Search

In the current medical climate, medical education is at risk of being de-emphasized, leading to less financial support and compensation for faculty. A rise in compensation plans that reward clinical or research productivity fails to incentivize and threatens to erode the educational missions of our academic institutions. Aligning compensation with the all-encompassing mission of academic centers can lead to increased faculty well-being, clinical productivity, and scholarship. An anonymous survey developed by members of the A.B. Baker Section on Neurologic Education was sent to the 133 chairs of neurology to assess the type of compensation faculty receive for teaching efforts. Seventy responses were received, with 59 being from chairs. Key results include the following: 36% of departments offered direct compensation; 36% did not; residency program directors received the most salary support at 36.5% full-time equivalent; and administrative roles had greatest weight in determining academic compensation. We believe a more effective, transparent system of recording and rewarding faculty for their educational efforts would encourage faculty to teach, streamline promotions for clinical educators, and strengthen undergraduate and graduate education in neurology.

Objective:To describe clinical and imaging responses in neurosarcoidosis to infliximab, a monoclonal antibody against tumor necrosis factor–α.Methods:Investigators at 6 US centers retrospectively identified patients with CNS sarcoidosis treated with infliximab, including only patients with definite or probable neurosarcoidosis following rigorous exclusion of other causes.Results:Of 66 patients with CNS sarcoidosis (27 definite, 39 probable) treated with infliximab for a median of 1.5 years, the mean age was 47.5 years at infliximab initiation (SD 11.7, range 24–71 years); 56.1% were female; 62.1% were white, 37.0% African American, and 3% Hispanic. Sarcoidosis was isolated to the CNS in 19.7%. Using infliximab doses ranging from 3 to 7 mg/kg every 4–8 weeks, MRI evidence of a favorable treatment response was observed in 82.1% of patients with imaging follow-up (n = 56), with complete remission of active disease in 51.8% and partial MRI improvement in 30.1%; MRI worsened in 1 patient (1.8%). There was clinical improvement in 77.3% of patients, with complete neurologic recovery in 28.8%, partial improvement in 48.5%, clinical stability in 18.2%, worsening in 3%, and 1 lost to follow-up. In 16 patients in remission when infliximab was discontinued, the disease recurred in 9 (56%), typically in the same neuroanatomic location.Conclusions:Most patients with CNS sarcoidosis treated with infliximab exhibit favorable imaging and clinical treatment responses, including some previously refractory to other immunosuppressive treatments.Classification of evidence:This study provides Class IV evidence that for patients with CNS sarcoidosis infliximab is associated with favorable imaging and clinical responses.

Objective: To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy. Methods: Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine. Results: Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit. Conclusions: Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology.

The WASID trial showed no advantage of warfarin over aspirin for preventing the primary endpoint of ischemic stroke, brain hemorrhage, or vascular death. In analyses of selected subgroups, there was no definite benefit from warfarin. Warfarin reduced the risk of the primary endpoint among patients with basilar artery stenosis, but there was no reduction in stroke in the basilar artery territory or benefit for vertebral artery stenosis or posterior circulation disease in general.

Background/Purpose: The Baltimore-Washington Cooperative Young Stroke Study is the largest biracial urban-suburban population-based study to examine the etiology of strokes in children. Methods: We identified all children aged 1 to 14 years discharged from all 46 hospitals in central Maryland and Washington, DC with a diagnosis of ischemic stroke and intracerebral hemorrhage in the years 1988 and 1991. Each medical record was reviewed by two neurologists for appropriateness of the diagnosis of stroke and for information on the patient9s history, clinical presentation, pertinent investigations, hospital stay, and outcome at time of discharge. Results: Eighteen children with ischemic infarction and 17 with intracerebral hemorrhage were identified. The most common cause of ischemic stroke was sickle-cell disease (39%), followed by vasculopathic (33%) and indeterminate(28%) causes. Causes of intracerebral hemorrhages were arteriovenous malformation (29%), hematologic (23%), vasculopathy (18%), surgical complication (12%), coagulopathy (6%), and indeterminate (12%). The overall incidence for childhood stroke was 1.29 per 100,000 per year, with ischemic stroke occurring at a rate of 0.58 per 100,000 and intracerebral hemorrhage occurring at a rate of 0.71 per 100,000. The incidence of stroke among children with sickle-cell disease was estimated to be 0.28% or 285 per 100,000 per year. Conclusion: Sickle-cell disease plays a disproportionately high role in childhood stroke when a biracial population is surveyed.

Background: There is a need to rigorously study the neurologic education of medical students, neurology residents, and neurologists to determine the effectiveness of our educational efforts. Methods: We review the status of neurologic education research as it pertains to the groups of interest. Results: We identify opportunities and impediments for education research. The introduction of the Accreditation Council for Graduate Medical Education core competencies, the Accreditation Council of Continuing Medical Education requirement to link continuing medical education to improved physician behavior and patient care, and the American Board of Medical Specialties/American Board of Psychiatry and Neurology–mandated maintenance of certification program represent research opportunities. Challenges include numerous methodologic issues such as definition of the theoretical framework of the study, adequate sample size ascertainment, and securing research funding. Conclusions: State-of-the-art education research will require multidisciplinary research teams and innovative funding strategies. The central goal of all concerned should be defining educational efforts that improve patient outcomes. GLOSSARY: AAN = American Academy of Neurology; ABPN = American Board of Psychiatry and Neurology; ACCME = Accreditation Council of Continuing Medical Education; ACGME = Accreditation Council for Graduate Medical Education; CME = continuing medical education; ERWG = Education Research Work Group; MOC = Maintenance of Certification; PI = Principal Investigator; RITE = Resident Inservice Training Examination.

Neurologists have a professional opportunity, an ethical responsibility, and sound clinical and economic reasons for engaging in efforts to improve patient safety. Better communication with patients and other providers, closer follow-up of consultation cases, and more focused supervision of trainees will help to reduce current patterns of error and misunderstanding. Patient education with attention to health literacy should improve adherence to management plans and help to bridge transitions of care across providers and sites. Through teaching and by example, neurologists can profoundly influence successive generations of clinicians to adopt safer practices, a culture of openness, and enhanced professionalism. The federal Safety and Quality Improvement Act of 2005, once implemented, should increase the evidence basis for safer care through voluntary, legally protected reporting of errors and adverse events within the framework of patient safety organizations.

Background Limited information exists on the frequency, trends in occurrence, risk factors, mechanisms, and outcome of ischemic stroke associated with illicit drug use among young adults in a geographically defined population. Methods We reviewed ischemic stroke in young adults (aged 15 to 44 years) in 46 regional hospitals for 1988 and 1991. We examined stroke mechanisms and outcome in patients with recent drug use. Results Recent illicit drug use was noted in 51/422 (12.1%) stroke patients. Patients with drug use were more likely than other stroke patients to be black ( p = 0.01), aged 25 to 39 years ( p = 0.004), and smokers ( p = 0.006), and were less likely to have hypertension ( p = 0.004) or diabetes mellitus ( p = 0.004). Drug use was the probable cause of stroke in 20 (4.7%) patients. Among 31 (7.3%) patients with drug use as a possible stroke mechanism, more likely diagnoses included cardioembolic stroke in 18, hematologidcollagen vascular in 6, nonatherosclerotic vasculopathy in 5, and atherosclerosis in 3. There was no difference in outcome between drug-associated and non-drug associated stroke. Conclusions Recent illicit drug use occurs in 12.1% of young adult stroke patients. Drug-associated young adult stroke seems to relate to vascular mechanisms other than those related to hypertension or diabetes. Case-control studies are needed.

Background: Few reports on stroke in young adults have included cases from all community and referral hospitals in a defined geographic region. Methods: At 46 hospitals in Baltimore City, 5 central Maryland counties, and Washington, DC, the chart of every patient 15 to 44 years of age with a primary or secondary diagnosis of possible cerebral arterial infarction during 1988 and 1991 was abstracted. Probable and possible etiologies were assigned following written guidelines. Results: Of 428 first strokes, 212 (49.5%) were assigned at least one probable cause, 80 (18.7%) had no probable cause but at least one possible cause, and 136 (31.8%) had no identified probable or possible cause. Of the 212 with at least one probable cause, the distribution of etiologies was cardiac embolism(31.1%), hematologic and other (19.8%), small vessel (lacunar) disease(19.8%), nonatherosclerotic vasculopathy (11.3%), illicit drug use (9.4%), oral contraceptive use (5.2%), large artery atherosclerotic disease (3.8%), and migraine (1.4%). There were an additional 69 recurrent stroke patients. Conclusions: In this hospital-based registry within a region characterized by racial/ethnic diversity, cardiac embolism, hematologic and other causes, and lacunar stroke were the most common etiologies of cerebral infarction in young adults. Nearly a third of both first and recurrent strokes had no identified cause.

Objective: We hypothesize that MRI based hemisphere volume increases in the first days after stroke is associated with neurological deterioration and functional outcome in patients with malignant edema. Background 70% of patients with malignant infarction die secondary to cerebral edema. A fundamental challenge in the development of treatment strategies is the lack of a validated imaging marker for brain edema. Design/Methods: We conducted a retrospective analysis of the EPITHET study MRI9s at stroke onset and at 3-5 days. We selected patients with an acute diffusion weighted imaging volume > 82cc, which is highly predictive for malignant edema. The involved hemisphere was manually outlined by two independent readers, and volumes were measured using Analyze software. We assessed inter-rater agreement, volume change between scans and the association of volume change with early neurological deterioration (END: NIHSS score worsening ≥4 points), 90-day modified Rankin Scale (mRS) score 0-4 and mortality. Results: Of 12 patients who met study criteria, average baseline and follow-up DWI lesion size was 138 cm 3 and 234 cm 3 , respectively. Mean time to follow-up MRI was 62 hours. Concordance correlation coefficients between readers were >0.90 for both hemisphere and ventricle volume assessment. Mean percent hemisphere volume increase was 16.2±8.3% (p Conclusions: In this exploratory analysis of severe ischemic stroke patients, statistically significant changes in hemisphere and ventricular volumes within the first week are consistent with expected changes of cerebral edema. MRI-based analysis of hemisphere growth appears to be a suitable biomarker for edema formation. Disclosure: Dr. Sheth has nothing to disclose. Dr. Yoo has nothing to disclose. Dr. Gonzalez has nothing to disclose. Dr. Kimberly has nothing to disclose. Dr. Chaudhry has nothing to disclose. Dr. Elm has nothing to disclose. Dr. Jacobson has received personal compensation for activities with Remedy Pharmaceuticals as the CEO.Dr. Jacobson has received compensation for serving as the CEO of Remedy Pharmaceuticals.Dr. Jacobson holds stock and/or stock options in Remedy Pharmaceuticals. Dr. Davis has received personal compensation for activities with Boehringer Ingelheim, Sanofi- Aventis, and Ever Pharma. Dr. Davis has received personal compensation in an editorial capacity for Associate Editor of Cerebrovascular Diseases. Dr. Donnan has nothing to disclose. Dr. Albers has received personal compensation for activities with Genentech and Lundbeck as a member of the Advisory Board. Dr. Albers has received research support from Genetech, Aventis, Sanofi, BI, Ono, and AstraZeneca. Dr. Stern has received personal compensation in an editorial capacity for the Neurologist. Dr. Stern has received research support from Remedy Pharmaceuticals, Inc.

The American Academy of Neurology (AAN) has determined that there is a need within the neurologic community to critically study the effectiveness of neurologic educational programs to ensure that they are meeting the needs of their constituents, including medical students, residents, fellows, and practicing neurologists. The AAN has also recognized the importance of strengthening its educational programs for quality improvement and credentialing purposes, as well as a need to train neurologic educators to perform and publish education research as one component of career development. The AAN Education Committee, together with the leadership of the AAN, brought these needs …

CSF lymphocyte subpopulations of eight patients with neurosarcoidosis were examined. CSF or CT was abnormal in all. The CSF T4/T8 (helper/suppressor) ratio was elevated at 6.8 and 7.6 in two patients; in one, there were only CSF T4 cells. The ratio was normal in five patients.

Mononeuritis multiplex and acute demyelinating polyneuropathy (Guillain-Barré syndrome) are well known in systemic lupus erythematosus (SLE). Chronic acquired demyelinating polyneuropathy has been reported rarely in SLE. Two young women had monophasic progressive weakness, areflexia, elevated CSF protein, and slow nerve conduction velocities as the first manifestation of SLE. Sural nerve biopsy in one patient revealed mild loss of myelinated fibers and an increased number of thinly myelinated fibers. Steroid therapy led to improvement in both patients. These patients demonstrate that chronic demyelinating polyneuropathy can be an unusual presentation of SLE, even preceding characteristic systemic disease by months.

We studied the effect of seizures and myoclonus following cardiopulmonary resuscitation (CPR) on the outcome of all comatose adult survivors of CPR over an 8-year period. Either seizures or myoclonus occurred in 50 of 114 patients (44%): seizures in 41 patients (36%) and myoclonus in 40 (35%). Status epilepticus or status myoclonus occurred in 36 patients (32%), and 19 (17%) had myoclonic status epilepticus (MSE). Seizures and myoclonus per se were not significantly related to outcome, but status epilepticus, status myoclonus, and, particularly, MSE were predictive of poor outcome as judged by survival and recovery of consciousness.

We reviewed 25 patients with neurosarcoidosis followed for at least 5 years or until death. Seventeen patients (68%) had a monophasic illness. Eight (32%) had a relapsing course, with recurrences similar to the original manifestations months later. Patients with cerebral manifestations or hydrocephalus were most likely to relapse. Seven of eight patients with relapsing disease had exacerbations while taking 10 mg prednisone or less.