Decrease of thyroid function after ischemic stroke is related to stroke severity.

BACKGROUND: Thyroid hormones are of fundamental importance for brain function. While low triiodothyronine levels during acute ischemic stroke (AIS) are associated with worse clinical outcomes, dynamics of thyroid function after AIS remains unknown. Thus, we longitudinally evaluated thyroid hormones after stroke and related them to stroke severity. METHODS: We prospectively traced thyroid stimulating hormone (TSH), free triiodothyronine (fT3), and free thyroxin (fT4) levels from the hyper-acute (within 24 h) to acute (3-5 days) and chronic (3-6 months) stages of ischemic stroke using a mixed regression model. Then, we analyzed whether stroke severity at presentation, expressed by National Institute of Health Stroke Scale (NIHSS), is associated with change in thyroid function. RESULTS: Forty-five patients were evaluated in hyper-acute and acute stages, while 29 were followed through chronic stage. TSH levels decreased from hyper-acute (2.91 ± 0.65 µIU/mL) to acute (2.86 ± 0.46 µIU/mL) and chronic stages of stroke (1.93 ± 0.35 µIU/m, p = 0.95). fT3 levels decreased from hyper-acute (2.79 ± 0.09 pg/ml) to acute (2.37 ± 0.07 pg/ml) stages, but recovered in chronic stage (2.78 ± 0.10 pg/ml, p < 0.01). fT4 levels decreased from hyper-acute (1.64 ± 0.14 ng/dl) to acute (1.13 ± 0.03 ng/dl) stages, and increased in the chronic stage (1.16 ± 0.08 ng/dl, p = 0.02). One-unit increase in presenting NIHSS was associated with 0.04-unit decrease of fT3 from hyper-acute to the acute stage (p < 0.01). CONCLUSION: There is a transient decrease of thyroid hormones after ischemic stroke, possibly driven by stroke severity. Larger studies are needed to validate these findings. Correction of thyroid function in acute stroke may be investigated to improve stroke outcomes.

Criteria for Emergency Brain MRI During Stroke-Alert.

OBJECTIVES: Intravenous (IV) tissue plasminogen activator (tPA) should be given to patients with acute ischemic stroke (AIS) and avoided in stroke mimics (SM). Select use of emergency brain magnetic resonance imaging (eMRI-brain) in stroke-alerts aids diagnosis, but accepted utilization criteria for eMRI-brain do not currently exist. We developed criteria for eMRI-brain and report the yield of eMRI-brain in stroke-alert patients. MATERIALS AND METHODS: We developed three history-based criteria for performing eMRI-brain during stroke-alerts: (1) history of previous similar deficits, (2) change in consciousness at onset of symptoms, (3) symptom presentation consistent with migraine aura. We then performed a retrospective chart review of patients who presented as a stroke-alert over a 5-year period and determined how these criteria affected administration of IV tPA to AIS and SM patients. RESULTS: Among 3,512 stroke-alerts, 230 (8.1%) patients met our criteria for eMRI-brain exams: 217 (92.6%) had SM and 17 (7.4%) had AIS. Our IV tPA decision-making analysis showed that based on eMRI-brain IV tPA was less frequently administered to SM patients (PCC-0.841, p=0.036) with less failures to administer IV tPA to patients with AIS (PCC -0.907, p-value=0.013, Pearson correlation coefficient). No patients became ineligible for IV tPA due to MRI-related time delays. CONCLUSIONS: Our history based criteria for performing eMRI-brain during stroke-alerts show a high yield of stroke mimics. Selective eMRI-brain improves decision-making accuracy regarding IV tPA administration.

Skill improvement during emergency response to terrorism training.

OBJECTIVES: To assess the individual and team skills acquired from an interactive training program to prepare emergency personnel to respond to terrorist acts. METHODS: We developed a 16-hour, two-day, multimedia- and simulation-enhanced course that places learners in realistic situations using the equipment required to respond to various chemical, biologic, radiologic, and explosive acts of terrorism. Small-group sessions and drills were conducted. Errors in skill performance were corrected immediately, and then skills were repeated to achieve mastery. Participants included emergency medical technicians, paramedics, nurses, and physicians. Team performance was assessed over four successive scenarios using a 100-mm visual analog scale. Individual learner skill acquisition was assessed with precourse and postcourse evaluation of selected skills in a randomized sampling of consenting learners. RESULTS: Nearly all teams achieved mastery of the required skills by the second assessment rotation. Individual learners demonstrated significant gains in the ability to emergently don personal protective equipment and administer a nerve agent antidote kit. CONCLUSIONS: An interactive, simulation-enhanced curriculum of terrorism response training for emergency responders can produce significant, quantifiable individual and team skill gain. Future studies should further address performance benchmarks for these newly acquired skills.

Development, implementation and outcomes of a training program for responders to acts of terrorism.

INTRODUCTION: Responding to acts of terrorism requires the effective use of public-safety and medical-response resources. The knowledge, skills and attitudes necessary to respond to future threats is unfamiliar to most emergency responders. OBJECTIVES: The purpose of this report to describe the development, implementation and evaluation of a multidisciplinary, interactive and simulation-enhanced course to prepare responders to acts of terrorism. METHODS: We used a 5-step systematic process to develop a blended-learning, simulation-enhanced training program. Learners completed a self-confidence questionnaire and written examination prior to the course and a self-confidence questionnaire, written examination and course evaluation when they finished the course. RESULTS: From July 7, 2003 to March 8, 2005, 497 consenting learners completed the course. After course completion, learners demonstrated significant increases in their knowledge of terrorism response (t = -64.3, df = 496, p < 0.05) and their confidence in responding to terrorist events (t = -45.5, df = 496, p < 0.05). Learner feedback about the course was highly positive. CONCLUSIONS: We successfully implemented a two-day course for professionals likely to respond to terrorist acts that included scenario-based performance training and assessment. Course participants increased their knowledge and were more confident in their ability to respond to acts of terrorism after participating in this course.

A multicenter study to provide evidence of construct validity in a computer-based outcome measure of neurology clinical skills.

BACKGROUND: Using computer-based simulation to assess clinical skill-a key competence for medical trainees-enables standardization and exposure to a broad sample of physical findings. The purpose of this study is to provide evidence of construct validity for a computer-based outcome measure of neurology clinical skills. METHOD: A total of 128 medical students and neurology residents at four institutions volunteered to take a 34-question computer-based test designed to measure neurology clinical skills. Subjects were classified into three groups based on level of training: novice, intermediate, and experienced. RESULTS: Overall performance increased with level of training. Question difficulty discriminated between groups as predicted. Twenty-six of 34 individual items discriminated between novices and more advanced learners. This test separated learners at different levels of training with a consistency of .92. CONCLUSION: This study provided evidence of construct validity for a computer-based outcome measure of neurology clinical skills.

Stroke training of prehospital providers: an example of simulation-enhanced blended learning and evaluation.

Since appropriate treatment of patients in the first few hours of ischemic stroke may decrease the risk of long-term disability, prehospital providers should recognize, assess, manage and communicate about stroke patients in an effective and time-efficient manner. This requires the instruction and evaluation of a wide range of competencies including clinical skills, patient investigation and management and communication skills. The authors developed and assessed the effectiveness of a simulation-enhanced stroke course that incorporates several different learning strategies to evaluate competencies in the care of acute stroke patients. The one-day, interactive, emergency stroke course features a simulation-enhanced, blended-learning approach that includes didactic lectures, tabletop exercises, and focused-examination training and small-group sessions led by paramedic instructors as standardized patients portraying five key neurological syndromes. From January to October 2000, 345 learners were assessed using multiple-choice tests as were randomly selected group of 73 learners using skills' checklists during two pre- and two post-course simulated patient encounters. Among all learners there was a significant gain in knowledge (pre: 53.9%+/-13.9 and post: 85.4%+/-8.5; p<0.001), and for the 73 learners a significant improvement in their clinical and communication skills (p<0.0001 for all). By using a simulation-enhanced, blended-learning approach, pre-hospital paraprofessionals were successfully trained and evaluated in a wide range of competences that will lead to the more improved recognition and management of acute stroke patients.

Development of a reliable multimedia, computer-based measure of clinical skills in bedside neurology.

PURPOSE: This study reports the development of reliable multimedia, computer-based measures of bedside neurology skills. METHOD: A consortium of neurologists and medical educators (1) identified bedside skills and (2) created a computer-based test. Test-item stems were multimedia clips of standardized patients. Options appeared as text. Sixty-one junior medical students responded to these items. RESULTS: The 77-item test yielded a reliability coefficient of 0.85. Subgroup item analysis resulted in reliability coefficients of 0.73 for the 20-question "pretest" (Test A) and 0.75 for the 20-question "posttest" (Test B). CONCLUSION: Two sets of test items were developed that can be used as outcome measures in studies that assess the effectiveness of educational interventions in bedside neurology.

Effectiveness of a cardiology review course for internal medicine residents using simulation technology and deliberate practice.

BACKGROUND: Objective evaluations of residents' clinical skills reveal serious deficits. PURPOSE: To develop, implement, and evaluate outcomes from a review course in cardiology bedside skills for internal medicine residents. METHODS: We used a 1-group pretest-posttest design with historical comparisons. The study was conducted at the University of Miami School of Medicine as part of the internal medicine residency program from July 1999 to June 2000. A total of 67 2nd- and 3rd-year medicine residents received an educational intervention involving deliberate practice using simulation technology. A total of 155 4th-year medical students in one intervention and one comparison group (n = 53) served as historical comparisons. Outcome measures were a reliable computer-delivered pretest and posttest that evaluate cardiology bedside skills. RESULTS: Residents who received the review course and medical students who received a comparable educational intervention showed large and statistically significant pretest-to-posttest improvement in bedside skills. These 2 groups are also significantly and substantially different at posttest from a comparison group of 4th-year medical students that did not receive a specific educational intervention. CONCLUSION: Educational interventions using simulation technology that engage learners in deliberate practice of clinical skills produce large improvements in a relatively short time, with little faculty involvement.

Simulation and new learning technologies.

Changes in medical practice that limit patient availability and instructors' time have resulted in poor physical diagnosis skills by learners at all levels. Advanced simulation technology, including the use of sophisticated multimedia computer systems, helps to address this problem. For many years 'Harvey', the Cardiology Patient Simulator, and the UMedic Multimedia Computer system have proven to be effective tools to teach and assess bedside cardiovascular skills when they are integrated into the required curriculum of medical school and postgraduate training. In the future, virtual reality technology, based initially on data from the Visible Human Data set, will provide the majority of simulation-based training. Models that provide a high level of visual fidelity and use sophisticated haptic devices that simulate the 'touch' and 'feel' of a procedure or examination are now being used in selected medical centers. The presence of these tools is not enough. Evidence-based outcomes must show these systems to be effective instruments for teaching and assessment, and medical educators must be willing to effect change in medical education to ensure the appropriate use of these systems in the next millennium.