A survey of neurologists' views on epilepsy surgery and medically refractory epilepsy.

There is a 20-year delay between the diagnosis of epilepsy and surgical treatment. The aim of this study was to describe the different views held by neurologists regarding refractory epilepsy that may contribute to the delay in referring patients for epilepsy surgery. Neurologists in Michigan were mailed a 10-item survey inquiring about their definition of medically refractory epilepsy and their decision-making process in referring patients for epilepsy surgery. Eighty-four neurologists responded (20%). The majority defined medically refractory epilepsy as failure of three monotherapy antiepileptic drug (AEDs) trials and at least two polytherapy trials. Nineteen percent responded that all approved AEDs had to fail before a patient could be defined as medically refractory. Eighty-two percent of the respondents had referred patients for epilepsy surgery. Almost 50% were not satisfied with the level of communication from epilepsy centers. One-third reported serious complications resulting from surgery. These findings suggest that further education and improved communication from comprehensive epilepsy centers may shorten the time to referral and ultimately improve the lives of patients with epilepsy.

Invited article: Neurology education research.

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.

Neurology resident learning in an end-of-life/palliative care course.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires neurology residents receive instruction in End-of-Life Care/Palliative Care (EOLPC), but survey data from 24 neurology programs in the National Residency End-of-Life Physician Education Project (NRELEP) demonstrated faculty and residents tend to rate themselves as able to perform EOLPC despite significant knowledge gaps. We participated in the NRELEP to develop an EOLPC course and assess resident learning following this new curriculum. METHODS: Fifteen residents and 8 nonparticipant faculty completed a content validated knowledge pretest and precourse EOLPC confidence self-assessment tool. The course plan developed during a NRELEP conference consisted of 14 weekly 1-hour sessions covering a variety of topics pertinent to EOLPC care in neurology. Sessions included lectures, role-play, and group problem-solving formats. Residents attended sessions while faculty did not. The postcourse assessment included a posttest and the EOLPC self-assessment, and was completed by 14 residents and 5 comparison faculty. RESULTS: The mean pretest score was 48.1% +/- 16.9% for residents and 59.0% +/-8.2% for faculty. Posttest scores improved to 67.2% +/- 10.6% for residents (t test, p +/- 0.001), but not for the faculty group (52.4% +/- 9.9%, p = 0.2). Resident EOLPC confidence self-assessment significantly improved after the course (precourse mean, 3.09 +/- 1.01; postcourse mean, 3.40 +/- 0.93, p < 0.001), while there was no change in faculty confidence (precourse mean, 3.48 +/- 0.82; postcourse mean, 3.41 +/- 0.82, p = 0.5). Residents performed significantly better than faculty on the posttest (p = 0.01). CONCLUSIONS: An EOLPC course was developed and implemented in this program. Residents exhibited demonstrable learning and improved self-assessment of confidence in providing EOLPC following introduction of the course.

Initiation of an effective neurology resident ethics curriculum.

The authors' neurology residency program used a case-based curriculum developed by the American Academy of Neurology's Ethics, Law and Humanities Committee to provide a resident education course in ethics. A pretest and post-test were developed and administered. A survey was completed at the end of the course to evaluate resident satisfaction. Post-test scores improved an average of 19% and this increase was significant (p < 0.0004). Residents found the course useful for their education and the time commitment acceptable.

Quality estimation of subdurally recorded, event-related potentials based on signal-to-noise ratio.

Our goal is to develop a direct brain interface (DBI) that will provide communication and environmental control to persons who are "locked-in" (or nearly so) as a consequence of brainstem stroke, amyotrophic lateral sclerosis (ALS), or other etiologies. Previously we demonstrated that templates constructed from trigger averaged event-related potentials (ERPs) can be cross-correlated with ongoing electrocorticograms (ECoGs) to detect ERPs associated with the performance of simple motor actions. However, it was difficult to predict a priori which of many candidate ECoG recording site(s) could provide signals that would provide adequate motor action detection. We present here a measure of ERP quality based on an estimate of the signal to noise ratio (SNR) associated with the formation of an ERP template from the performance of consecutive voluntary actions. Detection-theory-based receiver operator characteristics (ROCs) and a database of ECoGs (6000+) recorded from the cortical surface of awake human subjects were used to assess the usefulness of the SNR technique. The SNR method was found to predict the detection efficacy of ERPs when characterized over a wide parameter range, with the majority of ROC curve areas greater than 90%. This method was compared with our previously developed quality measure (the peak-to-baseline ratio) and found to provide significantly better performance (ROC area differences from 4.4% to 13.7%). Thus, the SNR estimate of the ERP is a useful tool to predict the efficacy of ERP templates for cross-correlation-based detection and assist in the selection of viable ERP templates for DBI applications.