Faculty Bibliography

Neurologists in both the inpatient and outpatient settings are increasingly using ultrasound to diagnose and manage common neurological diseases. Advantages include cost-effectiveness, the lack of exposure to ionizing radiation, and the ability to perform at the bedside to provide real-time data. There is a growing body of literature that supports using ultrasonography to improve diagnostic accuracy and aid in performing procedures. Despite the increasing utilization of this imaging modality in medicine, there has been no comprehensive review of the clinical applications of ultrasound in the field of neurology. We discuss the current uses and limitations of ultrasound for various neurological conditions. We review the role for ultrasound in commonly performed neurologic procedures including lumbar puncture, botulinum toxin injections, nerve blocks, and trigger point injections. We specifically discuss the technique for ultrasound-assisted lumbar puncture and occipital nerve block as these are commonly performed. We then focus on the utility of ultrasound in the diagnosis of neurologic conditions. This includes neuromuscular diseases such as motor neuron disorders, focal neuropathies, and muscular dystrophy as well as vascular conditions such as stroke and vasospasm in subarachnoid hemorrhage. We also address ultrasound's use in critically ill patients to aid in identifying increased intracranial pressure, hemodynamics, and arterial and/or venous catheterization. Finally, we address the importance of standardized ultrasound curricula in trainee education and make recommendations for the future directions of research and competency guidelines within our specialty.

BACKGROUND AND PURPOSE/OBJECTIVE:With the surge of critically ill COVID-19 patients, neurology and neurosurgery residents and advanced practice providers (APPs) were deployed to intensive care units (ICU). These providers lacked relevant critical care training. We investigated whether a focused video-based learning curriculum could effectively teach high priority intensive care topics in this unprecedented setting to these neurology providers. METHODS:Neurocritical care clinicians led a multidisciplinary team in developing a 2.5-hour lecture series covering the critical care management of COVID-19 patients. We examined whether provider confidence, stress, and knowledge base improved after viewing the lectures. RESULTS:A total of 88 residents and APPs participated across 2 academic institutions. 64 participants (73%) had not spent time as an ICU provider. After viewing the lecture series, the proportion of providers who felt moderately, quite, or extremely confident increased from 11% to 72% (60% difference, 95% CI 49-72%) and the proportion of providers who felt nervous/stressed, very nervous/stressed, or extremely nervous/stressed decreased from 78% to 48% (38% difference, 95% CI 26-49%). Scores on knowledge base questions increased an average of 2.5 out of 12 points (SD 2.1; p < 0.001). CONCLUSION/CONCLUSIONS:A targeted, asynchronous curriculum on critical care COVID-19 management led to significantly increased confidence, decreased stress, and improved knowledge among resident trainees and APPs. This curriculum could serve as an effective didactic resource for neurology providers preparing for the COVID-19 ICU.

OBJECTIVE:To estimate rates of all-cause and potentially preventable readmissions up to 90 days after discharge for aneurysmal subarachnoid hemorrhage (SAH) and medical comorbidities associated with readmissions BACKGROUND: Readmission rate is a common metric linked to compensation and used as a proxy to quality of care. Prior studies in SAH have reported 30-day readmission rates of 7-17% with a higher readmission risk among those with the higher SAH severity, ≥ 3 comorbidities, and non-home discharge. Intermediate-term rates, up to 90-days, and the proportion of these readmissions that are potentially preventable are unknown. Furthermore, the specific medical comorbidities associated with readmissions are unknown. METHODS:Index SAH admissions were identified from the 2013 Nationwide Readmissions Database. All-cause readmissions were defined as any readmission during the 30-, 60-, and 90-day post-discharge period. Potentially preventable readmissions were identified using Prevention Quality Indicators developed by the US Agency for Healthcare Research and Quality. Unadjusted and adjusted Poisson models were used to identify factors associated with increased readmission rates. RESULTS:Out of 9987 index admissions for SAH, 7949 (79%) survived to discharge. The percentage of 30-, 60-, and 90-day all-cause readmissions were 7.8, 16.6, and 26%, respectively. Up to 14% of readmissions in the first 30 days were considered potentially preventable and acute conditions (dehydration, bacterial pneumonia, and urinary tract infections) accounted for over half, whereas acute cerebrovascular disease was the most common cause for neurological return. In multivariable analysis, significant predictors of a higher readmission rate included diabetes (rate ratio [RR] 1.09, 95% confidence interval [CI] 1.03-1.15), congestive heart failure (RR 1.09, 1.003-1.18), and renal impairment (RR 1.35, 1.13-1.61). Only discharge home was associated with a lower readmission rate (RR 0.89, 0.85-0.93). CONCLUSIONS:SAH has a 30-day readmission rate of 7.8% which continues to rise into the intermediate-term. A low but constant proportion of readmissions are potentially preventable. Several chronic medical comorbidities were associated with readmissions. Prospective studies are warranted to clarify causal relationships.

As medical decisions fall under more scrutiny and society demands increasing transparency of care, it is likely that more opportunities for conflicts will emerge. Similarly, with increasing demand and a static supply, the issue of who receives treatment and for how long naturally will arise. This mismatch leads to discussions of resource utilization and limitation of care in light of patients' values and rights. Clinicians should always be forthcoming with the uncertainty of prognostication while also articulating the severity of a patient's disease in relation to the risk and benefits of an intervention. However, dispute over treatment course and the idea of futile care can arise for in a variety of reasons, both from the clinician and the patient. Without identifying the cause of these conflicts, it is impossible to have effective communication. At times, it is important to utilize various negotiating skills when resolving these disagreements. Regardless of the approach, practitioners need more training in and exposure to these types of conflicts. In this review, we provide a framework for the origins and current state of futility, challenges in the application of the term, and recommendations on how to approach conflict in these situations.