Changing the Landscape of Remediation: The Creation and Implementation of an Institution-Wide Graduate Medical Education Performance Enhancement Program.

Purpose Remediation is a daunting process for both residency leadership and trainees due to several factors including limited time and resources, variable processes, and negative stigma. Our objective was to transform the remediation process by creating a transparent institution-wide program that collates tools/resources, interdepartmental faculty mentors, and positive rebranding. Methods Education leadership across seven specialties created a process for trainees with professionalism and interpersonal-communication skills deficiencies. Formalized departmental program-based improvement plan (PIP) and an institutional house staff performance enhancement plan (HPEP) were developed by consensus of triggers/behaviors. Utilizing published literature, a toolkit was created and implemented. Trainees were enrolled in HPEP if PIP was unsuccessful or exhibited ≥1 major trigger. Wellness evaluations were incorporated into the process to screen for external contributing factors. Surveys were sent to the program director (PD), faculty mentor, and trainee one month and six months after participation. Results Between 2018 and 2021, 12 trainees were enrolled. Overall feedback from PDs and the trainees was positive. The main challenge was finding mutual time for the faculty mentor and trainee to meet. Six-month surveys reported no relapses in unprofessionalism. One-year follow-up of the trainees was limited. Conclusions Utilizing an institution-wide standardized process of performance improvement with the removal of negative stereotyping is a unique approach to remediation. Initial feedback is promising, and future outcome data are necessary to assess the utility. The HPEP may be adopted by other academic institutions and may shift the attitudes about remediation and allow trainees to see the process as an opportunity for professional growth.

Severe Epistaxis after Tissue Plasminogen Activator administration for Acute Ischemic Stroke in SARS-COV-2 Infection.

Patients with COVID-19 may suffer from hemorrhagic complications. Our article highlights two cases of COVID-19-infected patients, who suffered severe epistaxis after initiation of intravenous recombinant tissue plasminogen activator (IV-rtPA) for acute ischemic stroke, followed by a sudden decline in their clinical status and ultimately leading to death within days. Given the global impact and mortality of COVID-19, it is essential to be aware of its unusual presentation and improve therapeutic strategies. We present two cases of individuals who suffered from a large vessel occlusion of and were candidates for both IV-rtPA and mechanical thrombectomy. They received IV-rtPA but had epistaxis so severe that they were not able to receive MT and died within the next few days. There are many potential mechanisms by which epistaxis can happen in an individual with COVID-19 who received IV-rtPA including invasion of the nasal mucosa and endothelium through angiotensin-converting enzyme 2 receptors by the virus. We also hypothesize that the coagulation abnormality seen in COVID-19 patients can be potentiated by the use of treatments such as IV-rtPA. We review these issues with a diagram illustrating the possible mechanisms.

Comparison of State Medical Licensing Board Disclosures Regarding Resident Performance for United States Allopathic, Osteopathic, and Foreign Medical Graduates.

CONTEXT: While recent streamlining of the graduate medical education process signals an important change from the traditional dichotomy between doctors of osteopathic medicine (DOs) and US-trained doctors of medicine (USMDs), this new uniformity does not continue into the process for licensure, including state medical licensing verification of training (VOT) forms for DOs, MDs, and foreign medical graduates (FMGs). Wide variability remains. OBJECTIVE: To document the differences in the performance metrics program that directors are required to disclose to state medical licensing boards for DOs and FMGs compared with USMDs. METHODS: VOT forms were collected from all osteopathic and allopathic licensing boards for all US states, Washington DC, and US territories. The authors then reviewed VOT forms for questions pertaining to trainee performance only in states where VOT forms differed for DOs, USMDs, and FMGs. Licensing board questions were categorized as relating to disciplinary action, documents placed on file, resident actions, and nondisciplinary actions by the program. RESULTS: Fifty-six states and territories were included in the study (50 US states; Washington, DC; and 5 US territories). Most states and territories (46; 82.1%) used the same VOT form for DOs and USMDs. All states and territories except New York used the same form for FMGs and USMDs (55; 98.2%). Of the 14 states with an osteopathic board, Nevada used Federation Credentials Verification Service (FCVS) for DOs only, and 8 states used a unique osteopathic VOT form. Of these 8 osteopathic boards, 3 VOT forms did not ask any questions regarding resident performance during training. Of the remaining 5 forms, all asked about disciplinary actions. Ten states and 1 territory (US Virgin Islands) required the FCVS for both USMDs and FMGs, but not for DOs, while New York required FCVS only for FMGs. Nevada required FCVS only for DOs. CONCLUSION: Although VOT requirements for FMGs and USMDs were mostly the same within states, performance metric question sets varied greatly from state to state and within states for osteopathic vs allopathic licensing boards. Implementation of a standardized VOT form for all applicants that includes academic performance metrics may help ensure that medical licensure is granted to all physicians who demonstrate academic competency during training, regardless of their degree.

Stroke in COVID-19: a single-centre initial experience in a hotspot of the pandemic.

BACKGROUND: COVID-19, caused by SARS-CoV-2, is a global pandemic that has been an immense burden on healthcare systems all over the world. These patients may be at higher risk for acute ischaemic stroke (AIS). We present our experience with AIS in patients with COVID-19. METHODS: We reviewed all patients admitted to our hospital during a 6-week period with a positive nasopharyngeal swab test for SARS-CoV-2. Among these patients, we identified AIS. We reviewed the demographics, clinical, laboratory, imaging characteristics, treatments received and outcomes of AIS in patients with COVID-19. RESULTS: We identified 683 patients admitted with COVID-19 during the study period, of which 20 patients had AIS. Large-vessel occlusion (LVO) was noted in 11 patients (55%). Intravenous alteplase was administered in four patients (20%) and mechanical thrombectomy was performed in five patients (25%). Respiratory symptoms preceded the onset of AIS in most of the patients (70%) by 1 to 21 days. Mortality in patients with AIS was 50% compared with 26% of all COVID-19 admissions. Most of these patients died due to non-neurological causes (70%). Three patients with AIS had clinical and imaging findings consistent with COVID-19, but were negative for multiple nasopharyngeal swab tests. INTERPRETATION: LVO was more common in patients with AIS and COVID-19. They had more severe disease and higher mortality rates. Most of the patients had respiratory symptoms preceding AIS by days to weeks. This could explain certain patients with clinical picture of COVID-19 but negative nasopharyngeal swab tests.

Minimally invasive trigeminal ablation in patients with refractory trigeminal neuralgia who are ineligible for intracranial intervention.

We describe the use of minimally invasive trigeminal ablation, an endoscopic ablative technique to treat trigeminal neuralgia in patients who are traditionally poor surgical candidates. We present 4 patients who presented with refractory unilateral trigeminal neuralgia. Three of the patients had previously failed stereotactic radiosurgery and three of them have multiple sclerosis. Due either to lack of neurovascular compression, minimally invasive trigeminal ablation was offered. Intraoperatively, an incision is made along the buccal mucosa or mid-brow and the tissue is endoscopically dissected in a plane towards the symptomatic nerve. Once isolated, the epineurium is partially ablated with thermocautery and the tissue surrounding the nerve is decompressed. All patients reported resolution of their pain post-operatively and were pain free at last follow up. Two patients had mild hypesthesia over the ablated nerve territory. Minimally invasive trigeminal ablation is a safe and effective technique for symptomatic control of trigeminal neuralgia. The efficacy, low risk, and relative ease of the procedure makes it ideal for use in patients who are refractory to medical management and have no neurovascular compression, are unable to tolerate traditional surgery or have failed other therapies.

Mandated State Medical Licensing Board Disclosures Regarding Resident Performance.

BACKGROUND: State medical licensing boards ask program directors (PDs) to complete verification of training (VOT) forms for licensure. While residency programs use Accreditation Council for Graduate Medical Education core competencies, there is no uniform process or set of metrics that licensing boards use to ascertain if academic competency was achieved. OBJECTIVE: We determined the performance metrics PDs are required to disclose on state licensing VOT forms. METHODS: VOT forms for allopathic medical licensing boards for all 50 states, Washington, DC, and 5 US territories were obtained via online search and reviewed. Questions were categorized by disciplinary action (investigated, disciplined, placed on probation, expelled, terminated); documents placed on file; resident actions (leave of absence, request for transfer, unexcused absences); and non-disciplinary actions (remediation, partial or no credit, non-renewal, non-promotion, extra training required). Three individuals reviewed all forms independently, compared results, and jointly resolved discrepancies. A fourth independent reviewer confirmed all results. RESULTS: Most states and territories (45 of 56) accept the Federation Credentials Verification Service (FCVS), but 33 states have their own VOT forms. Ten states require FCVS use. Most states ask questions regarding probation (43), disciplinary action (41), and investigation (37). Thirty-four states and territories ask about documents placed on file, 36 ask about resident actions, and 7 ask about non-disciplinary actions. Eight states' VOT forms ask no questions regarding resident performance. CONCLUSIONS: Among the states and territories, there is great variability in VOT forms required for allopathic physicians. These forms focus on disciplinary actions and do not ask questions PDs use to assess resident performance.

Validation of ICH score in a large urban population.

OBJECTIVES: Hemorrhagic stroke cause around 10-20% of all strokes. ICH (Intracerebral Hemorrhage) score is a grading scale used to determine survival outcome after nontraumatic ICH at 30 days. It is a 6-point scale based on 5 independent variables, which are graded based on the weight of their association. These 5 variables are the Glasgow coma scale (GCS), ICH Volume, Intraventricular hemorrhage (IVH), Infratentorial origin and age. The aim of our study is to validate the ICH score in our population. MATERIALS AND METHODS: We conducted a retrospective chart review of 245 adult patients who presented with acute ICH to University Hospital, Newark between 1/1/2012 to 12/30/2015. GCS recorded in Emergency Department was used. Initial Computed tomography (CT) Head was used for calculating volume, IVH, and location origin, while ICH Volume was calculated using the ABC/2 method. The primary outcome was 30-day mortality. Patients with a hemorrhagic transformation of ischemic strokes or traumatic ICH were excluded. RESULTS: 245 patients met our inclusion criteria. 30-day mortality was 36%. ICH scores ranged from 0 to 5, and an increase in the ICH score was associated with an increase in 30-day mortality. 4 variables in the ICH score had a significant association with 30-day mortality: ICH Volume ≥30 ml (OR, 17.24; 95% CI, 8.33-35.66; P < 0.001), IVH (OR, 6.91; 95% CI, 3.72-12.85; P < 0.001), low GCS (P < 0.001) and infratentorial origin of bleed significant (OR, 2.17; 95% CI, 1.07-4.40; P 0.039). However, the association of age ≥ 80 years with respect to 30-day mortality wasn't statistically significant in our group (OR, 1.49; 95% CI, 0.70-3.17; P 0.325). CONCLUSIONS: Our study is one of the largest done at a single urban center to validate the ICH score. Age ≥ 80 years wasn't statistically significant with respect to 30-day mortality in our group. Restratification of the weight of individual variable in the ICH equation with modification of the ICH score can potentially more accurately establish mortality risk. Nevertheless, the overall prediction of mortality was accurate and reproducible in our study.

Long-Term Impact of Implementation of a Stroke Protocol on Door-to-Needle Time in the Administration of Intravenous Tissue Plasminogen Activator.

BACKGROUND: This study aims to evaluate the effectiveness of implementing a stroke protocol (SP) in improving door-to-needle time (DTNT) and door-to-computed tomography (DTCT) time from 2010 to 2014. Published data from the Get With The Guidelines-Stroke (GWTGS) participating hospitals showed that median DTNT = 75 minutes with 26.6% of the patients achieving the recommended DTNT of 60 minutes or less. Implementation of an SP, which specifies the role of nurses, physicians, and technicians during acute stroke evaluation, can improve DTNT. METHODS: This longitudinal quality assurance study was designed to compare the DTNT and the DTCT time pre- and post implementation of an SP in our hospital. Patients' data before (2009-2010) and after (2010-2014) the implementation of an SP were collected each year during the same 6-month period and compared using statistical software SPSS 20.0 for Windows (SPSS Inc., Chicago, IL). RESULTS: Although our DTNT did not significantly improve over the years, the median DTNT (59 minutes) was much less than the reported 75 minutes of GWTGS hospitals. Our DTCT time diminished from 20.6 minutes in 2009 to 15.9 minutes in 2014. The percentage of patients with a DTNT of 1 hour or less did not differ among all years (P = .296) and was 55.8%. CONCLUSIONS: Our study suggests that our performance in evaluating acute ischemic stroke patients within the American Heart Association/American Stroke Association suggested time window is reachable for prolonged periods of time. Continuous monitoring and education of all players involved are crucial to ensure best possible outcomes in the timely administration of intravenous tissue plasminogen activator.

Comparison of neurological healthcare oriented educational resources for patients on the internet.

The internet has become a major contributor to health literacy promotion. The average American reads at 7th-8th grade level and it is recommended to write patient education materials at or below 6th grade reading level. We tried to assess the level of literacy required to read and understand online patient education materials (OPEM) for neurological diseases from various internet resources. We then compared those to an assumed reference OPEM source, namely the patient education brochures from the American Academy of Neurology (AAN), the world's largest professional association of neurologists. Disease specific patient education brochures were downloaded from the AAN website. OPEM for these diseases were also accessed from other common online sources determined using a predefined criterion. All OPEM were converted to Microsoft Word (Microsoft Corp., Redmond, WA, USA) and their reading level was analyzed using Readability Studio Professional Edition version 2012.1 (Oleander Software, Vandalia, OH, USA). Descriptive analysis and analysis of variance were used to compare reading levels of OPEM from different resources. Medline Plus, Mayo clinic and Wikipedia qualified for OPEM analysis. All OPEM from these resources, including the AAN, were written above the recommended 6th grade reading level. They were also found to be "fairly difficult", "difficult" or "confusing" on the Flesch Reading Ease scale. AAN OPEM on average needed lower reading level, with Wikipedia OPEM being significantly (p<0.01) more difficult to read compared to the other three resources. OPEM on neurological diseases are being written at a level of reading complexity higher than the average American and the recommended reading levels. This may be undermining the utility of these resources.

A second case of Marburg's variant of multiple sclerosis with vasculitis and extensive demyelination.

Marburg's variant of multiple sclerosis is a rapidly progressive and malignant form of multiple sclerosis (MS) that usually leads to severe disability or death within weeks to months without remission. Few cases have been described in the literature since the original description by Marburg. The classic pathological findings usually include highly destructive zones of extensive demyelination, necrosis with dense cellular infiltrate, and giant reactive astrocytes. We report a case of a 31-year-old woman with Marburg's variant of MS who, over a period of eight months, became totally disabled, blind, and quadriplegic, with vocal cord paralysis, requiring a tracheostomy. The patient underwent diagnostic stereotactic brain biopsy. Clinical findings, magnetic resonance imaging (MRI), serologic and cerebrospinal fluid (CSF) findings, and neuropathology are discussed. MRI showed extensive white matter involvement in the brain and spinal cord that continuously progressed over time. A diagnostic stereotactic brain biopsy revealed extensive active demyelination with unexpected finding of active vasculitis and fibrinoid necrosis with a vascular inflammatory cell infiltrate, including polymorphonuclear neutrophils and rare eosinophils. Serologic work-up for vasculitis and neuromyelitis optica was unremarkable and the CSF showed only one oligoclonal band (OCB) not present in serum. This is the second case of Marburg's variant of MS that demonstrated both demyelination and vasculitis. In our case these features were demonstrated simultaneously, even though the demyelination was the predominant pathological finding. Since vasculitis is not a feature of classic MS, these findings pose the question as to whether Marburg's variant of MS is a true variant or different entity altogether.