Gregory Gruener

A standard test of heat-pain responses using CASE IV

Heat-pain threshold and stimulus response characteristics can be evaluated with graduated heating pulses from a radiant heat source or a contact thermode. Results may be used to: (1) evaluate differences in sensation among anatomical sites, sides of the body, and with development and aging; and (2) provide an end-point for the study of the efficacy of drugs; or to follow the course of sensory alteration in disease (medical practice, epidemiologic studies, and controlled clinical trials). Because there is great variability in how tests of this kind are performed and scored, comparisons of results among medical centers are difficult. To meet this need, we have developed, and here describe, a standardized and validated test of heat-pain. We use both pyramidal and trapezoid-shaped stimuli. The range of stimulus magnitudes we recommend is sufficient to test heat-pain at a sensitive region (the face) of young people and an insensitive region (the foot) of healthy old people. From tests on healthy subjects and patients, we find that neither our previously published forced-choice or 4, 2, and 1 stepping algorithms are suitable for testing heat-pain sensation. We, therefore, introduce the Non-Repeating Ascending with Null Stimuli (NRA-NS) algorithm which performs satisfactorily. The graphed data points of responses to increasingly stronger heat pulses were made up of two components-the no pain (0) response line and the heat-pain response line (> or = 1 numerical scaling of the pain responses graded from 1 [least] to 10 [greatest]). For the pain responses, we found that usually a curve could be fit using a quadratic equation. Using this equation, or interpolation where necessary, it is possible to compute the heat-pain detection threshold (HPDT or HP:0.5), an intermediate heat-pain response (HP:5.0), and the difference between the two (HP:5.0-0.5). Our studies show that a certain time is needed between successive stimuli and tests to minimize changing basal skin temperature or threshold. We also demonstrated that low or high baseline skin temperatures can affect heat-pain responses, therefore, we advocate specific testing conditions. Based on a study of 25 healthy subjects, the reproducibility of the test falls within +/-1 stimulus steps 88% of the time for HP:5.0 and 76% of the time for HP:0.5. The precise approaches employed to make the test standard and reproducible are described. We illustrate that the algorithm and testing system is able to document altered pain threshold with skin abrasion, with intradermal injection of nerve growth factor, and with diabetic polyneuropathy.

An analysis of lecture video utilization in undergraduate medical education: associations with performance in the courses.

BackgroundIncreasing numbers of medical schools are providing videos of lectures to their students. This study sought to analyze utilization of lecture videos by medical students in their basic science courses and to determine if student utilization was associated with performance on exams.MethodsStreaming videos of lectures (n = 149) to first year and second year medical students (n = 284) were made available through a password-protected server. Server logs were analyzed over a 10-week period for both classes. For each lecture, the logs recorded time and location from which students accessed the file. A survey was administered at the end of the courses to obtain additional information about student use of the videos.ResultsThere was a wide disparity in the level of use of lecture videos by medical students with the majority of students accessing the lecture videos sparingly (60% of the students viewed less than 10% of the available videos. The anonymous student survey revealed that students tended to view the videos by themselves from home during weekends and prior to exams. Students who accessed lecture videos more frequently had significantly (p < 0.002) lower exam scores.ConclusionWe conclude that videos of lectures are used by relatively few medical students and that individual use of videos is associated with the degree to which students are having difficulty with the subject matter.

Management of Critical Illness Polyneuropathy and Myopathy

A syndrome of generalized weakness, areflexia, and difficulty with weaning from a ventilator is a common clinical presentation in the critically ill patient, especially in the setting of sepsis, multiorgan failure, and hyperglycemia. At first believed to be a manifestation of nerve (critical illness neuropathy, CIN) or muscle (critical illness myopathy, CIM) dysfunction, our current conceptualization is as a spectrum (critical illness neuromuscular abnormalities, CINMA) that varies in extent and site(s) of involvement, but often a similar clinical presentation. Signs and symptoms of CINMA must be identified early to foster recovery and limit morbidity and mortality. The medical history is crucial in excluding preexisting neuromuscular conditions and electrodiagnostic testing helps to establish the diagnosis and prognostication. A stepwise approach to the management of a patient with CINMA is outlined, but avoiding potential medications, and ensuring supportive care are the primary interventions to consider. Recently intensive insulin therapy for hyperglycemia has been shown to lower the risk of CINMA and decrease the time of ventilatory support, but with a greater risk of hypoglycemia. Future therapeutic interventions will require a better understanding of disease pathogenesis, but may target proinflammatory cytokine and free-radical pathways, muscle gene expression, ion channel function, or proteolytic muscle protein mechanisms. Rehabilitation is an equally essential component in a patients management. Although prognosis depends on the extent of the underlying muscle and nerve damage, mild persistent deficits are common and severe disability may be persistent.

An audience response system may influence student performance on anatomy examination questions.

This study integrated an in‐house audience response system (ARS) in the human anatomy course over two years to determine whether students performed better on high‐stakes examinations following exposure to similar interactive questions in a large lecture format. Questions in an interactive ARS format were presented in lectures via PowerPoint presentations. Students who chose to participate in the anonymous ARS sessions submitted answers via their personal wireless devices (e.g., laptops, smartphones, PDAs, etc). Students were surveyed for feedback. Student participation in ARS activities was greatest (65–80%) in the first lecture. The number of students who actively participated in ARS activities decreased over the next four sessions, and then slightly increased in the last two sessions. This trend was the same for both years. Use of the ARS did not dramatically enhance overall student performance on examination questions that dealt with content similar to content presented in the ARS sessions. However, students who scored in the lower quartile of the examination performed better on the examination questions after the ARS was implemented. Accordingly, our findings suggest that the effect of ARS to improve student performance on examinations was not uniform. The overall benefit of an ARS to enhance the lecture experience was confirmed by student surveys. Anat Sci Educ.

Neuromyelitis Optica (NMO) Antibody Positivity in Patients with Transverse Myelitis and No Visual Manifestations

Background and Purpose: To describe a subgroup of patients with IgG antibody to Aquaporin 4 Protein (AQP4) specific to neuromyelitis optica (NMO), who did not have clinical manifestations of optic nerve involvement at the time of diagnosis. Methods: Assessment of five patients (four African Americans and one Latino) with myelitis, who were NMO IgG antibody positive, who had no detected optic nerve involvement, over a span of one to eighteen years. Results: Cerebrospinal fluid (CSF) studies showed lymphocytic pleocytosis, elevated interleukin (IL6), oligoclonal bands (OCB), myelin basic protein (MBP), and elevated albumin and IgG index. Serology showed an association with antinuclear antibody (ANA) positivity and antithyroid peroxidase (TPO) antibody. Our patients responded well to acute treatment with intravenous corticosteroids and long-term treatment with oral prednisone and azathioprine. Conclusions: The aquaporin protein autoimmune disease previously identified as neuromyelitis optica (NMO) may more correctly be identified as neuromyelitis (NM), and future diagnostic criteria should take into account the population of patients with antibody to aquaporin 4 protein, without clinically evident optic nerve pathology. Future research may indicate that the entity of NMO is a subcategory of the NM population.

Challenges for education.

The topic of education has been incorporated into most mission statements at academic institutions, organizations and professional societies, in fact it would be difficult to identify one in which it was absent. Yet, what does it mean, how do we achieve it and is it really viewed as an equal partner in the tripartite mission of clinical care, research, and teaching? Are the successful methods employed in education within neurology that much different from any other medical speciality or for that matter, should its’ pedagogy differ from say, history, art or romance languages? How do resources, training programs, healthcare institutions, infrastructure, and society influence the form of any educational program that is in place as well as influence its revision? This represents only a partial list of questions, most unanswered, but all relevant and highlighting why education is a fitting and equal partner within this Frontiers series whose ultimate goal is to support, influence, communicate, and facilitate advances in the field of neurology. Education is clearly an equal partner.

A Three-year Study of Lecture Multimedia Utilization in the Medical Curriculum: Associations with Performances in the Basic Sciences

This study assesses the frequency with which medical students access video and audio files of lectures in the basic sciences and attempts to determine if the use of such multimedia is associated with examination performance. Data from nine separate courses were analyzed over a three-year period. Students were required to log into the server, which recorded the date and time that specific multimedia files were accessed. The server logs were entered into an Excel spreadsheet, sorted according to student identification numbers and the frequencies of downloads and viewings tabulated by course and lecture. The scores received in each course by individual students were entered before deleting the identification number to preserve anonymity. The data were analyzed using Pearson’s correlation for the sample and one-way analysis of variance. Students viewed lecture videos more frequently than they downloaded the audio files, with the overall ratio of video viewings to audio downloads being 2.5:1. The majority of students (64–78%) accessed relatively few video and audio files of lectures (<10%), trends that were consistently seen in all courses. There were significant correlations for the frequency with which individual students viewed videos of lectures regardless of the course. The patterns for distribution of lecture videos viewed were similar from year-to-year and were unaffected by the elimination of course handouts. Finally, there was an inverse trend between the frequency with which students viewed videos of lectures and their performance in the courses as reflected in their final grades. We found that a small percentage (<10%) of all students regularly use lecture multimedia (audio and video), and results suggest that those students who perform less well on assessments use these multimedia resources to a greater extent.

Simulation-Based Mastery Learning Improves Medical Student Performance and Retention of Core Clinical Skills

Introduction Simulation-based mastery learning (SBML) improves procedural skills among medical trainees. We employed an SBML method that includes an asynchronous knowledge acquisition portion and a hands-on skill acquisition portion with simulation to assess senior medical student performance and retention of the following 6 core clinical skills: (a) ultrasound-guided peripheral intravenous placement, (b) basic skin laceration repair, (c) chest compressions, (d) bag-valve mask ventilation, (e) defibrillator management, and (f) code leadership. Methods Seven emergency medicine (EM) faculty members developed curricula, created checklists, and set minimum passing standards (MPSs) to test mastery of the 6 skills. One hundred thirty-five students on an EM clerkship were pretested on all 6 skills, viewed online videos asynchronously followed by a multiple choice computer-based skill-related quiz, received one-on-one hands-on skill training using deliberate practice with feedback, and were posttested until MPS was met. We compared pretest and posttest performance. We also retested, unannounced, a convenience sample (36%) of students from 1 to 9 months postintervention to assess skill retention. Results All students passed each quiz. The percentage of students who reached each MPS increased significantly (P < 0.001) from pretest to posttest for all 6 clinical skills. Ninety-eight percent of the students scored at or above the MPS when retested 1 to 9 months later. There was no significant decrease in mean score for any of the 6 skills between posttest and retention testing. Conclusions Simulation-based mastery learning using a substantial asynchronous component is an effective way for senior medical students to learn and retain EM clinical skills. This method can be adapted to other skill training necessary for residency readiness.

Computer-Based Testing in the Medical Curriculum: A Decade of Experiences at One School

This report summarizes more than a decade of experiences with implementing computer-based testing across a 4-year medical curriculum. Practical considerations are given to the fields incorporated within an item database and their use in the creation and analysis of examinations, security issues in the delivery and integrity of examinations, curricular integration, use of examination log files, effectiveness and timeliness of reports, and the potential for educational research. The solutions to many complicated issues have practical relevance and interest to the community of educators who are considering the adoption of this technology for assessment.

Neurologic aspects of lymphoma and leukemias.

The leukemias and lymphomas represent a heterogenous group of hematologic malignancies with protean manifestations. Neurologic sequelae of the diseases have been recognized almost since the time the conditions were first described in the mid-1800s. Although our understanding of the various presentations of these blood disorders has evolved along with our knowledge of the malignancies, accurate diagnosis can still be difficult. It is critical for neurologists to have a high index of clinical suspicion to appropriately recognize the heralding features. This review focuses on the relevant clinical neurologic features and diagnostic studies to identify leukemias and lymphomas affecting the nervous system.