Creating a New Set of Milestones for the Clinical Neurophysiology Fellowship.

INTRODUCTION: The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology first developed milestones for the clinical neurophysiology (CNP) fellowship in 2015. The milestones provide a comprehensive evaluation of the fellow's development based on six domains of competency. Here, we describe the development of a new set of milestones for CNP fellowship with level 1 as the incoming level, level 4 as the goal for graduation, and level 5 as the aspirational level that may not be achieved. METHODS: Committee members were nominated or volunteered to participate in the milestones update. Milestone development began with the creation of a shared mental model of the ideal skills and knowledge a graduating CNP fellow should attain. RESULTS: The CNP committee met virtually 7 times for a total of 14 meeting hours. Nine Patient Care and five Medical Knowledge milestones evolved from the seven Patient Care and six Medical Knowledge milestones that were in the first iteration. The committee incorporated 11 "Harmonized Milestones" into the revision and a supplemental guide was created. CONCLUSIONS: The revised Accreditation Council for Graduate Medical Education milestones for CNP fellowship contain important updates that program directors should review against their curricula to identify any gaps in learning. Program leadership should take note of two new Patient Care milestones for telemedicine and intraoperative monitoring. Clinical neurophysiology fellowships are not designed to provide level 4 competency across all milestones. The revised milestones should be viewed within the context of an individual program's goals.

Beriberi Neuropathy Mimicking Guillian-Barre Syndrome in a Teenager With Food Restriction: A Case Report.

Beriberi neuropathy (thiamine deficiency) and Guillian-Barre Syndrome (GBS) both can present with areflexia and progressive ascending weakness. A physical examination can be equivocal between the two. In cases where GBS is suspected clinically but initial work-up with cerebral spinal fluid (CSF) studies and magnetic resonance imaging (MRI) of the spine are not diagnostic, nerve conduction study/electromyography (NCS/EMG) should be done to evaluate beriberi neuropathy. Presumptive treatment should be started while awaiting confirmation from nutritional laboratory investigations. Here we present a rare case of a GBS mimic involving a 17-year-old patient with food restriction that led to thiamine deficiency causing beriberi neuropathy and Wernicke encephalopathy.

Training in Neurology: Neuro Day: An Innovative Curriculum Connecting Medical Students With Patients.

OBJECTIVE: To determine whether increased patient interaction, exposure to the neurologic examination, and access to positive neurology mentors increase interest in neurology for first-year medical students. METHODS: Neuro Day was a 2-part experience for first-year medical students. The first part consisted of a flipped classroom to teach the standard neurologic examination. The second part involved patient encounters modeled off of the traditional patient rounds. Students rotated from room to room, listening to patients' experiences with different neurologic diseases and eliciting pathologic neurologic examinations. Students were surveyed before and after Neuro Day. RESULTS: The result of the binomial test indicated that the proportion of medical students interested in neurology significantly increased from 78% to 85% (95% confidence interval [CI] 0.79-0.92; p = 0.034) after participating in Neuro Day. The proportion of students' knowledge of clinical neurology increased from 45% to 63.1% (95% CI 0.54-0.72; p < 0.0001), comfort with performing a neurologic examination increased from 30% to 78.4% (95% CI 0.70-0.86; p < 0.0001), and fear of studying neurology decreased from 46% to 26% (95% CI 0.17-0.34; p < 0.0001) following Neuro Day. One hundred percent of students indicated that they would recommend Neuro Day to their peers. CONCLUSION: Neuro Day is a feasible and effective model to incorporate into medical education. There was increased interest in and decreased fear of neurology. We anticipate that this paradigm can be used in the future to encourage students to consider a career in neurology.

Cost-Effectiveness of Peginterferon Beta-1a and Alemtuzumab in Relapsing-Remitting Multiple Sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system, affecting 2.5 million people globally and 400,000 people in the United States. While no cure exists for MS, the goal is to manage the disease using disease-modifying therapies (DMTs), which have been shown to slow disease progression and prevent relapses. Relapsing-remitting MS (RRMS) is the most common form of MS at the time of diagnosis. Peginterferon beta-1a (PEG) and alemtuzumab (ALT) were recently approved and have demonstrated good clinical outcomes, including reduced relapse rates in clinical trials. High costs associated with these DMTs necessitates cost-effectiveness analyses to understand their overall value in RRMS management. OBJECTIVES: To assess the cost-effectiveness of (a) Model 1: PEG relative to intramuscular interferon beta-1a (IM IFN), subcutaneous interferon beta-1b (SC IFN), glatiramer acetate 20 mg per mL (GA), fingolimod (FIN), natalizumab (NAT), and dimethyl fumarate (DMF), and (b) Model 2: ALT relative to subcutaneous interferon beta-1a 44 µg (IFN beta-1a 44 µg). Both analyses were conducted from a U.S. third-party payer perspective. METHODS: Two static decision models were used to compare the cost-effectiveness of PEG and ALT over a 1-year and a 2-year time horizon, respectively. Model inputs were drug acquisition costs (wholesale acquisition cost from RED BOOK); drug administration and monitoring costs (package inserts and Centers for Medicare & Medicaid Services 2015 Physician Fee Schedule); relapse rates and relapse rate reduction (clinical trials); and cost of managing relapses (published literature). All costs were adjusted to 2015 U.S. dollars using the medical care component of the Consumer Price Index. Outcomes measured were total cost of therapy per patient, cost per relapse avoided, and incremental cost-effectiveness ratios (ICERs) calculated as cost per relapse avoided. Sensitivity analysis was conducted to test model robustness given the uncertainty of model inputs and study assumptions. RESULTS: Model 1 results showed that PEG dominated IM IFN and GA, compared with SC IFN; PEG had an ICER of $1,978,000 per relapse avoided. Compared with FIN, NAT, and DMF, PEG was less expensive and less effective. Model 2 showed that ALT had an ICER of $25,276 per relapse avoided relative to IFN beta-1a 44 µg. CONCLUSIONS: In patients with RRMS, PEG is a viable alternative when compared with the DMTs in our model. Deciding whether to choose PEG over other DMTs would depend on multiple factors. On the other hand, ALT had an ICER of $25,276 cost per relapse avoided relative to IFN beta-1a 44 µg. The study results will assist payers in evaluating different medication choices for effective therapy. DISCLOSURES: No outside funding supported this study. Kamal has received research funding from Novartis Pharmaceuticals and the College of Psychiatric and Neurologic Pharmacists and also serves as a consultant for the Lynx Group. Dashputre and Pawar report no conflicts of interest. Study concept and design were primarily contributed by Dashputre, along with Kamal and Pawar. Dashputre took the lead in data collection, along with Kamal, and data analysis was performed by Dashputre, Kamal, and Pawar. The manuscript was written and revised primarily by Dashputre, along with Kamal and Pawar.

Infantile botulism: a case report.

Although rare, botulism should be a consideration in the differential diagnosis of hypotonia in children. The pattern of clinical presentation and physical examination should raise the suspicion to make the appropriate diagnosis. Prompt clinical diagnosis and immediate appropriate treatment reduce morbidity and/or mortality in this disease.

An approach to electrodiagnosis of peripheral neuropathies.

Peripheral neuropathies are the most common neuromuscular disorder seen by neurologists. Determining full features and characteristics based on history and physical examination alone can be difficult. Electrodiagnostic testing is an extension of the neurological examination and can assist in full characterization and provide unique information on underlying pathological processes. This article presents a practical approach to electrodiagnostic testing in patients with peripheral neuropathies.

The use of botulinum toxic injection to treat excessive drooling in children with neurological conditions.

Drooling is a frequent complaint in children with chronic neurological conditions. This is due to poor neuromuscular coordination of the oropharyngeal musculature. Treatment options such as anticholinergic medications and surgical treatment have generally been unsuccessful or associated with side effects and complications. A new treatment for these children is botulinum toxin injection into the parotid glands to decrease saliva production. This article reports on two cases in which this modality was effectively utilized to treat this neurological condition.