A Required, Combined Neurology-Physical Medicine and Rehabilitation Clerkship Addresses Clinical and Health Systems Knowledge Gaps for Fourth-Year Medical Students.

ABSTRACT: This study evaluated the impact of a 4-wk mandatory neurology-physical medicine and rehabilitation advanced-core clerkship for fourth-year medical students. The combined clerkship encouraged an interdisciplinary and function-based approach to the management of common neurologic, musculoskeletal, and pain complaints. Seventy-three fourth-year medical students participated in the rotation over 1 yr. A survey assessing knowledge and skill set topics was conducted before and after the clerkship. Qualitative feedback regarding the rotation was provided by the students and analyzed. Significant gaps in knowledge and skill sets were identified before the clerkship and successfully addressed by combined teaching modalities. These data demonstrate that an integrated neurology-physical medicine and rehabilitation clerkship can improve students' confidence in multiple domains. Integrating physical medicine and rehabilitation into core clerkships at other medical schools may provide an avenue to address curriculum gaps.

Early in-theater management of combat-related traumatic brain injury: A prospective, observational study to identify opportunities for performance improvement.

BACKGROUND: Combat-related moderate-to-severe traumatic brain injury (CRTBI) is a significant cause of wartime morbidity and mortality. As of August 2014, moderate-to-severe traumatic brain injuries sustained by members of the Department of Defense worldwide since 2000 totaled 32,996 cases. Previously published epidemiologic reviews describe CRTBI management at a "strategic" level, but they lack "tactical" patient-specific data required for performance improvement. In addition, scarce data exist regarding prehospital CRTBI care. METHODS: This is a prospective observational study of consecutive CRTBI casualties presenting to US Role 3 medical facilities. Admission variables including demographics, initial clinical findings, and laboratory results were collected. Head computed tomographic scan findings were noted. Interventions in the first 72 postinjury hours were recorded. Early in-theater mortality was noted, but longer-term outcomes were not. RESULTS: Casualties were predominately injured by explosive blasts (78.6%). Penetrating injuries occurred in 42.9%. On arrival, Glasgow Coma Scale (GCS) score was less than 8 for 47.7%. Hypothermia (temperature < 95.0°F) was present in 4.5%, and hypotension (systolic blood pressure < 90 mm Hg) in 21.1%. Hypoxia (O2 saturation < 90%) was observed in 52.5%. Both hypercarbia (Paco2 > 45 mm Hg, 50%) and hypocarbia (Paco2 < 36 mm Hg, 20.3%) were common on presentation. Head computed tomographic scan most commonly found skull fracture (68.9%), subdural hematoma (54.1%), and cerebral contusion (51.4%). Hypertonic saline was administered to 69.7% and factor VIIa to 11.1%. Early in-theater mortality at Role 3 was 19.4%. CONCLUSION: Avoidance of secondary brain injury by optimizing oxygenation, ventilation, and cerebral perfusion is the primary goal in the contemporary care of moderate-to-severe CRTBI. Ideally, this crucial care must begin as early as possible after injury. Given the frequency of hypotension, hypoxia, and both hypercarbia and hypocarbia upon Role 3 arrival, increased emphasis on prehospital management is indicated. LEVEL OF EVIDENCE: Therapeutic study, level IV; epidemiologic study, level III.

Focused comprehensive, quantitative, functionally based echocardiographic evaluation in the critical care unit is feasible and impacts care.

OBJECTIVES: To determine whether comprehensive quantitative echocardiogram could be used as a resuscitation tool in critically ill surgical patients and to assess its effect on patient care. DESIGN: Prospective observational. SETTING: The Trauma and Surgical Intensive Care Units of the University of Maryland Medical Center. PATIENTS: Critically ill trauma and surgical patients. INTERVENTIONS: The Focused Rapid Echocardiographic Evaluation (FREE), an abbreviated version of a comprehensive transthoracic echocardiogram, which is under an approved protocol, was performed. MEASUREMENTS AND MAIN RESULTS: Over a 30-month period, 791 FREEs were performed on 659 patients. The mean patient age was 60 (±17) years. Ninety-one percent were intubated and 80% were postoperative. Ejection fraction was reported for 95%, and cardiac index was reported for 89% of FREE studies. Right heart function was assessed for 94%. Measures of volume status--internal left ventricular diameter, inferior vena cava diameter, diameter change, and stroke volume variation--were reported for 88%, 79%, 75%, and 89% of patients, respectively. The FREE was judged to be useful by the consulting primary care team for 95% of patients, and altered the plan of care for 57%. The most common change was administration of a fluid bolus (43%), followed by change from an original prestudy plan to one of monitoring (24%), diuresis (23%), addition/titration of an inotropic agent (19%), and/or addition/titration of a vasoconstrictor (8%). CONCLUSIONS: The FREE is feasible and alters care in the intensive care unit by providing clinical data not otherwise available at the bedside. Further studies are warranted to assess the impact of comprehensive echocardiogram-directed resuscitation on patient outcomes.

Management of intracerebral pressure in the neurosciences critical care unit.

Management of intracranial pressure in neurocritical care remains a potentially valuable target for improvements in therapy and patient outcomes. Surrogate markers of increased intracranial pressure, invasive monitors, and standard therapy, as well as promising new approaches to improve cerebral compliance are discussed, and a current review of the literature addressing this metric in neuroscience critical care is provided.

Acute Treatment Options for Spinal Cord Injury.

OPINION STATEMENT: Most treatment options for acute traumatic spinal cord injury (SCI) are directed at minimizing progression of the initial injury and preventing secondary injury. Failure to adhere to certain guiding principles can be detrimental to the long-term neurologic and functional outcome of these patients. Therapy for the hyperacute phase of traumatic SCI focuses on stabilizing vital signs and follows the Advanced Trauma Life Support (ATLS) algorithm for ensuring stability of airway, breathing and circulation, and disability (neurologic evaluation)-with spinal stabilization-and exposure. Spinal stabilization, with cervical collars and long backboards, is used to prevent movement of a potentially unstable spinal column injury to prevent further injury to the spinal cord and nerve roots, especially during prehospital transport. Surgery to stabilize the spine is undertaken after life-threatening injuries (hemorrhage, evacuation of intracranial hemorrhage, acute vascular compromise) are addressed. Intensive care unit (ICU) admission is to be considered for all patients with high SCI or hemodynamic instability, as well as those with other injuries that independently warrant ICU admission. Avoidance of hypotension and hypoxia may minimize secondary neurologic injury. Elevating the mean arterial pressure above 85 mmHg for 7 days should be considered, to allow for spinal cord perfusion. The use of intravenous steroids (methylprednisolone) is controversial. Early tracheostomy in patients with lesions above C5 may reduce the number of ventilator days and the incidence of ventilator-associated pneumonia. Select patients may benefit from the placement of a diaphragmatic pacer. Aggressive measures, including CoughAssist and Intermittent Positive Pressure Breaths (IPPB), should be used to maintain lung recruitment and aid in the mobilization of secretions. Some patients with high SCI who are dependent on mechanical ventilation can eventually be liberated from the ventilator with consistent efforts from both the patient and the caregiver, along with some patience. Intermittent catheterization by the patient or a caregiver may be associated with a lower incidence of urinary tract infections, compared with an in-dwelling urinary catheter. Early mobilization of patients and a multidisciplinary approach (including respiratory therapists, nutritional experts, physical therapists, and occupational therapists) can streamline care and may improve long-term outcomes. A number of investigational drugs and therapies offer hope of neurologic recovery for some patients.

The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists.

BACKGROUND: Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences. METHODS: An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training. RESULTS: The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care. CONCLUSION: Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.

Paternal imprinting of the SLC22A1LS gene located in the human chromosome segment 11p15.5.

BACKGROUND: Genomic imprinting is an epigenetic chromosomal modification in the gametes or zygotes that results in a non-random monoallelic expression of specific autosomal genes depending upon their parent of origin. Approximately 44 human genes have been reported to be imprinted. A majority of them are clustered, including some on chromosome segment 11p15.5. We report here the imprinting status of the SLC22A1LS gene from the human chromosome segment 11p15.5 RESULTS: In order to test for allele specific expression patterns, PCR primer sets from the SLC22A1LS gene were used to look for heterozygosity in DNA samples from 17 spontaneous abortuses using PCR-SSCP and DNA sequence analyses. cDNA samples from different tissues of spontaneous abortuses showing heterozygosity were subjected to PCR-SSCP analysis to determine the allele specific expression pattern. PCR-SSCP analysis revealed heterozygosity in two of the 17 abortuses examined. DNA sequence analysis showed that the heterozygosity is caused by a G>A change at nucleotide position 473 (c.473G>A) in exon 4 of the SLC22A1LS gene. PCR-SSCP analysis suggested that this gene is paternally imprinted in five fetal tissues examined. CONCLUSIONS: This study reports the imprinting status of the SLC22A1LS gene for the first time. The results suggest imprinting of the paternal allele of this gene in five fetal tissues: brain, liver, placenta, kidneys and lungs.

Mutation analysis of the cathepsin C gene in Indian families with Papillon-Lefèvre syndrome.

BACKGROUND: PLS is a rare autosomal recessive disorder characterized by early onset periodontopathia and palmar plantar keratosis. PLS is caused by mutations in the cathepsin C (CTSC) gene. Dipeptidyl-peptidase I encoded by the CTSC gene removes dipeptides from the amino-terminus of protein substrates and mainly plays an immune and inflammatory role. Several mutations have been reported in this gene in patients from several ethnic groups. We report here mutation analysis of the CTSC gene in three Indian families with PLS. METHODS: Peripheral blood samples were obtained from individuals belonging to three Indian families with PLS for genomic DNA isolation. Exon-specific intronic primers were used to amplify DNA samples from individuals. PCR products were subsequently sequenced to detect mutations. PCR-SCCP and ASOH analyses were used to determine if mutations were present in normal control individuals. RESULTS: All patients from three families had a classic PLS phenotype, which included palmoplantar keratosis and early-onset severe periodontitis. Sequence analysis of the CTSC gene showed three novel nonsense mutations (viz., p.Q49X, p.Q69X and p.Y304X) in homozygous state in affected individuals from these Indian families. CONCLUSIONS: This study reported three novel nonsense mutations in three Indian families. These novel nonsense mutations are predicted to produce truncated dipeptidyl-peptidase I causing PLS phenotype in these families. A review of the literature along with three novel mutations reported here showed that the total number of mutations in the CTSC gene described to date is 41 with 17 mutations being located in exon 7.