Andrea N. Leep Hunderfund

Sonography in carpal tunnel syndrome

Introduction: Our objective in this study was to assess the diagnostic utility of the median nerve cross‐sectional area (CSA) at the wrist, the wrist–forearm ratio, and the wrist–forearm difference in patients with and without carpal tunnel syndrome (CTS). Methods: Individuals with electrodiagnostically proven CTS and asymptomatic control subjects were recruited prospectively from among patients referred to our electrodiagnostic laboratory. Blinded measurements of CSA were made from transverse sonographic images of the median nerve at the wrist (pisiform) and mid‐forearm. Results: Fifty‐five cases and 49 controls were recruited. Wrist median nerve CSA (15 vs. 9 mm2; P < 0.0001), wrist–forearm ratio (3.09 vs. 1.90 mm2; P < 0.0001), and wrist–forearm difference (10 vs. 4 mm2; P < 0.0001) were all significantly larger in CTS cases (areas under the curve = 0.89, 0.82, and 0.88, respectively). Conclusions: Median nerve CSA at the carpal tunnel inlet and wrist–forearm difference provides the best discrimination between patients with CTS and controls according to receiver operator characteristic (ROC) analysis. Age, gender, height, weight, and wrist size have no effect on CSA. Muscle Nerve, 2011

Orthostatic headache without CSF leak.

Objective: To describe the syndrome of orthostatic headache without CSF leak and propose potential mechanisms. Methods: From among 125 patients referred to one of us (B.M.) over a 5-year period for evaluation of orthostatic headache and suspected CSF leak, those patients with negative head and spine MRI, normal radioisotope cisternography and CT myelography, and normal recumbent CSF opening pressure were identified and their medical records reviewed. Results: Six patients satisfied the above criteria for absence of CSF leak. Four patients were men. Mean age at the time of evaluation was 39 years (range 20 to 65). Median duration of symptoms prior to evaluation at our institution was 2 years (range 0.5 to 16). An inciting event was present in two patients. Cochleovestibular symptoms were present in five patients. Mean CSF opening pressure was 140.3 mm H2O (range 86 to 186). Two patients underwent autonomic reflex screens; neither showed postural tachycardia syndrome. After mean follow-up of 45.5 months (range 31 to 67), one patient had experienced a complete spontaneous recovery while five had persistent orthostatic headache. Conclusions: Orthostatic headaches can occur without evidence of intracranial hypotension or detectable CSF leak despite extensive diagnostic testing. Clinical features alone are unlikely to differentiate between orthostatic headache with and without identifiable CSF leak. Potential mechanisms include 1) very slow or intermittent CSF leak that cannot be detected at the time of evaluation or by current diagnostic means or 2) increased compliance of the lower spinal CSF space without actual leak. GLOSSARY: HIP = hydrostatic indifferent point; SIH = spontaneous intracranial hypotension.

Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences with Cost-Conscious Care

Purpose To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care. Method Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index. Results Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001). Conclusions Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.

Median nerve ultrasound in diabetic peripheral neuropathy with and without carpal tunnel syndrome.

Introduction: Median nerve ultrasound shows increased cross‐sectional area (CSA) in carpal tunnel syndrome (CTS) and diabetic peripheral neuropathy (PN). The role of ultrasound in diagnosing CTS superimposed on diabetic PN is unknown. The objective of this study is to evaluate ultrasound for diagnosis of CTS in diabetic PN. Methods: Prospective recruitment of diabetics with electrodiagnostically proven PN, subdivided into cases (with CTS) or controls (without CTS). The gold standard for CTS was clinical diagnosis. NCS were correlated with blinded median nerve CSA ultrasound measurements. Results: Eight cases (CTS) and eight controls (no CTS) were recruited. Nerve conduction studies (NCS): Median nerve distal latencies (antidromic sensory; palmar; lumbrical motor; and lumbrical motor to ulnar interosseous difference) were significantly prolonged in CTS cases. No ultrasound measurement (distal median CSA, wrist‐forearm ratio, wrist‐forearm difference) reached significance to detect CTS. Area under the curve was greatest for lumbrical distal latency by receiver operator characteristic analysis (0.85). Conclusions: In this pilot study, NCS may be superior to ultrasound for identification of superimposed CTS in diabetic PN patients, but larger numbers are needed for confirmation. Muscle Nerve 47: 437–439, 2013

Residency Training: Quality improvement projects in neurology residency and fellowship Applying DMAIC methodology

Objective: Teaching quality improvement (QI) is a priority for residency and fellowship training programs. However, many medical trainees have had little exposure to QI methods. The purpose of this study is to review a rigorous and simple QI methodology (define, measure, analyze, improve, and control [DMAIC]) and demonstrate its use in a fellow-driven QI project aimed at reducing the number of delayed and canceled muscle biopsies at our institution. Methods: DMAIC was utilized. The project aim was to reduce the number of delayed muscle biopsies to 10% or less within 24 months. Baseline data were collected for 12 months. These data were analyzed to identify root causes for muscle biopsy delays and cancellations. Interventions were developed to address the most common root causes. Performance was then remeasured for 9 months. Results: Baseline data were collected on 97 of 120 muscle biopsies during 2013. Twenty biopsies (20.6%) were delayed. The most common causes were scheduling too many tests on the same day and lack of fasting. Interventions aimed at patient education and biopsy scheduling were implemented. The effect was to reduce the number of delayed biopsies to 6.6% (6/91) over the next 9 months. Conclusions: Familiarity with QI methodologies such as DMAIC is helpful to ensure valid results and conclusions. Utilizing DMAIC, we were able to implement simple changes and significantly reduce the number of delayed muscle biopsies at our institution.

Milestone-compatible neurology resident assessments A role for observable practice activities

Objective: Beginning in 2014, US neurology residency programs were required to report each trainees educational progression within 29 neurology Milestone competency domains. Trainee assessment systems will need to be adapted to inform these requirements. The primary aims of this study were to validate neurology resident assessment content using observable practice activities (OPAs) and to develop assessment formats easily translated to the Neurology Milestones. Methods: A modified Delphi technique was used to establish consensus perceptions of importance of 73 neurology OPAs among neurology educators and trainees at 3 neurology residency programs. A content validity score (CVS) was derived for each neurology OPA, with scores ≥4.0 determined in advance to indicate sufficient content validity. Results: The mean CVS for all OPAs was 4.4 (range 3.5–5.0). Fifty-seven (78%) OPAs had a CVS ≥4.0, leaving 16 (22%) below the pre-established threshold for content validity. Trainees assigned a higher importance to individual OPAs (mean CVS 4.6) compared to faculty (mean 4.4, p = 0.016), but the effect size was small (η2 = 0.10). There was no demonstrated effect of length of education experience on perceived importance of neurology OPAs (p = 0.23). Two sample resident assessment formats were developed, one using neurology OPAs alone and another using a combination of neurology OPAs and the Neurology Milestones. Conclusions: This study provides neurology training programs with content validity evidence for items to include in resident assessments, and sample assessment formats that directly translate to the Neurology Milestones. Length of education experience has little effect on perceptions of neurology OPA importance.

Patient Education in Neurology

Patient education is an important component of quality patient care and offers many potential benefits. Health care providers are responsible for giving patients the education they want and need to optimize their health and make health decisions. This review provides a definition of patient education; examines the potential benefits and effectiveness of patient education; builds a general framework for approaching patient education as it pertains to patient knowledge, behaviors, attitudes, and skills; and summarizes representative studies of patient education in selected neurologic conditions.

Ways to Write a Milestone: Approaches to Operationalizing the Development of Competence in Graduate Medical Education

Purpose To identify approaches to operationalizing the development of competence in Accreditation Council for Graduate Medical Education (ACGME) milestones. Method The authors reviewed all 25 “Milestone Project” documents available on the ACGME Web site on September 11, 2013, using an iterative process to identify approaches to operationalizing the development of competence in the milestones associated with each of 601 subcompetencies. Results Fifteen approaches were identified. Ten focused on attributes and activities of the learner, such as their ability to perform different, increasingly difficult tasks (304/601; 51%), perform a task better and faster (171/601; 45%), or perform a task more consistently (123/601; 20%). Two approaches focused on context, inferring competence from performing a task in increasingly difficult situations (236/601; 29%) or an expanding scope of engagement (169/601; 28%). Two used socially defined indicators of competence such as progression from “learning” to “teaching,” “leading,” or “role modeling” (271/601; 45%). One approach focused on the supervisor’s role, inferring competence from a decreasing need for supervision or assistance (151/601; 25%). Multiple approaches were often combined within a single set of milestones (mean 3.9, SD 1.6). Conclusions Initial ACGME milestones operationalize the development of competence in many ways. These findings offer insights into how physicians understand and assess the developmental progression of competence and an opportunity to consider how different approaches may affect the validity of milestone-based assessments. The results of this analysis can inform the work of educators developing or revising milestones, interpreting milestone data, or creating assessment tools to inform milestone-based performance measures.

Validity and feasibility of the EMG direct observation tool (EMG-DOT)

Objective: To develop a new workplace-based EMG direct observation tool (EMG-DOT) and gather validity evidence supporting its use for assessing electrodiagnostic skills among postgraduate medical trainees. Methods: The EMG-DOT was developed by experts using an iterative process. Validity evidence from content, response process, internal structure, relations to other variables, and consequences of testing was collected during the 2013–2014 academic year. Results: Of 3,412 studies performed by trainees during the study period, 299 (9%) were assessed using the EMG-DOT. Of these, 203 (68%) involved a physician rater and 96 (32%) involved a technician rater. The 14-item EMG-DOT had excellent internal-consistency reliability (Cronbach α 0.94). Correlations between individual items and criterion-referenced global ratings of performance ranged from 0.36 to 0.72 (all p < 0.001). Mean total scores increased from 70% to 80% over 4 months of the EMG rotation (p < 0.001) despite a corresponding significant increase in case complexity (0.21–0.74 on a 3-point rating scale; p < 0.001). Trainees reported that the observational assessment exercise improved their knowledge or skills in 82% of encounters (188/230) and that feedback generated by the EMG-DOT improved the quality of care provided to patients in 58% (133/230). Trainees were “satisfied” or “very satisfied” with the observational assessment exercise in 96% of encounters (234/243). Conclusions: This study provides validity evidence supporting the use of EMG-DOT scores to assess electrodiagnostic skills of residents and fellows. The EMG-DOT can be used to inform milestone-based assessments of trainee performance in neurology, child neurology, physical medicine and rehabilitation, neuromuscular, and clinical neurophysiology training programs.

Clinical Reasoning: A 55-year-old man with weight loss, ataxia, and foot drop

A 55-year-old man with prior alcohol abuse and an 80 pack-year smoking history was referred for evaluation of a 3-month history of subacute-onset, progressively worsening imbalance without back pain. He began using a cane to ambulate after multiple falls. He also described recent right foot weakness, numbness in his feet and fingertips, and unintentional 25-pound weight loss over the past year. His medical history was significant for hypertension, gastroesophageal reflux disease, diverticulitis, and pelvic abscesses. A paternal grandfather had lung cancer. He reported a remote history of IV drug use. General examination revealed cachexia. Neurologic examination findings were complex. Gait examination revealed severe ataxia, a high steppage gait on the right, and a positive Romberg sign. The total ataxia score using the Scale for Assessment and Rating of Ataxia (higher scores indicate increased severity)1 was 14/40, including gait, 5/8; stance, 4/6; sitting, 1/4; speech disturbance, 0/4; finger chase, 0/4; nose-finger test, 0/4; fast alternating hand movements, 2/4; and heel-shin slide, 2/4. Nystagmus was not present. Strength testing revealed hip and knee flexion weakness bilaterally (grade 4/5) and severe (grade 2/5) weakness of right ankle dorsiflexion and eversion but preserved inversion strength. Reflexes were brisk in the upper extremities and normal in the lower extremities and plantar responses were flexor. Sensory testing revealed absent lower extremity vibration, absent joint position at the toes, and reduced pinprick in the feet without a sensory level. Initial laboratory testing revealed a hemoglobin of 9.3 g/dL (normal range 13.5–17.5).