Search

Cerebral atrophy is a common finding in elderly patients; however, cerebrovascular disease causing progressive focal cerebral atrophy and dysfunction is unusual. In this report, we present 3 cases of hemicerebral atrophy due to ipsilateral internal carotid artery (ICA) stenosis or occlusion mimicking neurodegenerative conditions. Patient 1 had a frontal dysexecutive syndrome potentially consistent with a diagnosis of behavioral variant frontotemporal dementia; however, neuroimaging revealed a chronically occluded left ICA and a pattern of atrophy restricted to the left middle cerebral artery territory, suggestive of a vascular etiology. Patient 2 presented with progressively worsening seizures and right-sided weakness consistent with left hemispheric dysfunction, with radiographic evidence of left hemicerebral atrophy. Angiography revealed a chronic dissection of the left ICA leading to left cerebral hypoperfusion. Patient 3 had asymmetric parkinsonism, alien limb, and cognitive impairment consistent with a diagnosis of corticobasal syndrome. His imaging, however, revealed atrophy and encephalomalacia within the anterior circulation watershed territories with chronic, severe stenosis of the left ICA suggestive of a chronic hypoperfused state. In this case series, we report 3 examples of hemicerebral atrophy secondary to chronic ipsilateral ICA vascular disease with diverse progressive clinical symptoms mimicking primary neurodegenerative conditions. This case series highlights the importance of considering chronic hypoperfusion and large-vessel severe stenosis or occlusion in patients with cognitive impairment and evidence of asymmetric brain atrophy. In addition to symptomatic treatment, the management of vascular risk factors including treatment with antiplatelet agents, statins, and revascularization procedures can be considered.

Background Despite increasing awareness of inequities in healthcare in neurology, health equity is not a core competency of neurology training. To meet this need, we implemented a health equities curriculum for neurology residents at the Hospital of the University of Pennsylvania. Methods A seven-lecture health equities curriculum was implemented during the 2019-2020 academic year. Surveys were distributed pre-and post-curriculum to assess resident demographics, previous training in health equities, curriculum effectiveness addressing health equities topics, and resident appraisal of the curriculum. Results On average, residents attended 2-3 lectures. Most of the residents who participated were White-Non Latinx women. Residents who did not participate in the curriculum listed clinical responsibilities as the main reason for absenteeism. Residents who participated felt the curriculum was at least somewhat effective in addressing health disparities, cultural competency, and implicit bias. 64% of the residents felt the curriculum was effective in improving their preparedness in caring for underserved patients. Conclusion Implementing a health equities curriculum in neurology residency programs is feasible and well-received by residents. Given inconsistent attendance and a small sample size, we are unable to assess its true effectiveness. Nonetheless, residents felt it prepared them in addressing disparities in neurological care. A longer curriculum will help in assessing the effectiveness of this curriculum intervention. A standard health equities curriculum should be implemented across neurology residency programs, and health equities should be considered a core competency topic for the American Board of Psychiatry and Neurology (ABPN) certification.

A 45-year-old woman presented with lower-extremity weakness. She first noted weakness in her ankles and feet 5 months previously. The weakness progressed to involve her knees and hips, and she had been unable to walk without support for the prior 2 months.

BACKGROUND Nonemergent communications between nursing staff and residents often occur randomly throughout the workday at teaching institutions, resulting in inefficiency and interruptions of scheduled resident educational conferences or periods of overnight rest. OBJECTIVE The aim of this study was to determine whether a quality improvement communication strategy can reduce interruptive notifications during scheduled resident didactic sessions. METHODS We conducted a prospective, mixed-methods trial of a communication strategy between nurses and residents in 3 neurology units of an academic institution. We measured content and volume of notifications from nurses to residents during scheduled conferences and overnight and categorized these notifications according to levels of urgency. We implemented an intervention requiring multidisciplinary evening work rounds between the on-call resident and charge nurse and batching of nonemergent communications. Survey data were collected. RESULTS The total census during the 6-month study period was 728 patients. Of the 704 resident-reported nursing notifications, 50% could be safely deferred until change of shift. After the intervention, there was a 52% decrement of notifications (0.52 vs 0.25 notifications per patient, P < .01). The preintervention survey response rate was 65% for nurses (46/71) and 100% for residents (26/26), whereas postintervention response rates were 51% for nurses (36/71) and 96% for residents (24/25). Both nurses and residents responded more favorable in the postintervention period across multiple items that addressed patient safety, utility, and satisfaction (P < .01 for comparisons). CONCLUSIONS A scheduled nurse-resident communication system reduced interruptive calls during educational conferences and overnight by half. This intervention was perceived as safe and effective and resulted in higher satisfaction among participants.

Background: Non-emergent communications between nursing staff and covering providers often occur randomly throughout the workday at teaching institutions, resulting in inefficiency and interruptions of scheduled resident educational conferences or periods of overnight rest. Methods: We conducted a prospective, mixed-methods, crossover trial of a communication strategy between nurses and residents in 3 neurology units of a single academic institution. We measured content and volume of notifications from nurses to residents during scheduled conferences and overnight, and categorized these notifications according to levels of urgency. We implemented an intervention requiring evening work rounds between the on-call provider and charge nurse, and batching of non-emergent communications. Survey data were collected to determine perceived safety, utility, and satisfaction of the intervention. Results: The total census during the 6-month study period was 728 patients with a mean case-mix index of 1.86 (indicating moderate disease complexity). Of the total 704 provider-reported nursing notifications, there was a 56.3% decrement of notifications in the post-intervention period. Of the total 299 nurse-reported notifications, there was a 46.9% decrement in the post-intervention period. Both nurses and residents provided more favorable survey responses in the post-intervention period across multiple items that addressed patient safety, utility, and satisfaction (p Conclusions: A scheduled nurse-resident communication system reduced interruptive calls during educational conferences and overnight by half. This intervention was safe, effective, and resulted in higher satisfaction among nurses and residents.

On average, 4 clinical questions arise per patient encounter1 and about half the time, information needs are left unresolved.2 There is significant interest in capturing, sharing, and using knowledge within the daily work of health professionals in order to improve health outcomes. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act offers up to $27 billion over 10 years to providers demonstrating “meaningful use” of electronic health records (EHRs).3 “Meaningful use” implies more than just recording information; use of the EHR should improve patient care.

SECTION 1 Case presentation. A 59-year-old woman with a history of hypertension developed acute bilateral flaccid leg weakness while watching television. She had shifted her weight while sitting on the couch and suddenly felt a sharp pain in her lower back and right leg. When she stood up to walk she noticed that her legs were numb; over the course of 1 hour she became unable to move her legs. She could not urinate voluntarily, and had dribbling incontinence. She was brought to the emergency department for evaluation. Questions for consideration: 1. Where does acute paraplegia localize and what is the differential diagnosis?

Objective: Effective stroke care does not end with acute treatment during hospitalization, but extends through Objective: Effective stroke care does not end with acute treatment during hospitalization, but extends through rehabilitation and secondary stroke prevention. In transitions across care environments, stroke patients are vulnerable to errors in communication of diagnosis and treatment. This study aimed to demonstrate that formalized communication between the neurology team and the rehabilitation medicine team would promote secondary stroke prevention and minimize interruptions during rehabilitation. Methods: The intervention was a standardized verbal handoff by phone between the discharging neurology resident and the admitting rehabilitation resident regarding each patient at transfer. This retrospective cohort study compared a pre-intervention control group (September 2012- February 2013) and a post-intervention group transferred with the handoff (September 2013- January 2014). The outcomes measured included errors in communication of stroke severity, stroke mechanism, medications, and recommended follow-up (appointments and tests) as well as emergent brain imaging, return to the acute care facility, and readmission. Results: The pre- and post-intervention groups were similar with respect to number of patients (50 vs. 52) and demographics including gender (52% vs. 54% female), age (65.8 vs. 64.0 years), severity of illness as measured by the NIHSS (10 vs. 6.5), and stroke type (84% vs. 77% ischemic). Implementation of the handoff decreased errors in communication of diagnosis (NIHSS 92% vs. 74%, p=0.02; stroke mechanism 54% vs. 30%, p=0.02). Furthermore, the handoff decreased the proportion with errors in reconciliation of critical medications (42% vs. 23%, p=0.04). However, the intervention did not significantly reduce interruptions of the rehabilitation program, such as emergent brain imaging (8% vs. 12%, p=0.55) or transfers back to the acute care hospital (26% vs. 21%, p=0.56). Conclusions: Standardized handoffs decreased errors in communication of diagnosis and critical medications for secondary stroke prevention.

The incidence of neurologic complications from bariatric surgery is rising with the prevalence of obesity and the increasing number of bariatric surgeries. We report a 25-year-old woman who developed subacute progressive weakness and areflexia followed by confusion, ophthalmoplegia, and nystagmus following bariatric surgery. While the differential of generalized weakness with altered mental status is broad, vitamin deficiency should be routinely suspected after bariatric surgery to prevent permanent neurological injury. Multifocal neurological dysfunction in our patient represented beriberi and Wernicke's encephalopathy related to vitamin B1 deficiency.

The definition of hypertension has continuously evolved over the last 50 years. Hypertension is currently defined as a blood pressure greater than 140/90 mmHg. One in every four people in the US has been diagnosed with hypertension. The prevalence of hypertension increases further with age, affecting 75% of people over the age of 70. Hypertension is by far the most common risk factor identified in stroke patients. Hypertension causes pathologic changes in the walls of small (diameter

Importance Acquired neuromyotonia is increasingly recognized as an autoimmune disorder, frequently associated with antibodies against voltage-gated potassium channel complex proteins. We present a case of acquired neuromyotonia as the heralding symptom of recurrent thymoma in a patient with myasthenia gravis. Observations A report of a single case of a 53-year-old man with myasthenia gravis and a prior thymectomy presenting with 2 months of diffuse, involuntary muscle twitching in the absence of myasthenic symptoms, electrophysiologically confirmed to be neuromyotonia. Further evaluation revealed the recurrence of malignant thymoma, accompanied by refractory arrhythmia. Serologic and cerebrospinal fluid testing confirmed the presence of antibodies directed against 2 voltage-gated potassium channel–associated proteins: LGI1 and Caspr2. Conclusions and Relevance This case highlights the overlap of myasthenia, neuromyotonia, and thymoma, emphasizing the importance of appropriate tumor screening in the presence of either of the former 2 conditions.

Importance Peripheral neuropathy is a prevalent condition that usually warrants a thorough history and examination but has limited diagnostic evaluation. However, rare localizations of peripheral neuropathy often require more extensive diagnostic testing and different treatments. Objective To describe rare localizations of peripheral neuropathy, including the appropriate diagnostic evaluation and available treatments. Evidence Review References were identified from PubMed searches conducted on May 29, 2015, with an emphasis on systematic reviews and randomized clinical trials. Articles were also identified through the use of the authors’ own files. Search terms included common rare neuropathy localizations and their causes, as well as epidemiology , pathophysiology , diagnosis , and treatment . Findings Diffuse, nonlength-dependent neuropathies, multiple mononeuropathies, polyradiculopathies, plexopathies, and radiculoplexus neuropathies are rare peripheral neuropathy localizations that often require extensive diagnostic testing. Atypical neuropathy features, such as acute/subacute onset, asymmetry, and/or motor predominant signs, are frequently present. The most common diffuse, nonlength-dependent neuropathies are Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and amyotrophic lateral sclerosis. Effective disease-modifying therapies exist for many diffuse, nonlength-dependent neuropathies including Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and some paraprotein-associated demyelinating neuropathies. Vasculitic neuropathy (multiple mononeuropathy) also has efficacious treatment options, but definitive evidence of a treatment effect for IgM anti-MAG neuropathy and diabetic amyotrophy (radiculoplexus neuropathy) is lacking. Conclusions and Relevance Recognition of rare localizations of peripheral neuropathy is essential given the implications for diagnostic testing and treatment. Electrodiagnostic studies are an important early step in the diagnostic evaluation and provide information on the localization and pathophysiology of nerve injury.

Patient nonattendance in neurology and other subspecialty clinics is closely linked to longer waiting times for appointments. We developed a new scheduling system for residents' clinic that reduced average waiting times from4 months toor =3 weeks. The purpose of this study was to compare nonattendance for clinics scheduled using the new model (termed "rapid access") vs those scheduled using the traditional system.In the rapid access system, nonestablished (new) patients are scheduled on a first-come, first-served basis for appointments that must occur within 2 weeks of their telephone request. Nonattendance for new patient appointments (cancellations plus no-shows) was compared for patients scheduled under the traditional vs the rapid access scheduling systems. Nonattendance was compared for periods of 6, 12, and 18 months following change in scheduling system using the chi2 test and logistic regression.Compared to the traditional scheduling system, the rapid access system was associated with a 50% reduction in nonattendance over 18 months (64% [812/1,261 scheduled visits] vs 31% [326/1,059 scheduled visits], p0.0001). In logistic regression models, appointment waiting time was a major factor in the relation between rapid access scheduling and nonattendance. Demographics, diagnoses, and likelihood of scheduling follow-up visits were similar between the 2 systems.A new scheduling system that minimizes waiting times for new patient appointments has been effective in substantially reducing nonattendance in our neurology residents' clinic. This rapid access system should be considered for implementation and will likely enhance the outpatient educational experience for trainees in neurology.

SECTION 1 A 52-year-old Korean woman with a history of poorly controlled Type 1 diabetes presented for evaluation of abnormal movements of her right arm and leg. The movements began insidiously in her right hand and arm, progressing over several months to involve the right foot as well. She was unaware of the movements until her husband noticed them. Over time the movements became more violent, eventually leading to severe flinging movements in the right arm. The movements interfered with activity. They were neither suppressible nor associated with any unpleasant internal sensation. In retrospect, her husband felt that the onset had been heralded by several months of subtle personality change: he described her as more quiet, and no longer “the life of the party.” She was known to the clinic, having presented the year prior with several years of progressive numbness and paraesthesias in the feet, lower legs, and hands. An EMG at that time revealed severe sensorimotor polyneuropathy, attributed to her long-standing diabetes. She had no other known medical illnesses. Her only medication was insulin and she was never treated with antipsychotic, antiemetic, or hormone replacement therapies. She denied the use of herbal or over-the-counter medications. There was no history of any toxic exposures. She was married without children and was a homemaker. She was adopted. Question for consideration: What is the differential diagnosis of hemichorea/ hemiballismus?

Importance Peripheral neuropathy is a highly prevalent and morbid condition affecting 2% to 7% of the population. Patients frequently experience pain and are at risk of falls, ulcerations, and amputations. We aimed to review recent diagnostic and therapeutic advances in distal symmetric polyneuropathy, the most common subtype of peripheral neuropathy. Observations Current evidence supports limited routine laboratory testing in patients with distal symmetric polyneuropathy. Patients without a known cause should undergo a complete blood cell count, comprehensive metabolic panel, vitamin B 12 measurement, serum protein electrophoresis with immunofixation, fasting glucose measurement, and glucose tolerance test. The presence of atypical features such as asymmetry, non–length dependence, motor predominance, acute or subacute onset, and prominent autonomic involvement should prompt a consultation with a neurologist or neuromuscular specialist. Electrodiagnostic tests and magnetic resonance imaging of the neuroaxis contribute substantial cost to the diagnostic evaluation, but evidence supporting their use is lacking. Strong evidence supports the use of tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, and voltage-gated calcium channel ligands in the treatment of neuropathic pain. More intensive glucose control substantially reduces the incidence of distal symmetric polyneuropathy in patients with type 1 diabetes but not in those with type 2 diabetes. Conclusions and Relevance The opportunity exists to improve guideline-concordant testing in patients with distal symmetric polyneuropathy. Moreover, the role of electrodiagnostic tests needs to be further defined, and interventions to reduce magnetic resonance imaging use in this population are needed. Even though several efficacious medications exist for neuropathic pain treatment, pain is still underrecognized and undertreated. New disease-modifying medications are needed to prevent and treat peripheral neuropathy, particularly in type 2 diabetes.