palliative care consultations, and increased hospice bed availability. Importantly, it highlights the limitations of using in-hospital mortality as a quality indicator in this patient population.

A Novel Serious Illness Communication Curriculum Improves Neurology Residents' Confidence and Skills.

Background and Purpose: Competency in serious illness communication is mandated by the Accreditation Council of Graduate Medical Education. Previous efforts to teach communication skills have been hampered by intensive time requirements. In this study, we developed and evaluated a brief goals-of-care communication curriculum for neurology residents. Methods: We developed and implemented a two-part curriculum based on themes identified from a needs assessment: (1) fundamental physician-patient communication skills; and (2) counseling surrogate decision makers and providing neuroprognostication. We used a three-pronged pre-post study design to evaluate the impact of the curriculum: resident self-assessment surveys, direct observations of resident-patient interactions, and patient perception surveys using the Communication Assessment Tool. Results: Residents reported a significant increase in mean scores [standard deviation] of confidence practicing fundamental communication skills, such as offering opportunities for emotion (3.84 [0.9] vs. 4.54 [0.6], p = 0.002), and goals-of-care communication skills, such as using triggers for serious conversations (2.65 [0.7] vs. 3.29 [0.5], p = 0.004). Observed resident-patient interactions showed significant improvement in fundamental communication skills, such as involving the patient in decision making (1.89 [0.6] vs. 4.0 [0.9], p < 0.001). There was no significant impact on patient perception of resident communication skills in the three months following the intervention. Conclusions: A brief, learner-centered curricular intervention improved neurology residents' confidence in serious illness communication and improved their skills as judged by trained observers.

Leptomeningeal Disease Secondary to Thr60Ala Transthyretin Amyloidosis: Case Report and Review of the Literature.

A 31-year-old woman with transthyretin (TTR) amyloidosis secondary to a Thr60Ala mutation developed recurrent stroke-like episodes with fluctuating mental status. Evaluation for stroke and seizures was unrevealing. She was found to have leptomeningeal contrast enhancement on magnetic resonance imaging, which was confirmed to be CNS TTR amyloidosis on histopathology following brain and dura biopsy. While leptomeningeal disease has rarely been known to be associated with TTR amyloidosis, this is the first documented case of leptomeningeal disease secondary to a Thr60Ala mutation in the TTR gene. A literature review of TTR amyloidosis is presented with special focus on the treatment of leptomeningeal TTR amyloidosis.

Re-Emergence of Poliovirus in the United States: Considerations and Implications.

The first case of paralytic poliomyelitis in nearly a decade in the US was discovered in a 20-year-old unvaccinated man from Rockland County, New York, in July 2022, who developed acute flaccid myelitis. The isolated virus from stool sampling was found to be a circulating vaccine-derived poliovirus type 2, derived from the oral polio vaccine. Since the discovery of this case, local wastewater surveillance has revealed evidence of circulating vaccine-derived poliovirus type 2 in local counties, as well as in New York City, representing community transmission. In the wake of the coronavirus disease 2019 pandemic, routine vaccination administration has declined globally, with increasing numbers of communities not vaccinated for poliovirus. Now, with evidence of local community transmission, the clinical implication for at-risk unvaccinated individuals is significant. Here, we review the epidemiological origin of this discovered strain of poliovirus, national and international methods of surveillance for poliovirus, and neurological features of poliovirus. We also highlight the opportunities and challenges involved in monitoring suspected cases, as well as the unique role neurologists might play in national and global poliomyelitis surveillance. ANN NEUROL 2022;92:725-728.

Impact of a relationship-centered care communication curriculum on pediatric residents' practice, perspectives, and opportunities to Develop expertise.

OBJECTIVES: To investigate the impacts of a Relationship-Centered Care (RCC) communication curriculum with coaching on pediatric residents 1) self-reported use of RCC strategies and perspectives, and 2) opportunities to develop adaptive expertise. METHODS: Residents (n = 77) completed a 4 h RCC training and shared resultant RCC goals with Coaches (n = 15). Data included resident surveys and reflections immediately post-training, and resident and coach surveys 6-months later. Reported use of RCC strategies were compared over time with paired t-tests. Qualitative data were analyzed using open coding guided by sensitizing principles from the RCC framework and adaptive expertise. RESULTS: Pediatric residents reported significant increases (p < 0.001) in use of 4/9 RCC strategies after 6 months: eliciting all concerns, chunking information, checking for understanding, and teach-back. Resident reflections highlighted shifts in perspective around RCC. Training combined with coaching provided opportunities for residents to develop adaptive expertise through adapting and innovating across settings and contexts. CONCLUSION: Residents had significant increases in reported use of key RCC strategies after a training combined with coaching and demonstrated opportunities to develop adaptive expertise. PRACTICE IMPLICATIONS: Residency programs should include RCC training with an emphasis on the new and challenging strategies and provide opportunities to practice and receive coaching.

Neurohospitalist Practice and Well-Being During the COVID-19 Pandemic.

BACKGROUND AND PURPOSE: Neurohospitalists play an important role in, and have been variably affected by, the ongoing COVID-19 pandemic. In this study, we survey neurohospitalists to characterize practice changes and the impact of the pandemic on their well-being. METHODS: A 22-item survey was distributed to neurohospitalists through the Neurohospitalist Society and the American Academy of Neurology Neurohospitalist, Stroke & Vascular Neurology, and Critical Care & Emergency Neurology Sections. RESULTS: After 2 weeks of collection, 123 responses were received, with 57% of respondents practicing in academic settings, 23% in private practice, and 7% in community hospitals. A minority of neurohospitalists (8%) were redeployed to care for COVID-19 or non-COVID-19 medicine patients. The most common neurologic diagnoses they reported in COVID-19 patients were delirium (85%), cerebrovascular events (75%), and seizure (35%); however, most neurohospitalists (59%) had evaluated fewer than 10 patients with COVID-19. Respondents observed that fewer patients with unrelated neurological diseases were admitted to the hospital compared to before the pandemic. Neurohospitalists experienced changes in administrative (27%), educational (15%), and research duties (11%), and had overall worse well-being and work-life balance (77%). CONCLUSIONS: The most common neurologic diagnoses seen in COVID-19 patients by neurohospitalists in this sample are delirium, cerebrovascular disease, and seizure. Though the majority of survey respondents reported not being primary frontline providers, they report key clinical and operational roles during the pandemic, and report worse well-being as compared to before the pandemic. Our data suggests that there are opportunities to improve neurohospitalists' experience through flexible work practices and providing family care support.

Education Research: Understanding barriers to goals of care communication for neurology trainees.

OBJECTIVE: To describe the perspectives of neurology residents regarding barriers to effective goals of care discussions and to identify residents' current and desired educational strategies to improve goals of care communication. METHODS: All neurology residents at our institution were invited to voluntarily participate in focus groups. Residents were organized into 3 focus groups by year of training. Moderators asked residents open-ended questions about current goals of care communication practice and ideas for improving the frequency and effectiveness of goals of care discussions. All responses were audiorecorded, transcribed, and de-identified. Transcripts of the focus groups were independently read and coded by members of the research team. We performed thematic analysis to identify and systematize relationships across coded data. RESULTS: Twenty out of 29 neurology residents participated in the focus groups. We identified 3 overarching domains impeding goals of care communication: patient factors, resident factors, and systems factors. Residents proposed specific desired strategies to address these 3 domains with the goal of improving the frequency and efficacy of goals of care communication. The desired strategies included receiving feedback from patients and families, developing resident-focused educational opportunities through direct observation and coaching, and systems changes by documenting goals of care discussions. CONCLUSIONS: Neurology residents identify multiple barriers to effective goals of care communication and propose specific desired strategies for improvement. This detailed input from residents will be incorporated into future curricular interventions to improve confidence and skill in leading goals of care discussions.

Intrathoracic meningocele associated with neurofibromatosis Type 1 and a novel technique for surgical repair: case report.

Neurofibromatosis Type 1 (NF1) is a neurocutaneous disorder that can have associated spinal abnormalities related to both bone and dural dysplasia. Thoracic meningoceles are one spine anomaly associated with NF1, although they are a fairly uncommon pathology. Surgical techniques to treat these meningoceles, usually undertaken only when the patient is symptomatic, are targeted at decreasing the size of the protrusion and improving lung capacity. Surgical interventions discussed in the literature include shunting the pseudomeningocele, primary repair with laminectomy, thoracoscopic plication, and reinforcement of the closure with cement, muscle, or fascia. Authors here report the case of a 43-year-old woman with NF1 with worsening pulmonary function tests and in whom shunting of the pseudomeningocele failed. Subsequently, a posterolateral thoracotomy was performed. The dura mater was reconstructed and primarily closed. On this closure a Gore-Tex soft-tissue patch was placed along with polypropylene mesh and Evicel fibrin sealant, followed by titanium mesh. At the end of the procedure, a chest tube was left in place and therapeutic pneumoperitoneum was performed to decrease the dead space as the lung did not fully expand with positive-pressure ventilation. The patient's pulmonary function tests improved after the procedure. Thoracic meningoceles are uncommon and difficult pathologies to treat surgically. Although shunting is arguably the least invasive surgical option, it can fail in some patients. When it does fail, there are other options that require a multidisciplinary approach and careful attention to the dural closure and reinforcing layers.

Directed Differentiation of Oligodendrocyte Progenitor Cells From Mouse Induced Pluripotent Stem Cells.

Several neurological disorders, such as multiple sclerosis, the leukodystrophies, and traumatic injury, result in loss of myelin in the central nervous system (CNS). These disorders may benefit from cell-based therapies that prevent further demyelination or are able to restore lost myelin. One potential therapeutic strategy for these disorders is the manufacture of oligodendrocyte progenitor cells (OPCs) by the directed differentiation of pluripotent stem cells, including induced pluripotent stem cells (iPSCs). It has been proposed that OPCs could be transplanted into demyelinated or dysmyelinated regions of the CNS, where they would migrate to the area of injury before terminally differentiating into myelinating oligodendrocytes. OPCs derived from mouse iPSCs are particularly useful for modeling this therapeutic approach and for studying the biology of oligodendrocyte progenitors because of the availability of mouse models of neurological disorders associated with myelin deficiency. Moreover, the utility of miPSC-derived OPCs would be significantly enhanced by the adoption of a consistent, reproducible differentiation protocol that allows OPCs derived from different cell lines to be robustly characterized and compared. Here we describe a standardized, defined protocol that reliably directs the differentiation of miPSCs to generate high yields of OPCs that are capable of maturing into oligodendrocytes.