Jessica Lee

Education Research: Evaluating acute altered mental status: Are incoming interns prepared?

Background: Clinical evaluation of hospitalized patients with acute altered mental status (AMS) is a common task of interns, regardless of medical specialty. The effectiveness of medical education to ensure competence in this area is unknown. Objective: To measure competency of new interns in the evaluation and management of AMS using an Objective Structured Clinical Examination (OSCE). Methods: A cohort study was conducted with 61 medical school graduates entering internship at a single teaching hospital in 2006. Interns from all major specialty fields were included. The OSCE consisted of a 12-minute simulated encounter with a human patient simulator and nurse actor. Each intern’s performance was graded by the same neurologist, using criteria agreed upon by consensus of the neurology faculty. Competency in obtaining a history, performing a neurologic examination, generating a differential diagnosis, and ordering diagnostic studies was graded. Overall performance was scored on a percentage scale from 0 to 100. Results: Overall performance scores ranged from 19 to 43 with a mean of 31.4 (SD ± 5.6). Hypoglycemia was identified as a potential cause of AMS by 72.1% of interns, while fewer identified urinary tract infection (45.9%) and seizure (13.1%). While many interns ordered a CXR (86.9%) and head CT (80.3%), few requested a toxicology screen (21.3%) or lumbar puncture (3.3%). Only 41% of interns performed a neurologic examination. Conclusion: New interns are not well-prepared to evaluate patients with altered mental status in the inpatient setting as measured by an Objective Structured Clinical Examination.

Neurologic Complications of Infective Endocarditis

Infective endocarditis is an infection of the inner surface or endocardium of the heart, in most instances involving the heart valves or the mural portion of the endocardium. As nonbacterial organisms such as rickettsia, fungi, and even viruses may also cause endocarditis, the term “infective endocarditis” is preferred over the older terminology of “bacterial endocarditis.” Despite advancements in medical treatment and surgical therapies over the last few decades, infective endocarditis continues to be associated with a poor prognosis. There are many different factors affecting the clinical outcome in patient with infective endocarditis, including the type of organism and its virulence, patient characteristics, comorbid illness, time to diagnosis and treatment, indications for surgery, and time to surgery when indicated. In this article, we will review the epidemiology of endocarditis, the neurologic complications of infective endocarditis, and the current therapeutic strategies.

Cerebral venous sinus thrombosis secondary to otomastoiditis

A 64-year-old man with chronic sinusitis and frequent antibiotic use failed a visual acuity examination. Funduscopy showed right papilloedema. There was tenderness to palpation over the right mastoid. Physical examination was otherwise normal. T2-weighted MRI of the brain demonstrated right otomastoiditis (figure 1A). Post-gadolinium T1-weighted MRI showed extensive right-sided dural enhancement (figure 1B). MR venogram of the head revealed cerebral venous sinus thrombosis (CVST) involving the superior sagittal sinus (figure …

Factors Associated with Moyamoya Syndrome in a Kentucky Regional Population

OBJECTIVES Our study aimed to report both new and previously identified conditions associated with moyamoya syndrome in a Western population and to present our outcomes after surgical treatment with indirect bypass. METHODS We performed a retrospective chart review of patients evaluated at our institution from June 2011 to June 2015 who were diagnosed with moyamoya. Data collected include patient demographics, presenting manifestations, vessels involved, comorbid conditions, abnormal laboratory values, treatments administered, and clinical outcomes. RESULTS Thirty-one patients with moyamoya were enrolled (11 male and 20 female), with 84% Caucasian and 16% African-American. The most common comorbidity was hypertension in 61% of the patients. Coexisting autoimmune conditions were present in 26%, with another 13% having coexisting prothrombotic disorders. Diabetes mellitus was not found to correlate with the Suzuki grade of disease at presentation (P = .30). When noninvasive imaging was performed before the cerebral angiogram, the computed tomography angiography had a false-negative rate of 59%, and magnetic resonance angiography had a false-negative rate of 33%. Twenty-one patients underwent surgical intervention, 2 underwent intracranial stenting, and 19 underwent indirect bypass with encephaloduroarteriosynangiosis. At an average 28-month follow-up, all 15 patients who had an angiogram after intervention showed evidence of neovascularization. CONCLUSIONS Autoimmune and prothrombotic disorders were found to be comorbid in patients with moyamoya at much higher rates than expected in the general population. Diabetes mellitus was not significantly correlated with Suzuki grade. Angiogram remains an important diagnostic modality when noninvasive imaging is negative for vasculopathy. We demonstrate excellent evidence of revascularization within 1 year with intracranial stenting and indirect bypass.

DETECTION OF COGNITIVE IMPAIRMENT AFTER ACUTE ISCHEMIC STROKE: VALIDATION OF BRIEF AND MORE COMPREHENSIVE COGNITIVE SCREENING INSTRUMENTS AND IMPLICATIONS FOR BEST PRACTICE

Background: Prior to cognitive decline identifiable via objective testing, older adults often become aware of subtle changes in memory and thinking that impact daily life. This preclinical period, termed subjective cognitive impairment (SCI), may be a key to early detection of dementia-related decline. However, current measurement of SCI is inconsistent across studies and does not consider the multiple ways older adults interpret and answer such questions. Methods:Cognitive interviewing, a structured approach to analyzing sources of response error when individuals respond to questions, was used to systematically appraise older adults’ interpretation of and response to twenty self-report SCI assessment items commonly used in research. The sample (n1⁄455) included independently-living adults age 60 or over with SCI and without dementia; purposive sampling was used to obtain a range of SCI severity. A cognitive interview guide utilized verbal probing techniques to evaluate comprehension, interpretation, difficulty, and potential alternate wording of each item. Interviews were audio-recorded and transcribed, then coded for problem identification using the Question Appraisal System (QAS-99). Results: The most common problem area identified across SCI items was clarity: problems related to communicating the intent or meaning of the question. Specific problems in this area included vague wording that led to multiple ways of interpreting the question (e.g., lack of specificity in identifying important vs. unimportant instances of forgetting) as well as unspecified reference periods (e.g., differences in interpretation of the time frame “happened recently”). Additionally, some questions were inherently affect-laden even when affective language was not included (e.g., comparing one’s memory to peers) and led to respondent resistance when answering. Conclusions:Identifying problems with current assessment items and individual differences in reporting biases across older adult respondents will help to inform future SCI assessment methods. These findings could also aid in the interpretation of current evidence regarding the associations among SCI and a variety of negative outcomes in older adults.

Frederick George Flynn, DO, FAAN (1948–2015)

The world lost a wonderful neurologist, husband, father, and friend with the passing of Col. (Ret.) Frederick George Flynn. Dr. Flynn was a distinguished behavioral neurologist, educator, and patient advocate. In addition, he spent many years in service to neurology through his diligent work for the American Academy of Neurology (AAN).

Communication challenges in complex medical environments.

The provision of health care is becoming increasingly complex and can involve multiple providers and care setting transitions, particularly as the population is living longer, and often with chronic disease. The Electronic Health Record (EHR) was intended to provide a comprehensive documentation of a patients health-related information; however, health care systems often function in isolation with EHRs that are unique only to that system. The EHR may also limit face-to-face communication between treating physicians within the same system. It is only with diligent effort that changes in medical management plans are conveyed among providers. When multiple providers are involved in a patients care, physician-to-patient communication may also suffer, which can impact patient satisfaction and outcome. This article describes a scenario in which several lapses in communication occurred, and it outlines other common pitfalls while providing possible solutions for improving communication across the health care spectrum.