Citations

Background: Progressive motor impairment anatomically associated with a “critical” lesion has been described in primary demyelinating disease. Most “critical” lesions occur within the spinal cord. Objective: To describe the clinical and radiological features of “critical” lesions of the cervicomedullary junction (CMJ). Methods: Observational study on people presenting with a CMJ lesion associated with primary demyelinating disease-related progressive motor impairment. Clinical data were extracted by chart review. Brain and spinal cord magnetic resonance images were reviewed to characterize the CMJ lesion and determine additional demyelination burden. Results: Forty-one people were included: 29 (71%) had progression from onset and 12 (29%) had a relapse onset (secondary progressive) course. Most had progressive hemiparesis (21 (51%)) or progressive quadriparesis (15 (37%)) with a median Expanded Disability Status Scale (EDSS) of 5.5 (2.0–8.5) at last follow-up. No “critical” CMJ lesion enhanced; most were bilateral (25 (61%)). Brain magnetic resonance images were otherwise normal in 16 (39%) or with a restricted demyelination burden in 15 (37%). Cervical and thoracic cord MRIs were without additional lesions in 25 (61%) and 22/37 (59%), respectively. Conclusion: CMJ “critical” lesions can correlate with progressive motor impairment even with few or no additional magnetic resonance imaging (MRI) lesions. Lesion location is an important determinant of progressive motor impairment in demyelinating disease.

Abstract Among people with multiple sclerosis, cognitive impairment occurs commonly and is a potent predictor of disability. Some multiple sclerosis patients present with severe cognitive impairment, and distinguishing multiple sclerosis-related cognitive impairment from co-existent progressive neurodegenerative diseases such as Alzheimer disease poses a diagnostic challenge. The use of biomarkers such as PET and CSF proteins may facilitate this distinction. The study was a retrospective, descriptive study on convenience samples of separate cohorts, one of cognitively impaired multiple sclerosis patients evaluated on autopsy to demonstrate coincidence of both multiple sclerosis and neurodegenerative cognitive diseases. The second cohort were cognitively impaired multiple sclerosis patients evaluated by biomarker to investigate possible additional neurodegenerative cognitive disorders contributing to the cognitive impairment. We investigated selected biomarkers among 31 severely impaired patients (biomarker cohort) and 12 severely impaired patients assessed at autopsy and selected 24 (23 biomarker cohort, 1 autopsy cohort) had comprehensive neurocognitive testing. Biomarker cohort investigations included 18F-Fluorodeoxyglucose PET and/or CSF amyloid Aβ1-42, phospho-tau and total tau levels. The autopsy cohort was evaluated with comprehensive neuropathological assessment for aetiology of cognitive impairment. The cohorts shared similar sex, age at multiple sclerosis onset and multiple sclerosis clinical course. The autopsy-cohort patients were older at diagnosis (69.5 versus 57 years, P = 0.006), had longer disease duration [median (range) 20 years (3–59) versus 9 (1–32), P = 0.001] and had more impaired bedside mental status scores at last follow-up [Kokmen median (range) 23 (1–38) versus 31 (9–34) P = 0.01]. Autopsy-cohort patients confirmed, or excluded, coexistent neurogenerative disease by neuropathology gold standard. Most biomarker-cohort patients had informative results evaluating coexistent neurogenerative disease. Biomarkers may be useful in indicating a coexistent neurodegenerative disease earlier, and in life, in patients with multiple sclerosis and significant cognitive impairment.

Abstract Background Preoperative risk scores facilitate patient selection, but postoperative risk scores may offer valuable information for predicting outcomes. We hypothesized that the postoperative Sequential Organ Failure Assessment (SOFA) score would predict mortality after left ventricular assist device (LVAD) implantation. Methods We retrospectively reviewed data from 294 continuous‐flow LVAD implantations performed at Mayo Clinic Rochester during 2007 to 2015. We calculated the EuroSCORE, HeartMate‐II Risk Score, and RV Failure Risk Score from preoperative data and the APACHE III and Post Cardiac Surgery (POCAS) risk scores from postoperative data. Daily, maximum, and mean SOFA scores were calculated for the first 5 postoperative days. The area under receiver‐operator characteristic curves (AUC) was calculated to compare the scoring systems' ability to predict 30‐day, 90‐day, and 1‐year mortality. Results For the entire cohort, mortality was 5% at 30 days, 10% at 90 days, and 19% at 1 year. The Day 1 SOFA score had better discrimination for 30‐day mortality (AUC 0.77) than the preoperative risk scores or the APACHE III and POCAS postoperative scores. The maximum SOFA score had the best discrimination for 30‐day mortality (AUC 0.86), and the mean SOFA score had the best discrimination for 90‐day mortality (AUC 0.82) and 1‐year mortality (AUC 0.76). Conclusions We observed that postoperative mean and maximum SOFA scores in LVAD recipients predict short‐term and intermediate‐term mortality better than preoperative risk scores do. However, because preoperative and postoperative risk scores each contribute unique information, they are best used in concert to predict outcomes after LVAD implantation.

Background Elevated intrathecal immunoglobulin G (IgG; oligoclonal bands (OCBs)) or IgG in people with progressive motor impairment due to “critical” demyelinating lesions are of uncertain significance. Objective Compare clinical/radiological features of people with “critical” demyelinating lesion-induced progressive motor impairment with/without elevated intrathecal IgG synthesis. Methods A total of 133 people with progressive motor impairment attributable to “critical” demyelinating lesions (corticospinal tract location, consistent with the progressive motor deficit) were compared regarding clinical and radiological presentation with and without ≥2 unique cerebrospinal fluid (CSF) OCB and/or IgG index ≥0.85. Results Ninety-eight (74%) had CSF-elevated OCB and/or IgG index, higher with increased magnetic resonance imaging-lesion burden. No differences were found with/without CSF abnormalities in sex (46 of 98 female (47%) vs. 22 of 35 (63%), p = 0.11), onset-age (median 49 vs. 50 years, p = 0.5), progression from onset (62 of 98 (63%) vs. 25 of 35 (71%)), progression post-relapse (36 of 98 (37%) vs. 10 of 35 (29%), p = 0.4), and duration between demyelinating disease onset and CSF examination (30 (0–359) vs. 48 (0–323) months p = 0.7). “Critical” lesions were radiologically similar, most commonly cervical spine located (72 of 98 (74%) vs. 19 of 35 (54%), p = 0.18) both with/without CSF abnormalities. Conclusions People with “critical” demyelinating lesion-induced progressive motor impairment typically have elevated intrathecal IgG (OCB and/or IgG) and similar clinical and radiological presentation regardless of CSF findings, therefore representing valid presentations of progressive demyelinating disease.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic interrupted the administration of the APPLIED Examination, the final part of the American Board of Anesthesiology (ABA) staged examination system for initial certification. In response, the ABA developed, piloted, and implemented an Internet-based “virtual” form of the examination to allow administration of both components of the APPLIED Exam (Standardized Oral Examination and Objective Structured Clinical Examination) when it was impractical and unsafe for candidates and examiners to travel and have in-person interactions. This article describes the development of the ABA virtual APPLIED Examination, including its rationale, examination format, technology infrastructure, candidate communication, and examiner training. Although the logistics are formidable, we report a methodology for successfully introducing a large-scale, high-stakes, 2-element, remote examination that replicates previously validated assessments.

BACKGROUND: Anesthesiology residents’ experiences and perspectives about their programs may be helpful in improving training. The goals of this repeated cross-sectional survey study are to determine: (1) the most important factors residents consider in choosing an anesthesiology residency, (2) the aspects of the clinical base year that best prepare residents for anesthesia clinical training, and what could be improved, (3) whether residents are satisfied with their anesthesiology residency and what their primary struggles are, and (4) whether residents believe their residency prepares them for proficiency in the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and for independent practice. METHODS: Anesthesiologists beginning their US residency training from 2013 to 2016 were invited to participate in anonymous, confidential, and voluntary self-administered online surveys. Resident cohort was defined by clinical anesthesia year 1, such that 9 survey administrations were included in this study—3 surveys for the 2013 and 2014 cohorts (clinical anesthesia years 1–3), 2 surveys for the 2015 cohort (clinical anesthesia years 1–2), and 1 survey for the 2016 cohort (clinical anesthesia year 1). RESULTS: The overall response rate was 36% (4707 responses to 12,929 invitations). On a 5-point Likert scale with 1 as “very unimportant” and 5 as “very important,” quality of clinical experience (4.7–4.8 among the cohorts) and departmental commitment to education (4.3–4.5) were rated as the most important factors in anesthesiologists’ choice of residency. Approximately 70% of first- and second-year residents agreed that their clinical base year prepared them well for anesthesiology residency, particularly clinical training experiences in critical care rotations, anesthesiology rotations, and surgery rotations/perioperative procedure management. Overall, residents were satisfied with their choice of anesthesiology specialty (4.4–4.5 on a 5-point scale among cohort-training levels) and their residency programs (4.0–4.1). The residency training experiences mostly met their expectations (3.8–4.0). Senior residents who reported any struggles highlighted academic more than interpersonal or technical difficulties. Senior residents generally agreed that the residency adequately prepared them for independent practice (4.1–4.4). Of the 6 ACGME Core Competencies, residents had the highest confidence in professionalism (4.7–4.9) and interpersonal and communication skills (4.6–4.8). Areas in residency that could be improved include the provision of an appropriate balance between education and service and allowance for sufficient time off to search and interview for a postresidency position. CONCLUSIONS: Anesthesiology residents in the United States indicated they most value quality of clinical training experiences and are generally satisfied with their choice of specialty and residency program.