Promoting Careers in Neurology: Mentorship of Medical Students.

Research in neurological disorders is expanding at a phenomenal pace, and the need for neurologists is increasing as the population ages. This results in a critical requirement for medical students entering the neurology pipeline. Mentoring, whether formal or informal, ensures that students are inspired and supported to enter the field of neurology. Students should also receive structured mentoring throughout their longitudinal curriculum. Informal mentoring programs enable expanded opportunities for collaborations in education, research, and outreach. Faculty, residents, fellow medical students, and other health professionals all participate in medical student mentoring. Each relationship offers unique aspects to individual growth and development. Specific programmatic guidance and mentoring qualities are presented in this paper.

Alcohol use and hospital readmissions following stroke: A safety net hospital experience.

OBJECTIVE: The purpose of this study is to identify predictors of stroke-related readmissions at 30days on a safety net hospital level and suggest interventions to reduce the number of readmissions. BACKGROUND: Hospital readmissions are an important measure of the quality of health care services. Readmissions indicate unresolved problems from the index admission, inadequate post-hospitalization care, or a mixture of these factors. Additionally, hospital readmissions are associated with a substantial economic burden on the health care system. The study's purpose is to identify predictors of stroke-related readmissions within 30days on a hospital level and suggest interventions to reduce the number of readmissions. METHODS: We conducted a single-center retrospective study of patients admitted to Boston Medical Center (BMC) and diagnosed with ischemic and hemorrhagic stroke. Unadjusted and adjusted logistic regressions were used to evaluate possible predictors of stroke related readmissions. RESULTS: Of 352 patients admitted with a diagnosis of ischemic or hemorrhagic stroke at BMC during the study period, 44 (12.5%) patients were readmitted to BMC within 30days. Current alcohol abuse was significantly associated with readmission (OR 95% CI 1.03-5.62). Discharge against medical advice was also associated, though the sample size was small. CONCLUSIONS: These results suggest that early inpatient and post-hospitalization interventions to address alcohol abuse during the index hospital admission may reduce the rate of hospital readmission within 30days. The results have prompted interventions on the stroke service such as early inpatient social work and addiction medicine involvement for patients with risk factors of alcohol abuse.

Cefepime induced neurotoxicity: A case series and review of the literature.

Cefepime is a fourth generation cephalosporin which is bactericidal for broad spectrum of organisms. This is a case-series of three patients who presented to our hospital with confusion secondary to cefepime use to treat urinary tract infection (UTI) and health care associated pneumonia (HCAP), after excluding other common etiologies of altered mental status (AMS). Of these three patients, one had progressive expressive aphasia and the other two demonstrated asynchronous myoclonic activity of the limbs. The symptoms were seen within four to five days of initiating the treatment and resolved within three days of discontinuation of cefepime. Acute structural abnormalities were excluded by computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. Electroencephalogram (EEG) showed diffuse slowing activity with triphasic waves consistent with encephalopathy. In one patient, renal function was within normal limits, whereas it was abnormal in two patients. To our knowledge, this is the first report of cefepime induced asynchronous myoclonus and expressive aphasia in a patient with normal kidney function.

A survey based study on sleep disturbance in postural tachycardia syndrome.

BACKGROUND: Postural tachycardia syndrome (POTS) is an autonomic disturbance characterized by an excessive increase in heart rate when an individual moves from a sitting to an upright position. POTS patients often complain of fatigue, daytime sleepiness and insomnia, but there is limited evidence to elucidate the mechanism or the prevalence of sleep-related symptoms in POTS, as well as the effect on patient quality of life. Here, we investigated the prevalence of sleep disturbances in POTS patients, as well as the use of medication and effects on daily life. METHODS: A survey was administered to 30 patients with POTS. The survey contained 22 questions on various characteristics of sleep disturbances in POTS. Answers were recorded on a five-point Likert rating scale. RESULTS: The majority of the patients reported fatigue (96.7%) and low energy (93.3%) during the day. Most (83.3%) patients reported that they do not feel well rested when waking up in the morning. More than half of the patients reported trouble falling asleep at night (63.3%) and maintaining sleep through the night (62.1%). Despite the frequent complaint of sleep disturbance, a very low percentage of POTS patient actually report seeking treatment. CONCLUSION: In this study, we explored the prevalence of sleep disturbance in patients with POTS. Almost all POTS patients reported trouble with sleep and fatigue; however, there is major discrepancy between the high percentage of symptoms and small percentage of patients seeking medical assistance for better sleep quality.

Gastrointestinal dysfunction in postural tachycardia syndrome.

BACKGROUND: Postural tachycardia syndrome (POTS) is a dysautonomia defined by an exaggerated increase in heart rate upon changing posture. It is associated with disturbances involving multiple organ systems, including neurologic, dermatologic, and gastrointestinal (GI) symptoms. Previous studies identified GI complaints in these patients and showed gastric emptying and electrical activity abnormalities. However, the full spectrum of GI symptoms and their impact on quality of life remains unclear. METHODS: A 30-question survey of GI symptoms was collected from 28 patients with POTS seen in the Boston Medical Center Autonomic Clinic. Answers were recorded on a Likert rating scale. Symptoms were positive if patients answered "strongly agree" or "agree" and negative if they answered "strongly disagree" or "disagree." Responses were collected and analyzed. RESULTS: The most commonly reported GI symptoms were nausea (86%), irregular bowel movements (71%), abdominal pain (70%), and constipation (70%). Additionally, 82% of patients reported having GI symptoms more than once per week, and 71% reported having seen a GI specialist, and symptoms did not improve with changes in position. Twelve patients had undergone a gastric emptying study, and six of these patients reported receiving a diagnosis of gastroparesis or delayed gastric emptying. CONCLUSIONS: GI disturbances are common, frequent, and prolonged in patients with POTS, likely impacting quality of life. Given the importance of the enteric nervous system to normal GI functioning, the same autonomic impairment leading to POTS may result in abnormal gut motility and ultimately subjective GI discomfort.

The Dermatological Manifestations of Postural Tachycardia Syndrome: A Review with Illustrated Cases.

Postural tachycardia syndrome (POTS) is a syndrome of excessive tachycardia with orthostatic challenge, and relief of such symptoms with recumbence. There are several proposed subtypes of the syndrome, each with unique pathophysiology. Numerous symptoms such as excessive tachycardia, lightheadedness, blurry vision, weakness, fatigue, palpitations, chest pain, and tremulousness are associated with orthostatic intolerance. Other co-morbid conditions associated with POTS are not clearly attributable to orthostatic intolerance. These include chronic headache, fibromyalgia, functional gastrointestinal or bladder disorders, cognitive impairment, and sleep disturbances. Dermatological manifestations of POTS are also common and wide ranging, from livedo reticularis to Raynaud's phenomenon, from cutaneous flushing to erythromelalgia. Here, we provide three illustrative cases of POTS with dermatological manifestations. We discuss the potential pathophysiology underlying such dermatological manifestations, and how such mechanisms could in turn help guide development of management.

A survey-based analysis of symptoms in patients with postural orthostatic tachycardia syndrome.

Postural orthostatic tachycardia syndrome (POTS) is a type of dysautonomia seen most commonly in young women and children. It is defined as an increase in heart rate of 30 beats per minute (bpm) or more within 10 minutes of standing in adults, or by 40 bpm or more in children in the absence of orthostatic hypotension. In addition to typical autonomic symptoms, POTS patients report a wide range of subjective complaints in multiple organ systems, though the exact frequencies are unclear. To address the symptom frequency, we had 39 patients with POTS at our institution complete an intake form consisting of a list of 37 symptoms. The most frequently reported symptoms included palpitations, lightheadedness, and headache, although sleep disturbances, gastrointestinal complaints, sensitivity to temperature, and rash were also common.

Ehlers-Danlos Syndrome and Postural Tachycardia Syndrome: a relationship study.

OBJECTIVE: This study examines a possible relationship between Ehlers-Danlos Syndrome (EDS) and Postural Tachycardia Syndrome (POTS). DESIGN/METHODS: We retrospectively reviewed 109 medical records of patients suffering from autonomic dysfunction exhibiting at least one POTS symptom from one urban clinic for EDS and POTS diagnoses between 2006 and 2013. The presence of EDS within the POTS and non-POTS populations was calculated and compared to that of the general population. RESULTS: The review revealed 39 (36F:3M) patients with POTS (mean ± SD age, 32.5 ± 11.8 years) with 7 cases of EDS yielding a prevalence of 18% (95% exact CI: 8%, 34%), a statistically significant difference from the suggested prevalence of EDS in the general population of 0.02% (p<0.0001). 70 patients (53F:17M) without POTS (mean ± SD age, 51.1 ± 14.7 years) contained 3 cases of EDS, yielding a prevalence of 4% (95% exact CI: 1%, 12%), a statistically significant difference from the general population (p<0.0001). The prevalence of EDS was significantly higher in the POTS group compared to the non-POTS group (p=0.0329). The odds ratio comparing the odds of EDS for POTS versus non-POTS patients is 4.9 (95% CI: 1.2, 20.1). CONCLUSION: The presence of EDS may be significantly higher in patients with POTS than that of the general population and in autonomic patients without POTS. We suspect an additional underlying mechanism of POTS caused by EDS.

Evaluating exposure to abuse and violence in neurological patients.

OBJECTIVE: The relationship between abuse and violence and the care of neurological patients is an important topic not often addressed, and studies suggest that most neurologists do not routinely screen patients for abuse. In this pilot study, our aim was to demonstrate a simple and effective strategy for screening patients for exposure to abuse. METHODS: A total of 103 consecutive patients reporting to an academic neurology clinic specializing in autonomic and movement disorders were screened for a history of abuse and violence. A set of 6 questions were included in the standard patient intake questionnaire. The questions were then repeated verbally during the physician history taking. All patients were provided with information on available local resources for abuse counseling during the visit. Retrospective chart review analysis was performed to determine the prevalence of history of abuse in the population, the most common type of abuse suffered, and the number of individuals reporting current abuse. RESULTS: Twenty-two of the 103 patients (21%) screened for abuse reported exposure to abuse or violence. Two patients with ongoing issues with abuse were identified. The most commonly reported abuse was being a witness to violence (65%), followed by physical abuse (41%), sexual and emotional abuse (36% each), and financial abuse (23%). The neurological disorders most frequently observed in these patients were chronic pain, neuropathy, autonomic dysfunction, headache, and Parkinson disease. CONCLUSIONS: Patients with neurological disorders may have been exposed to abuse and violence. It is important to recognize these issues and address them routinely in the neurological evaluation. A simple, effective way to accomplish screening in the outpatient setting is through the use of an intake questionnaire combined with verbal clarification.

The role of the neurologist in cases of abuse and neglect.

OBJECTIVE: The objective of this article is to define abuse and neglect and underscore the importance of their assessment in the practice of neurology. REVIEW STUDY: This review outlines the medical and psychologic consequences of abuse and neglect and their impact on individuals and family units. It highlights specific neurologic repercussions of abuse and neglect and provides clinical scenarios that a neurologist may encounter. CONCLUSIONS: Abuse and neglect impact neurology patients. By assessing and referring our patients to the appropriate resources, we may improve their outcomes and help to break the cycle of abuse.