Impact of Simulation on Critical Care Fellows' Electroencephalography Learning.

Introduction Continuous electroencephalography (EEG) is an important monitoring modality in the intensive care unit and a key skill for critical care fellows (CCFs) to learn. Our objective was to evaluate with CCFs an EEG educational curriculum on a web-based simulator. Methods This prospective cohort study was conducted at a major academic medical center in Florida. After Institutional Review Board approval, 13 CCFs from anesthesiology, surgery, and pulmonary medicine consented to take an EEG curriculum. A 25-item EEG assessment was completed at baseline, after 10 EEG interpretations with a neurophysiologist, and after 10 clinically relevant EEG-based simulations providing clinical EEG interpretation hints. A 50-minute tutorial podcast was viewed after the baseline assessment. Main assessment outcomes included multiple outcomes related to web-based simulator performance: percent of hints used, percent of first words on EEG interpretation correct, and percent hint-based EEG interpretation score correct, with higher scores indicating more correct answers. Participants completed a 25-item EEG assessment before (baseline) and after the web-based simulator. Results All 13 CCFs completed the curriculum. Between scenarios, there were differences in percent of hints used (F9,108 = 11.7, p < 0.001), percent of first words correct (F9,108 = 13.6, p < 0.001), and overall percent hint-based score (F9,108 = 14.0, p < 0.001). Nonconvulsive status epilepticus had the lowest percent of hints used (15%) and the highest hint-based score (87%). Overall percent hint-based score (mean across all scenarios) was positively correlated with change in performance as the number of correct answers on the 25-item EEG assessment from before to after the web-based simulator activity (Spearman's rho = 0.67, p = 0.023). Conclusions A self-paced EEG interpretation curriculum involving a flipped classroom and screen-based simulation each requiring less than an hour to complete significantly improved CCF scores on the EEG assessment compared to baseline.

The RITE of Passage: Learning Styles and Residency In-Service Training Examination (RITE) Scores.

Introduction The objective of the pilot study was to determine the association between learning preferences and improvement in the American Academy of Neurology Residency In-Service Training Examination (RITE) scores from postgraduate year 2 (PGY-2) to postgraduate year 3 (PGY-3) in neurology residents. Methods Neurology residents at the University of Florida were approached to participate, and their consent was obtained. VARK inventory, representing four modalities (visual, aural, read/write, kinesthetic) of learning preferences, was completed by participants. Participants could pick more than one modality. The number of responses in each sensory domain was recorded, with higher numbers indicating stronger preference. Residents' performance on the RITE was recorded for PGY-2 and PGY-3. Results Seventeen residents completed the VARK inventory and 16 had data for RITE. Residents demonstrated overall positive change in RITE from PGY-2 to PGY-3 (mean change = 6%; 95%CI: 4%, 9%). The median number of responses was highest for the kinesthetic domain (median = 7, range = 1-12), followed by visual (median = 6, range = 2-12), aural (median = 4, range = 1-10), and read/write (median = 4, range = 1-10). Among VARK domains, the number of responses in read/write had the strongest correlation with mean change in RITE performance from PGY-2 to PGY-3 (r = 0.45; 95%CI: -0.08, 0.78); residents in the high read/write group (number of response above median) had greater mean change in RITE performance (9%; 95%CI: 6%, 12%) while those in the low read/write group showed little to no increase in RITE from PGY-2 to PGY-3 (2%; 95%CI: -1%, 6%). Conclusions Higher VARK survey responses in the read/write domain were related to greater change in RITE scores from PGY-2 to PGY-3. These findings seem intuitively obvious considering the format of the RITE. These pilot data permit further investigation of individual resident learning preference and how it relates to test performance. By understanding a resident's learning style, both educators and the resident will have an awareness of areas that need to be improved to be successful, which may be via remedial curricula and self-study activities.

An online, interactive, screen-based simulator for learning basic EEG interpretation.

OBJECTIVE: Develop and pilot test a simulator that presents ten commonly encountered representative clinical contexts for trainees to learn basic electroencephalogram (EEG) interpretation skills. METHODS: We created an interactive web-based training simulator that allows self-paced, asynchronous learning and assessment of basic EEG interpretation skills. The simulator uses the information retrieval process via a free-response text box to enhance learning. Ten scenarios were created that present dynamic (scrolling) EEG tracings resembling the clinical setting, followed by questions with free-text answers. The answer was checked against an accepted word/phrase list. The simulator has been used by 76 trainees in total. We report pilot study results from the University of Florida's neurology residents (N = 24). Total percent correct for each scenario and average percent correct for all scenarios were calculated and correlated with most recent In-training Examination (ITE) and United States Medical License Examination (USMLE) scores. RESULTS: Neurology residents' mean percent correct scenario scores ranged from 27.1-86.0% with an average scenario score of 61.2% ± 7.7. We showed a moderately strong correlation r = 0.49 between the ITE and the average scenario score. CONCLUSION: We developed an online interactive EEG interpretation simulator to review basic EEG content and assess interpretation skills using an active retrieval approach. The pilot study showed a moderately strong correlation r = 0.49 between the ITE and the average scenario score. Since the ITE is a measure of clinical practice, this is evidence that the simulator can provide self-directed instruction and shows promise as a tool for assessment of EEG knowledge.

Left Ventricular Assist Device Artifact in EEG.

Left ventricular assist devices are increasingly used as therapy for patients with severe congestive heart failure. These patients typically receive care in the intensive care unit when EEG monitoring is necessary. Identification of artifacts created by these devices is important for accurate EEG diagnosis, thus avoiding unnecessary therapies that may result in complications or require intubation of the patient. This report describes a case of a patient with altered mental status and history of congestive heart failure with a left ventricular assist device who developed seizures following left subdural hematoma and emergent evacuation. While being treated for seizures, the EEG showed a diffuse continuous and regular delta, predominant on the left that mirrored the electrocardiogram (EKG) rhythm strip and appeared to indicate an external artifact. Moving the amplifier farther away from the heart and repositioning the patient resolved the artifact. It is important to recognize potential sources of interference and artifacts when these devices are involved. This case illustrates how clinicians can prevent administration of unneeded therapies to these patients.

Brain's compensatory response to drug-induced cognitive impairment.

INTRODUCTION: Topiramate (TPM), a frequently prescribed antiseizure medication, can cause severe cognitive side-effects. Though these side-effects have been studied behaviorally, the underlying neural mechanisms are unknown. In a double-blind, randomized, placebo-controlled, crossover study of TPM's impact on cognition, nine healthy volunteers completed three study sessions: a no-drug baseline session and two sessions during which they received either TPM or placebo. Electroencephalogram was recorded during each session while subjects performed a working-memory task with three memory-loads. RESULTS: Comparing TPM with baseline we found the following results. (a) TPM administration led to declines in behavioral performance. (b) Fronto-central event-related potentials (ERP) elicited by probe stimuli, representing the primary task network activity, showed strong memory-load modulations at baseline, but the magnitude of these load-dependent modulations was significantly reduced during TPM session, suggesting drug-induced impairments of the primary task network. (c) ERP responses over bilateral fronto-temporal electrodes, which were not load sensitive at baseline, showed significant memory-load modulations after TPM administration, suggesting the drug-related recruitment of additional neural resources. (d) At fronto-central scalp sites, there was significant increase in response amplitude for low memory-load during TPM session compared to baseline, and the amplitude increase was dependent on TPM plasma concentration, suggesting that the primary task network became less efficient under TPM impact. (e) At bilateral fronto-temporal electrodes, there were no ERP differences when comparing low memory-load trials, but TPM administration led to an increase in ERP responses to high load, the magnitude of which was positively correlated with task performance, suggesting that the recruited neural resources were beneficial for task performance. Placebo-TPM comparison yielded similar effects albeit with generally reduced significance and effect sizes. CONCLUSION: Our findings support the hypothesis that TPM impairs the primary task network by reducing its efficiency, which triggers compensatory recruitment of additional resources to maintain task performance.

EEG Artifact Versus Subclinical Status Epilepticus in a Patient Following Cardiac Arrest.

BACKGROUND: A challenge in ICU EEG interpretation is identifying subclinical status epilepticus versus patterns on the ictal-interictal continuum versus other repetitive patterns. In the electrically noisy intensive care unit, identifying and eliminating interference and artifact allow accurate diagnoses from the EEG, avoiding unnecessary treatment or sedation. METHODS: We present a case during Impella (Abiomed Inc, Danvers, MA) continuous flow left ventricular assist device use where the EEG artifact was initially misinterpreted as seizure by the resident and treated as status epilepticus because of the "focal" sharply contoured repetitive pattern. During percutaneous coronary intervention (PCI), an 88-year-old developed ventricular tachycardia followed by ventricular fibrillation requiring chest compressions for 10 min, multiple defibrillations, and treatment with epinephrine, amiodarone, calcium, bicarbonate, and magnesium. The patient had an Impella placed during PCI with therapeutic hypothermia initiated after the cardiopulmonary arrest. His neurological exam demonstrated preserved pupillary, corneal, gag and cough reflexes and spontaneous respirations. RESULTS: Long-term video EEG monitoring is included in our institution's hypothermia protocol. Initial baseline EEG performed 2 h after PCI showed a persistent rhythmic sharp discharge from the left central temporal region resembling left hemisphere status epilepticus. The sharp waves have an alternating repeating 2:1 relationship with the EKG rhythm strip. This is best seen in the left hemisphere, which we posit is related to the Impella's positioning across the aortic valve pointing toward the patient's left side. A chest x-ray confirmed the device's position immediately before EEG monitoring. Arterial pressure tracings were not available in the chart. CONCLUSIONS: There is a low-amplitude spiky artifact; however, there was no pacing at that time. It is possible that synergistic flow with systole/diastole reinforced the pulsatility with movement of the Impella, resulting in the alternating pattern. The patient's hemodynamic instability precluded extensive troubleshooting with the Impella device, but after EEG repositioning, the artifact was eliminated.

Not Everything That Shakes Is a Seizure: A Case Report.

Not everything that shakes is an epileptic seizure. We present a patient who repeatedly exhibited severe shaking at emergence from general anesthesia. Her nonepileptic myoclonus was mistaken for a refractory seizure and treated with benzodiazepines and intravenous anesthetics. The resulting depressed level of consciousness rendered myoclonus clinically indistinguishable from refractory seizures. Over the course of 6 procedures, we found that levetiracetam, a first-line antiepileptic drug, effectively suppressed her myoclonus. The episodic nature of perioperative anesthesia care presents a challenge for differentiating myoclonus from seizure while balancing the concerns raised by different surgical procedures, rare comorbidities, and the subjective patient experience.

Prior Podcast Experience Moderates Improvement in Electroencephalography Evaluation After Educational Podcast Module.

BACKGROUND: There is continued interest in using technology to enhance medical education and the variables that may affect its success. METHODS: Anesthesiology residents and fourth-year medical students participated in an electroencephalography (EEG) educational video podcast module. A 25-item evaluation tool was administered before any EEG education was provided (baseline), and the podcast was then viewed. Another 25-item evaluation tool was administered after podcast viewing (after podcast). Ten EEG interpretations were completed with a neurophysiologist with an additional 25-item evaluation tool administered after the interpretations (after 10 EEG interpretations). Participants were surveyed concerning technology and podcasting experience before the educational module and their responses to the podcast educational model. Multiple analyses were performed (1) to evaluate differences in improvement in EEG evaluation scores between the podcast module and the standard didactics (control group); and (2) to evaluate potential moderation by technology and the podcast experience on the change in mean EEG evaluation scores from after the podcast module to after 10 EEG interpretations. RESULTS: A total of 21 anesthesiology residents and 12 fourth-year medical students participated. Scores on the 25-item evaluation tool increased with each evaluation time (P ≤ 0.001). Moderation analyses revealed that individuals with more podcast experience (≥4 previous podcasts) had greater increases in scores after a podcast and 10 EEG interpretations compared with individuals with less experience (≤3 previous podcasts) (P = 0.027). Furthermore, compared with a control group with similar baseline characteristics that received only standard didactics without a podcast, those in the podcast group had greater increases in mean EEG evaluation scores between baseline and after 10 EEG interpretations. CONCLUSIONS: In reviewing the improvement in EEG evaluation after a podcast education module, those with more podcast experience achieved greater gains in EEG evaluation scores. For EEG education, those receiving the podcast education module showed greater increases in scores compared with those receiving didactic teaching without podcasting, as measured by change in a mean EEG evaluation scores.

Posttraumatic stress disorder caused by the misattribution of seizure-related experiential responses.

Patients with temporal lobe seizures sometimes experience what John Hughlings Jackson described as "dreamy states" during seizure onset. These phenomena may be characterized by a re-experiencing of past events, feelings of familiarity (déjà vu), and hallucinations. In previous reports, patients have been aware of the illusory nature of their experiences. Here, however, the case of a patient with a documented 37-year history of temporal lobe epilepsy who is not aware is described. Fifteen years ago, the patient saw visions of traumatic autobiographical events that he had never previously recalled. He believed them to be veridical memories from his childhood, although evidence from his family suggests that they were not. The patient's psychological reaction to the "recovery" of these traumatic "memories" was severe enough to qualify as posttraumatic stress disorder (PTSD). To our knowledge, this is the first report of PTSD caused by the misattribution of mental states that accompany a seizure.

Performance of patients with epilepsy or psychogenic non-epileptic seizures on four measures of effort.

Exaggeration of cognitive symptoms or poor effort on cognitive testing has been addressed primarily in the traumatic brain injury literature. The present investigation aims to extend the evaluation of effort to the epilepsy monitoring setting, where base rates of failure on effort testing remain unknown for patients with intractable epilepsy (ES), psychogenic nonepileptic seizures (PNES), or both conditions (ES+PNES). In addition, this investigation explores how well four measures of effort (DMT, LMT, TOMM, PDRT) distinguish between these diagnostic groups. Results show that 20% of the combined sample failed one or more effort measure. When examining failure rates for each diagnostic group, 22% of epilepsy patients, 24% of PNES patients, and 11% of ES+PNES patients performed suboptimally on one or more measure of effort. The utility of these effort measures to differentiate between these diagnostic groups appears limited. Further research is needed to clarify the base rate of poor effort in the epilepsy monitoring unit setting in general and in these three diagnostic groups specifically.

A comparison of MMPI-2 decision rules in the diagnosis of nonepileptic seizures.

The differential diagnosis of epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES) continues to be a common concern in epilepsy treatment centers. The MMPI/MMPI-2 is the most commonly studied psychological measure in the differential diagnosis of ES and PNES. Wilkus, Dodrill, and Thompson (1984) and Derry and McLachlan (1996) both developed decision rules for use with the MMPI and MMPI-2 to assist in this diagnostic discrimination. Both sets of decision rules were evaluated in a sample of ES (n=58), PNES ( n=29) and epilepsy plus PNES (n=19) patients. Validity of the epilepsy diagnosis was established with 24-hr video-EEG monitoring in all cases. The two sets of decision rules applied to the MMPI-2 showed sensitivities of 68% and 48% and specificity values of 55% and 58%. Calculation of positive and negative predictive power for both sets of rules at three different base rates suggests that use of these rules can result in a large number of false positive diagnoses of PNES.

A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures.

The diagnosis of psychogenic nonepileptic seizures (PNES) is complex. Long-term electroencephalogram monitoring with video recording (video EEG) is the most common method of differential diagnosis of epilepsy and PNES. However, video EEG is complex, costly, and unavailable in some areas. Thus, alternative diagnostic techniques have been studied in the search for a diagnostic method that is as accurate as video EEG, but more cost effective, convenient, and readily available. This paper reviews the literature regarding possible diagnostic alternatives and organizes findings into 7 areas of study: demographic and medical history variables, seizure semiology, provocative testing, prolactin levels, single photon emission computed tomography, psychological testing, and neuropsychological testing. For each area, the literature is summarized, and conclusions about the accuracy of the technique as a diagnostic tool are drawn. Overall, it appears unlikely that any of the reviewed alternative techniques will replace video EEG monitoring; rather they may be more successful as complementary diagnostic tools. An important focus for further investigations involves combinations of diagnostic techniques for the differential diagnosis of epilepsy and PNES.

Progressive dementia and hypersomnolence with dream-enacting behavior: oneiric dementia.

BACKGROUND: Sleep disorders are associated with several types of degenerative dementias, including Alzheimer and prion diseases. Animal models have demonstrated abolition of rapid eye movement atonia, resulting in dream-enacting complex movements termed oneiric behavior, and patients with fatal familial insomnia may have vivid dreams that intrude on wakefulness. OBJECTIVE: To describe a new form of progressive dementia with hypersomnia and oneiric behavior. METHODS: Neuropsychological and polysomnographic studies of a middle-aged woman with a progressive dementia, excessive daytime sleepiness, and a vertical gaze palsy. RESULTS: Neuropsychological testing revealed decreased verbal fluency, impaired attention and working memory, amnesia, poor recall, and bradyphrenia with hypersomnia. Polysomnography revealed a rapid eye movement behavioral disorder with complete absence of slow wave sleep. Prion protein analysis did not reveal the mutation associated with fatal familial insomnia, and other diagnostic test findings were unrevealing. CONCLUSION: Our patient had a previously unreported syndrome of progressive dementia associated with rapid eye movement behavioral disorder and the absence of slow wave sleep.