Generalizability of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) Scale to Assess Medical Student Performance on Core EPAs in the Workplace: Findings From One Institution.

PURPOSE: Assessment of the Core Entrustable Professional Activities for Entering Residency (Core EPAs) requires direct observation of learners in the workplace to support entrustment decisions. The purpose of this study was to examine the internal structure validity evidence of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) scale when used to assess medical student performance in the Core EPAs across clinical clerkships. METHOD: During the 2018-2019 academic year, the Virginia Commonwealth University School of Medicine implemented a mobile-friendly, student-initiated workplace-based assessment (WBA) system to provide formative feedback for the Core EPAs across all clinical clerkships. Students were required to request a specified number of Core EPA assessments in each clerkship. A modified O-SCORE scale (1 = "I had to do" to 4 = "I needed to be in room just in case") was used to rate learner performance. Generalizability theory was applied to assess the generalizability (or reliability) of the assessments. Decision studies were then conducted to determine the number of assessments needed to achieve a reasonable reliability. RESULTS: A total of 10,680 WBAs were completed on 220 medical students. The majority of ratings were completed on EPA 1 (history and physical) (n = 3,129; 29%) and EPA 6 (oral presentation) (n = 2,830; 26%). Mean scores were similar (3.5-3.6 out of 4) across EPAs. Variance due to the student ranged from 3.5% to 8%, with the majority of the variation due to the rater (29.6%-50.3%) and other unexplained factors. A range of 25 to 63 assessments were required to achieve reasonable reliability (Phi > 0.70). CONCLUSIONS: The O-SCORE demonstrated modest reliability when used across clerkships. These findings highlight specific challenges for implementing WBAs for the Core EPAs including the process for requesting WBAs, rater training, and application of the O-SCORE scale in medical student assessment.

Improving Passage Rate on USMLE Step 2 Clinical Skills: Results from a Pilot Program.

In the United States (US), successful passage of United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (Step 2 CS) is required to enter into residency training. In 2017, the USMLE announced an increase in performance standards for Step 2 CS. As a consequence, it is anticipated that the passage rate for the examination will decrease significantly for both US and international students. While many US institutions offer a cumulative clinical skills examination, their effect on Step 2 CS passage rates has not been studied. The authors developed a six-case, standardized patient (SP)-based examination to mirror Step 2 CS and measured impact on subsequent Step 2 CS passage rates. Students were provided structured quantitative and qualitative feedback and were given a final designation of "pass" or "fail" for the practice examination. A total of 173 out of 184 (94.5%) students participated in the examination. Twenty SPs and $26,000 in direct costs were required. The local failure rate for Step 2 CS declined from 4.5% in the year proceeding the intervention to 2.1% following the intervention. In the same timeframe, the US failure rate for Step 2 CS increased from 3.8 to 5.1%, though the difference between local and national groups was not significantly different (P = .07). Based on the initial success of the intervention, educational leaders may consider developing a similar innovation to optimize passage rates at their institutions.

Are Scores From NBME Subject Examinations Valid Measures of Knowledge Acquired During Clinical Clerkships?

PURPOSE: The National Board of Medical Examiners' Clinical Science Subject Examinations are a component used by most U.S. medical schools to determine clerkship grades. The purpose of this study was to examine the validity of this practice. METHOD: This was a retrospective cohort study of medical students at the Virginia Commonwealth University School of Medicine who completed clerkships in 2012 through 2014. Linear regression was used to determine how well United States Medical Licensing Examination Step 1 scores predicted Subject Examination scores in seven clerkships. The authors then substituted each student's Subject Examination standard scores with his or her Step 1 standard score. Clerkship grades based on the Step 1 substitution were compared with actual grades with the Wilcoxon rank test. RESULTS: A total of 2,777 Subject Examination scores from 432 students were included in the analysis. Step 1 scores significantly predicted between 23% and 44% of the variance in Subject Examination scores, P < .001 for all clerkship regression equations. Mean differences between expected and actual Subject Examination scores were small (≤ 0.2 points). There was a match between 73% of Step 1 substituted final clerkship grades and actual final clerkship grades. CONCLUSIONS: The results of this study suggest that performance on Step 1 can be used to identify and counsel students at risk for poor performance on the Subject Examinations. In addition, these findings call into the question the validity of using scores from Subject Examinations as a high-stakes assessment of learning in individual clerkships.

Aberrant drug-taking behaviors and headache: patient versus physician report.

OBJECTIVE: To explore prevalence of aberrant medication-taking behaviors (AMTB) among headache patients and treating physician's awareness of such behaviors. METHODS: Fifty patientphysician dyads were surveyed on patients' AMTB. RESULTS: The most frequently endorsed behaviors by patients and physicians, respectively, were going to the ER for pain medication (n = 19) and continuing to take pain medication despite minimal relief (n = 23). For the majority of AMTB, phi coefficients indicating level of patient-physician agreement were equal to chance. CONCLUSIONS: Headache patients perform a wide range of AMTB. Low rates of patient-physician agreement indicate that physicians possess limited knowledge of patients' AMTB.

Seizures in the elderly: Nuances in presentation and treatment.

Acute symptomatic seizures and epilepsy are two of the most common neurologic complaints in the elderly. Stroke is the leading underlying etiology for both. Because clinical seizure manifestations in the elderly often differ from those in younger adults, they may be difficult to recognize or may be misdiagnosed. Interpretation of diagnostic tests in elderly patients with seizures is often complicated by comorbidities, and treatment decisions require careful consideration in the context of age-related physiologic changes, comorbidities, and the use of concomitant medications. Treatment of an acute seizure with a clear precipitating cause involves correcting the underlying etiology; antiepileptic drug (AED) therapy is generally reserved for patients with epilepsy (recurrent unprovoked seizures). The prognosis for elderly epilepsy patients treated with AEDs is generally good. Both older and newer AEDs are efficacious but have respective advantages and disadvantages; no ideal AED yet exists. Status epilepticus is a neurologic emergency that is particularly frequent in the elderly and associated with high mortality, although treatment can be effective.

New horizons in ambulatory electroencephalography.

Since its inception 30 years ago, AEEG has continued to evolve--from four-channel tape recorders to 32-channel digital recorders with sophisticated automatic spike and seizure detection algorithms. AEEG remains an important tool in epilepsy evaluation. In the near future, smaller, faster, and more sophisticated AEEGs will be developed. Seizure detection/anticipation systems will allow the wearer to be forewarned of a seizure so that appropriate safety measures can be taken. With further refinement in our understanding of nonlinear dynamic analysis to define the pre-ictal state, AEEG will be coupled with an accurate seizure anticipation device in a closed-loop system, providing a time window during which therapeutic intervention can occur, to prevent a seizure. The therapeutic intervention will most likely involve vagus nerve or deep brain stimulation. An alternative is that the patient may learn to recognize early symptoms of the pre-ictal state and use behavioral biofeedback interventions to avoid a clinical seizure. In order to achieve convenient ambulatory recording and seizure detection that could realistically improve the lives of patients with refractory epilepsy, the process of miniaturization of such a device to a convenient size must be accomplished. One of the aspects of epilepsy that patients find most frustrating, and that most limits activities, is the vulnerability to sudden unexpected incapacitation due to the occurrence of a seizure. With miniaturization of AEEG and seizure anticipation technology, and advancements in our ability to identify the transition from pre-ictal to ictal state, there is realistic hope that patients with refractory epilepsy may gain control over their seizures and enjoy significantly improved quality of life.

Doing Duo - a case study of entrainment in William Forsythe's choreography "Duo".

Entrainment theory focuses on processes in which interacting (i.e., coupled) rhythmic systems stabilize, producing synchronization in the ideal sense, and forms of phase related rhythmic coordination in complex cases. In human action, entrainment involves spatiotemporal and social aspects, characterizing the meaningful activities of music, dance, and communication. How can the phenomenon of human entrainment be meaningfully studied in complex situations such as dance? We present an in-progress case study of entrainment in William Forsythe's choreography Duo, a duet in which coordinated rhythmic activity is achieved without an external musical beat and without touch-based interaction. Using concepts of entrainment from different disciplines as well as insight from Duo performer Riley Watts, we question definitions of entrainment in the context of dance. The functions of chorusing, turn-taking, complementary action, cues, and alignments are discussed and linked to supporting annotated video material. While Duo challenges the definition of entrainment in dance as coordinated response to an external musical or rhythmic signal, it supports the definition of entrainment as coordinated interplay of motion and sound production by active agents (i.e., dancers) in the field. Agreeing that human entrainment should be studied on multiple levels, we suggest that entrainment between the dancers in Duo is elastic in time and propose how to test this hypothesis empirically. We do not claim that our proposed model of elasticity is applicable to all forms of human entrainment nor to all examples of entrainment in dance. Rather, we suggest studying higher order phase correction (the stabilizing tendency of entrainment) as a potential aspect to be incorporated into other models.

Status epilepticus in the setting of acute encephalitis.

Ms. Q, a 29-year-old woman, began to behave strangely, claiming to see and hear imaginary people. The following day, she was confused and somnolent in the morning. In the late morning, she had a generalized tonic-clonic seizure and was transported to the hospital. Her past medical and developmental histories were unremarkable. She took a daily oral contraceptive and had no drug allergies. She worked as a teacher and had been married for one year. On initial examination, blood pressure was 129/82, pulse 88, respiratory rate 16, temperature 37.5 °C. She was stuporous, moving her arms appropriately in response to a painful stimulus. Pupils were 2 mm and reactive. There was no gaze preference, and the rest of the examination was nonfocal. About 30 minutes after her first seizure, she had a second GTCS and was given 4 mg lorazepam intravenously. She had a third GTCS 6 min after her second seizure and received a second dose of lorazepam. Initial blood tests-including complete blood count, comprehensive metabolic panel, urinalysis, and toxic screen-were normal. Head CT was normal. She remained stuporous. EEG demonstrated waxing and waning electrographic ictal activity, and she was loaded with fosphenytoin. Intermittent electrographic seizure activity persisted, and a continuous infusion of intravenous propofol was administered. After 24 hr, propofol was weaned, but electrographic seizures recurred and it was restarted.

De novo generalized periodic discharges related to anesthetic withdrawal resolve spontaneously.

Pentobarbital and propofol are used for the treatment of refractory status epilepticus or elevated intracranial pressure, typically with continuous EEG monitoring. We report a series of patients who developed generalized periodic discharges related to anesthetic withdrawal (GRAWs), different from previous seizure activity. At times, this pattern was misinterpreted as recurrent seizure activity, leading to reinstitution of drug-induced coma, but resolved spontaneously without additional treatment.We identified five patients who developed GRAWs during pentobarbital or propofol withdrawal. Two patients received pentobarbital for increased intracranial pressure. One patient received pentobarbital and propofol for encephalopathy accompanied by a rhythmic EEG pattern erroneously thought to be ictal. Two patients received pentobarbital for refractory partial status epilepticus. In all cases, anesthetic agents were withdrawn after 24 to 48 hours of burst suppression on EEG. We analyzed the course of GRAWs on EEG and the associated clinical outcomes.All five patients developed GRAWs, consisting of periodic 1 to 4 Hz generalized periodic discharge, not previously seen on EEG. In all cases, the pattern eventually resolved spontaneously, over 12 to 120 hours. However, in three cases, the pattern was initially thought to represent ictal activity, and drug-induced coma was reinitiated. The pattern recurred during repeated anesthetic withdrawal, was then recognized as nonictal, and then resolved without further treatment. In all cases but one, the patients exhibited improvement to near-baseline mentation.Generalized periodic discharges related to anesthetic withdrawal may occur de novo after pentobarbital or propofol withdrawal. They should resolve spontaneously without treatment and without recurrence of clinical seizure activity. However, GRAWs are not likely to represent status epilepticus and should not prompt resumption of drug-induced coma, unless there is reappearance of original electrographic seizure activity.

Status epilepticus.

Status epilepticus (SE) is one of the most commonly occurring neurologic emergencies. About 40% of SE cases occur in people with epilepsy. Convulsive SE is easily recognized, but nonconvulsive SE is not and requires both a high index of suspicion and EEG confirmation. SE has a high mortality risk and requires rapid effective treatment for optimal response to therapy and outcome. The goal of treatment is to stop all clinical and electrographic seizures while maintaining vital functions. If seizures continue after initial treatment with a benzodiazepine, additional antiepileptic therapy should be administered. When SE is refractory to these treatments, continuous IV infusion with midazolam, propofol, or a barbiturate suppresses seizure activity. Standard treatment protocols are useful in promoting rapid intervention with appropriate medications.

Treatment of refractory complex partial seizures: role of vigabatrin.

Vigabatrin (VGB) is an antiepileptic drug that was designed to inhibit GABA-transaminase, and increase levels of gamma-amino-butyric acid (GABA), a major inhibitory neurotransmitter in the brain. VGB has demonstrated efficacy as an adjunctive antiepileptic drug for refractory complex partial seizures (CPS) and for infantile spasms (IS). This review focuses on its use for complex partial seizures. Although VGB is well tolerated, there have been significant safety concerns about intramyelinic edema and visual field defects. VGB is associated with a risk of developing bilateral concentric visual field defects. Therefore, the use of VGB for complex partial seizures should be limited to those patients with seizures refractory to other treatments. Patients must have baseline and follow-up monitoring of visual fields, early assessment of its efficacy, and ongoing evaluation of the benefits and risks of VGB therapy.

Comparisons of the mortality and clinical presentations of status epilepticus in private practice community and university hospital settings in Richmond, Virginia.

We prospectively compared the clinical course of 119 patients treated for status epilepticus (SE) in private practice community hospitals and 344 SE patients treated in the VCU university hospitals in Richmond, Virginia USA over a 2-year period to test the hypothesis that SE presents with the same mortality and clinical patterns in both clinical settings. Of the patients reviewed, the major etiologies for SE were cerebrovascular disease, decreased anti-epileptic drug levels in epileptic patients, anoxia-hypoxia, and remote symptomatic. The other etiologies included were alcohol related, trauma, central nervous system infections, tumors, systemic infection, metabolic disorders, idiopathic, and hemorrhage. These observations provide the first direct prospective comparison of SE present in university and private practice community hospital settings in the same geographic area. Mortality was the highest in the elderly population while the pediatric population had low mortality in both clinical settings. Etiology risk factors for outcome were similar for both the populations. The data also suggest that the higher degree of illness severity in university hospitals may be associated with a higher incidence of SE, but not with mortality or a different clinical presentation of the condition. The results of this study demonstrate that SE has the same mortality and is present in an essentially identical manner in university and private practice community hospitals and underscores the fact that mortality in SE is not just associated with tertiary care hospitals and the importance of recognizing the severity of SE in the private practice setting.

Conversions between monotherapies in epilepsy: expert consensus.

To develop expert consensus for conversion between antiepileptic drug (AED) monotherapies, an 11-member panel used the Delphi Technique over three rounds to: (1) identify relevant issues, (2) vote on the issues, and (3) develop consensus. The panel agreed on the basic principle to taper the existing AED only after a presumably efficacious dose of the planned AED was reached. Application is modified by adverse effects possibly attributable to the existing drug, in which case earlier or more rapid tapering of the existing drug should be considered. Patients with uncontrolled seizures, as well as seizure-free patients for whom driving privileges are a consideration, may benefit from slower tapering by smaller dosage decrements of the existing AED. For 10 of the 12 AEDs considered, the panel made titration recommendations concerning initial and target doses for the planned AED, supplementing limited data in the prescribing information. This expert guidance will aid in the period of transitional polytherapy with AEDs from monotherapy to monotherapy.

Status Epilepticus.

Status epilepticus (SE) is a common neurologic emergency with a high mortality. Immediate recognition and rapid treatment are essential. After initial stabilization of airway and circulation, the patient should be treated as soon as possible with an intravenous (IV) benzodiazepine, followed immediately by IV fosphenytoin. If SE persists, general anesthesia should be initiated, with intubation and cardiac monitoring. Electroencephalogram must also be monitored to ensure suppression of all seizures. Etiology of SE should be assessed through history, examination, blood tests, and brain imaging.

Management of status epilepticus.

Status epilepticus is an increasingly recognized public health problem in the United States. Status epilepticus is associated with a high mortality rate that is largely contingent on the duration of the condition before initial treatment, the etiology of the condition, and the age of the patient. Treatment is evolving as new medications become available. Three new preparations--fosphenytoin, rectal diazepam, and parenteral valproate--have implications for the management of status epilepticus. However, randomized controlled trials show that benzodiazepines (in particular, diazepam and lorazepam) should be the initial drug therapy in patients with status epilepticus. Despite the paucity of clinical trials comparing medication regimens for acute seizures, there is broad consensus that immediate diagnosis and treatment are necessary to reduce the morbidity and mortality of this condition. Moreover, investigators have reported that status epilepticus often is not considered in patients with altered consciousness in the intensive care setting. In patients with persistent alteration of consciousness for which there is no clear etiology, physicians should be more quickly prepared to obtain electroencephalography to identify status epilepticus. Physicians should rely on a standardized protocol for management of status epilepticus to improve care for this neurologic emergency.