Podcast-Based Medical Education and Content Alignment with National Education Bodies

Introduction

Despite the rapid expansion of medical education podcasts in the past decade, there are few efforts to characterize the landscape of available content for specific medical specialties. We trialed a method of rigorous characterization for the field of neurology.

Materials and Methods

Using a censoring date of July 25, 2022, we queried the top three podcast platforms for neurology education podcasts: Apple Podcasts, Spotify, and Google Podcasts. We characterized podcasts based on total number of episodes, episode release frequency, target audience, and affiliation type. We characterized individual episodes by length and primary content area as defined by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Psychiatry and Neurology (ABPN). We compared content availability with content recommendations from these education bodies.

Results

We identified 30 podcasts sharing 1772 episodes and totaling 46,287 min. The ACGME subspecialties most frequently covered were vascular neurology (5082 total min, 11%), neuroimmunology (4,406, 10%), and neuromuscular diseases (3,771, 8%). Subjects that were underrepresented included palliative neurology (89 min, 0.2%), neuropathology (95 min, 0.2%), and bioethics (171 min, 0.4%). The coverage of ABPN examination topics varied substantially from the content distribution for the examination.

Discussion

The current landscape of neurology education podcasts features heterogeneous coverage of topics and varies considerably from recommended distribution of content by national education bodies. As podcasts have tremendous potential in supplementing neurology education, characterizing available content may help various stakeholders in the neurology education pipeline optimize the use of this e-learning modality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01971-0.

Social Work in Outpatient Neurology at a Safety-Net Hospital: A 200-Hour Profile

Social work plays a critical role in preventive health and mitigation of healthcare disparities, but few studies focus on its role in multi-specialty clinics serving marginalized populations. We aimed to characterize the role of outpatient neurology social work at an urban, safety-net hospital. In December 2021, we introduced a dedicated social worker to a neurology clinic primarily caring for an underserved patient population. We logged and characterized the first 200 consecutive hours of patient encounters, classifying interventions based on a recently popularized 10-category scheme in social work literature derived from natural language processing and machine learning algorithms. We characterized 125 encounters with neurology patients referred to social work. The neurology social worker spent the greatest amount of time on care coordination (40%), followed by housing insecurity (14%) and applications and reporting (11%). Interventions that required the most time per case included housing (129 min), applications and reporting (120 min), care coordination (96 min). The majority of interventions were directly related to the patient's underlying neurologic disorder, highlighting the importance of a neurology-specific social worker. Embedding a social worker in a multi-specialty neurology clinic may address many of the root causes of neurologic health disparities.

Hereditary gelsolin amyloidosis: a rare cause of cranial, peripheral and autonomic neuropathies linked to D187N and Y447H substitutions

INTRODUCTION

Hereditary gelsolin (AGel) amyloidosis is a systemic disease that is characterised by neurologic, ophthalmologic, dermatologic, and other organ involvements. We describe the clinical features with a focus on neurological manifestations in a cohort of patients with AGel amyloidosis referred to the Amyloidosis Centre in the United States.

METHODS

Fifteen patients with AGel amyloidosis were included in the study between 2005 and 2022 with the permission of the Institutional Review Board. Data were collected from the prospectively maintained clinical database, electronic medical records and telephone interviews.

RESULTS

Neurologic manifestations were featured in 15 patients: cranial neuropathy in 93%, peripheral and autonomic neuropathy in 57% and bilateral carpal tunnel syndrome in 73% of cases. A novel p.Y474H gelsolin variant featured a unique clinical phenotype that differed from the one associated with the most common variant of AGel amyloidosis.

DISCUSSION

We report high rates of cranial and peripheral neuropathy, carpal tunnel syndrome and autonomic dysfunction in patients with systemic AGel amyloidosis. The awareness of these features will enable earlier diagnosis and timely screening for end-organ dysfunction. The characterisation of pathophysiology will assist the development of therapeutic options in AGel amyloidosis.

Telemedicine in Neurology: Challenges and Opportunities

Objective

Our objective is to explore challenges encountered by neurologists with the use of telemedicine in neurology.

Methods

A cross- sectional study via an anonymous survey to explore neurologists' experiences with telemedicine. They survey was sent to randomly selected 200 participants from Academic Institutions in the United States. Descriptive statistics were reported as percentages for each survey question.

Results

110 neurologists completed the survey. Fifty-one percent of neurologists stated that they experienced technological issues in (1%-20%) of telemedicine visits and 57% of neurologists needed technological assistance from informational technology support. With regards to the impact of limited neurological examination via telemedicine, 34% of neurologists agreed that the limited examination makes them worried that they are providing a suboptimal care to patients and 55% recommended a subsequent in-person visit (in 1%-20% of telemedicine visits) for further evaluation. Among the challenges that hindered patients' ability to participate in telemedicine visits, 95% of neurologists rated patients' technological challenges with setting up telemedicine to be the most common issue encountered, 37% of neurologists rated patient's cognitive/mental disability to be the second most common challenge to complete telemedicine visits as well as availability of interpreter services for non-English speaking patients. Neurologists rated improving administrative support (39%), integration of EMR for video and telephone calls (37%), and sufficient time allotment to complete telemedicine visits (27%) to be the most important issues to address to optimize the use of telemedicine in neurology.

Significance

Potential opportunities to improve neurologists' experiences in telemedicine include improving technological support, integration of virtual platforms within the EMR, and adequate administrative support. Patients with cognitive/physical disabilities may need additional support to engage in the health system via telemedicine.

Clinical Reasoning: A 23-Year-Old Man With Progressive Asymmetric Weakness and Numbness

We report a case of a 23-year-old man who presented with progressive asymmetric weakness and numbness in his distal extremities over four months, with initial symptoms starting days after a coronavirus 2019 (COVID-19) vaccine booster. Initial neurologic exam was notable for distal weakness of both upper and lower extremities that was more pronounced on the left, complete areflexia, and decreased distal sensation to pinprick and vibration without loss of proprioception. Nerve conduction studies demonstrated a generalized, non-length-dependent, sensorimotor, demyelinating polyneuropathy, with conduction block seen in multiple compound muscle action potentials. Sensory nerve action potentials were normal in absolute terms, but had asymmetric amplitudes.Based on the patient's nerve conduction studies, he was diagnosed with a specific immune-mediated neuromuscular disorder. He was started on intravenous immunoglobulin, but within days of the first infusions experienced a rare and potentially life-threatening complication. He received appropriate treatment and was started on alternative immunotherapy, after which his symptoms improved.Our case exemplifies the features of a specific subtype of a more common immune-mediated neuromuscular diagnosis with unique elements of history, examination, and nerve conduction studies that required interpretation in the clinical context. We also discuss a rare side effect of a commonly used immunotherapy and its risk factors, and comment on the likelihood that this diagnosis may be related to a preceding COVID-19 vaccine booster.

Neurological manifestations of hereditary transthyretin amyloidosis: a focus on diagnostic delays

BACKGROUND

The recent availability of disease-modifying therapies for hereditary transthyretin amyloid (ATTRv) amyloidosis warrants urgency for earlier diagnosis and timely identification of active disease state among genetic carriers.

METHODS

We reviewed clinical neurological data of all patients with ATTRv amyloidosis with initial visits at our amyloidosis centre between January 2016 and December 2018. We abstracted the signs and symptoms of neurological manifestations, as well as rates and patterns of diagnostic testing.

RESULTS

Of 92 patients with 19 different transthyretin (TTR) mutations, 66 and 36% had symptoms attributed to large-fibre and small-fibre neuropathy, respectively, compared to 75 and 66% with corresponding examination findings. Thirty-six patients with V122I ATTR mutation had asymptomatic polyneuropathy identified on neurological examination, eight without concurrent cardiac disease. Seventy-three percent of patients had symptoms of carpal tunnel syndrome (CTS), while 26% had dysautonomia. The average delays between the onset of symptoms of large fibre neuropathy (LFN) or CTS to ATTRv amyloidosis diagnosis were 2.9 and 6.7 years, respectively.

DISCUSSION

Our study found higher rates of polyneuropathy by examination than patient-reported symptoms, especially among those with V122I TTR amyloidosis, signalling asymptomatic polyneuropathy. Our findings suggest the need for routine neurological examinations and other testing for genetic carriers to achieve earlier identification of active disease state.

Disparities in Telehealth use During the COVID-19 Pandemic

The coronavirus 2019 pandemic led to rapid expansion of outpatient telemedicine. We sought to characterize patient factors influencing outpatient teleneurology utilization at an urban safety-net hospital. We reviewed all neurology televisits scheduled between June 15, 2020 to April 15, 2021. We used the chi-squared test and multivariate logistic regression to characterize patient demographic factors associated with televisit completion and video use. Of 8875 scheduled televisit encounters, 7530 were completed successfully, 44% via video. Non-English speaking patients, Black patients, Latinx patients, and those with a zip code-linked annual income less than $50,000 were less likely to successfully complete a scheduled televisit. The same demographic groups other than Latinx ethnicity were also less likely to use the video option. Our study found unequal telehealth utilization based on patients’ demographic factors. Currently declining telemedicine reimbursement rates asymmetrically affect audio-only visits, which may limit telehealth access for vulnerable patient populations.

Predictors of hematologic response and survival with stem cell transplantation in AL amyloidosis: a 25-year longitudinal study

High-dose melphalan and stem cell transplantation (HDM/SCT) is an effective treatment for selected patients with AL amyloidosis. We report the long-term outcomes of 648 patients with AL amyloidosis treated with HDM/SCT over 25 years. Hematologic CR was achieved by 39% of patients. The median duration of hematologic CR was 12.3 years, and 45% of patients with a hematologic CR had no evidence of a recurrent plasma cell dyscrasia at 15 years after HDM/SCT. With a median follow-up interval of 8 years, the median event-free survival (EFS) and overall survival (OS) were 3.3 and 7.6 years, respectively. Patients with a hematologic CR had a median OS of 15 years, and 30% of these patients survived >20 years. On multivariable analysis, dFLC >180 mg/L and BM plasma cells >10% were independently associated with shorter EFS, whereas BNP >81 pg/mL, troponin I >0.1 ng/mL, and serum creatinine >2.0 mg/dL were independently associated with shorter OS. We developed a prognostic score for EFS, which incorporated dFLC >180 mg/L and BMPC% >10% as adverse risk factors. Patients with low-risk (0 factors), intermediate-risk (1 factor), and high-risk (2 factors) disease had median EFS estimates of 5.3, 2.8, and 1.0 years, respectively (p<0.001). The 100-day treatment-related mortality rate was 3% in the latest treatment period (2012-2021), and the 25-year risk of t-MDS/AML was 3%. We conclude that HDM/SCT induces durable hematologic responses and prolonged survival with improved safety in selected patients with AL amyloidosis. This article is protected by copyright. All rights reserved.

Using Technology Adoption Theories to Maximize the Uptake of E-learning in Medical Education

INTRODUCTION

While the use of e-learning tools in medical education is guided by robust literature on their design and evaluation, there is sparse literature on strategies that maximize their adoption among trainees.

METHODS

In this scoping review, we searched Web of Science for studies on technology adoption theories as applied to education, using a final censoring date of August 1, 2021.

RESULTS

Based on our findings, we identified three representative theories: (1) technology acceptance model, (2) technology adoption life cycle, and (3) domestication theory.

DISCUSSION

We describe these theories in detail, examine their prior applications, and propose specific uses within medical e-learning.

Two-Year Profile of Preventable Errors in Hospital-Based Neurology

Background and Objectives:

Medical errors are estimated to cause 7,000 deaths and cost 17-29 billion USD per year, but there is a lack of published real-world data on preventable errors, in particular in hospital-based neurology. We sought to characterize the profile of errors that occur on the inpatient neurology services at our institution in order to inform strategies on future error prevention.

Methods:

We reviewed all cases of preventable errors occurring on the inpatient neurology services from July 1, 2018 to June 30, 2020, logged in institutional error reporting systems and reviewed at departmental morbidity and mortality conferences (M&MC). Each case was characterized by primary category of error, level of harm as determined by the Agency for Healthcare Research & Quality (AHRQ) Common Format Harm Scale version 1.2, primary intervention, and recurrence within one year, with a final censoring date of June 30, 2021.

Results:

Of 72 cases, 43 (60%) were attributed to errors in clinical decision-making and 20 (28%) to systems or electronic health record-related errors. The majority of cases resulted in in-conference education on systems-based errors (29%) at departmental M&MCs followed by in-conference education on clinical neurology (25%). Among errors classified primarily as clinical, 28% were addressed via systems-based interventions including in-conference education on systems issues and changes in written protocol. In 23 cases (32%), a similar error recurred within one year of the presentation. In total, 7 cases (10%) resulted in a change in written protocol, none with recurrences.

Discussion:

Systems-based interventions may reduce both clinical and systems-based errors, and protocol changes are effective when feasible. Given the important goal of optimizing care for every patient, quality leaders should conduct continuous audits of preventable errors and quality improvement systems in their clinical areas.

The Nature of Interruptions Among Inpatient Residents: a Time-Motion Observation-Based Mixed Methods Study

Interruptions are germane to inpatient medical practice but carry the consequences of reduced error prevention, psychological stress, and impaired knowledge consolidation among trainees. In this mixed methods study, we captured 172 task changes via time-motion observations of four residents on a general neurology service and completed semi-structured interviews with the same group. Twenty-five percent of task changes were due to interruptions, the majority via pager communications, and only 2% required urgent clinical attention. Residents reported frustration towards inefficient aspects of the pager system. Given the high rates of interruptions identified, we propose mitigating strategies such as triaging communications by urgency.

Isolated High-Grade Malignancy of the Spinal Cord Presenting as Longitudinally Extensive Transverse Myelitis

This article characterizes 2 cases of longitudinally extensive transverse myelitis (LETM) that did not respond to immunotherapy and were diagnosed by biopsy as primary central nervous system (CNS) malignancies. Diffuse H3 K27M-mutant glioma is a recently described entity with very few cases of isolated spinal disease described in adults. Primitive neuroectodermal tumor is similarly uncommon in the spinal cord. Malignancies should be considered in patients who fail to improve with immunomodulatory therapy. We believe the experiences of our center will raise awareness about that point, broaden the existing understanding of the diagnostic approach to LETM, and highlight the need for additional studies.

Shortcomings of Rapid Clinical Information Dissemination: Lessons From a Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has led to an acceleration of clinical information dissemination to unprecedented speeds, a phenomenon only partially explained by formal efforts of the scientific community. These have ranged from the establishment of open-source platforms for review of article preprints to the elimination of journal paywalls for COVID-19-related publications. In addition, informal efforts that rely on various modern media platforms that promote, repackage, and synthesize information have played substantial adjunctive roles, many of which did not exist during the severe acute respiratory syndrome pandemic of 2003. Although these latter efforts have greatly bolstered the speed of knowledge dissemination, their unregulated nature subjects them to risk for facilitating the spread of misinformation. In our opinion, the role of modern media in influencing clinical knowledge dissemination was not adequately examined even before the pandemic and therefore remains largely unchecked. In this article, we examine the spread of information in the field of COVID-19 and neurologic disorders, develop a simple model that maps various modern media tools on to the dissemination pipeline, and critically examine its components. Through this exercise, we identify opportunities for the scientific community to regulate and safeguard the clinical knowledge dissemination process, with implications both for the pandemic and beyond.

Optimizing the operation of an electrodiagnostic laboratory during the COVID-19 pandemic: A 6-month single-center experience

Introduction/Aims

The initial surge of the coronavirus disease‐2019 (COVID‐19) pandemic in early 2020 led to widespread cancellation of elective medical procedures in the United States, including nonurgent outpatient and inpatient electrodiagnostic (EDx) studies. As certain regions later showed a downtrend in daily new cases, EDx laboratories have reopened under the guidance of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). In our reopening experience guided by the AANEM, we measured relevant outcomes to determine further workflow adaptations. We aimed to detail our experience and share the lessons learned.

Methods

We reviewed the clinical volumes, billing data, diagnosis distributions, and rates of COVID‐19 exposure and transmission among patients and staff in our EDx laboratory during the first 6 months of reopening, starting on June 1, 2020. For context, we detailed the recent AANEM guidelines we adopted at our laboratory, supplemented by other consensus statements.

Results

We completed 816 outpatient studies from June 1 to December 1, 2020, reaching 97% of the total volume and 97% of total billing compared with the same time period in 2019. The average relative value units per study were similar. There were no major shifts in diagnosis distributions. We completed 10 of 12 requested inpatient studies during this period. There were no known COVID‐19 transmissions between patients and staff.

Discussion

Our experience suggests that it is possible to safely operate an EDx laboratory under the guidance of the AANEM and other experts, with clinical volume and billing rates comparable to pre‐pandemic baselines.

The Effects of Video Instruction on Neuroscience Intensive Care Unit Nursing Skills in Case Presentations and Neurological Examinations

ABSTRACT

BACKGROUND: The emergence of neuroscience intensive care units (NSICUs) for the past decades has led to growing interest in targeted training for NSICU nurses. We sought to evaluate the use of video instruction on NSICU nurses' skills in case presentations and neurological examinations, which has timely advantages as an asynchronous and distanced learning modality. METHODS: We enrolled NSICU and surgical intensive care unit nurses who took shifts in the NSICU at our institution. Participants were observed by a neurocritical care attending physician presenting the clinical details of an admitted patient and conducting a neurological examination, with both parties completing a 10-item evaluation on NSICU nursing presentation and examination skills. Participants randomized to an intervention group were given access to an instructional video on NSICU nursing skills. A median of 21 days later, participants were observed by a physician blinded to study randomization, with both parties recompleting the evaluation. Differences between day 1 and day 21 scores were analyzed using paired sample t tests. RESULTS: Fifteen NSICU and 55 surgical intensive care unit nurses were enrolled. Surgical intensive care unit nurses in both the intervention and control groups had statistically significant improvement between day 1 and day 21 physician-rated scores, with a greater increase in the intervention group; self-rated scores did not change. For NSICU nurses, there were no differences in physician-rated or self-rated scores for either group. CONCLUSIONS: Surgical intensive care unit nurses who underwent direct observation and self-evaluation had improvement in physician-rated NSICU nursing skills, likely as these activities allowed for reflective observation in Kolb's experiential learning cycle. Greater improvement in participants who viewed an instructional video highlights its value as a teaching modality for nurses.

Posterior Reversible Encephalopathy Syndrome in Patients with Coronavirus Disease 2019: Two Cases and A Review of The Literature

INTRODUCTION

Encephalopathy is a common complication of coronavirus disease 2019. Although the encephalopathy is idiopathic in many cases, there are several published reports of patients with posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019.

OBJECTIVE

To describe the diverse presentations, risk factors, and outcomes of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019.

METHODS

We assessed patients with coronavirus disease 2019 and a diagnosis of posterior reversible encephalopathy syndrome at our institution from April 1 to June 24, 2020. We performed a literature search to capture all known published cases of posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019.

RESULTS

There were 2 cases of posterior reversible encephalopathy syndrome in the setting of coronavirus 2019 at our institution during a 3-month period. One patient was treated with anakinra, an interleukin-1 inhibitor that may disrupt endothelial function. The second patient had an underlying human immunodeficiency virus infection. We found 13 total cases in our literature search, which reported modest blood pressure fluctuations and a range of risk factors for posterior reversible encephalopathy syndrome. One patient was treated with tocilizumab, an interleukin-6 inhibitor that may have effects on endothelial function. All patients had an improvement in their neurological symptoms. Interval imaging, when available, showed radiographic improvement of brain lesions.

CONCLUSIONS

Risk factors for posterior reversible encephalopathy syndrome in patients with coronavirus disease 2019 may include underlying infection or immunomodulatory agents with endothelial effects in conjunction with modest blood pressure fluctuations. We found that the neurological prognosis for posterior reversible encephalopathy syndrome in the setting of coronavirus disease 2019 infection is favorable. Recognition of posterior reversible encephalopathy syndrome in this patient population is critical for prognostication and initiation of treatment, which may include cessation of potential offending agents and tight blood pressure control.

Leveraging Trends in Neurology Admissions for Departmental Planning During the COVID-19 Pandemic

The COVID-19 pandemic has led to shifts in healthcare utilization for patients both with and without COVID-19. We aimed to determine how trends in neurology service admissions during the pandemic may aid in departmental planning by predicting future clinician staffing and other needs. We examined all admissions to the general neurology, stroke, and neurocritical care services from January 31 to May 16, 2020 at our tertiary-care hospital using an electronic health record query, comparing these to analogous data in 2019. We trended admission rates and projected future censuses using logarithmic regression, tracked changes in length of stay (LOS), and quantified shifts in presentations of specific diagnoses. Daily rates of admissions declined sharply during the week of March 13, 2020 (the week after pandemic status was declared by the World Health Organization). On the censoring date, we projected a return to pre-pandemic censuses in the week of June 21 and used this information to make decisions regarding neurology resident schedules. There was a trend toward increased LOS for general neurology and stroke patients between March 27 and April 9, 2020 compared to in 2019, with subsequent decline coinciding with early hospital initiatives. Since March 13, 2020, there has been a trend toward reduced presentations of ischemic stroke, suggesting a need for community education on stroke awareness. Characterizing early trends in neurology admissions may allow physician administrators to plan local and community-level responses to the pandemic.

Neurological Complications of Leprosy

Leprosy is a challenging international health concern. Despite tremendous efforts in reducing worldwide disease prevalence in the past decades, some countries remain endemic and are plagued by high levels of disability. The neurological complications of leprosy are varied and complex, with current research focused on evaluating tools for earlier diagnosis of neuropathy, especially in resource-limited countries. While treatment with multidrug therapy is highly effective, active research aims to simplify regimens to improve adherence, minimize adverse effects, and prevent antimicrobial resistance. Although promising progress has been made in the past decades, further efforts are needed to push the international community toward achieving worldwide elimination.

New Media, Technology and Neurology Education

The use of technology in neurology education has revolutionized many aspects of medical teaching, addressing some important challenges of modern education such as information overload and the unique needs of millennial learners. However, it also has inherent problems, such as depersonalization and high development costs. Due to the heterogeneity of different applications, it is difficult to establish general principles to guide front line educators, but it may be possible to describe "minimum" best practice elements. In this article, we examine commonalities of some of the most successful uses of technology in neurology education. We suggest the following for effective application of technology: (1) match technology to predetermined educational objectives, (2) characterize learners in relationship to technology, (3) optimize how technological components fit into the learning environment, (4) monitor and manage learner engagement with technology, (5) perform cost analyses, and (6) explore opportunities for educational scholarship and research.

Using learning analytics to evaluate a video-based lecture series

BACKGROUND

The video-based lecture (VBL), an important component of the flipped classroom (FC) and massive open online course (MOOC) approaches to medical education, has primarily been evaluated through direct learner feedback. Evaluation may be enhanced through learner analytics (LA) - analysis of quantitative audience usage data generated by video-sharing platforms.

METHODS AND RESULTS

We applied LA to an experimental series of ten VBLs on electroencephalography (EEG) interpretation, uploaded to YouTube in the model of a publicly accessible MOOC. Trends in view count; total percentage of video viewed and audience retention (AR) (percentage of viewers watching at a time point compared to the initial total) were examined. The pattern of average AR decline was characterized using regression analysis, revealing a uniform linear decline in viewership for each video, with no evidence of an optimal VBL length. Segments with transient increases in AR corresponded to those focused on core concepts, indicative of content requiring more detailed evaluation. We propose a model for applying LA at four levels: global, series, video, and feedback.

DISCUSSION AND CONCLUSIONS

LA may be a useful tool in evaluating a VBL series. Our proposed model combines analytics data and learner self-report for comprehensive evaluation.

Exacerbation of myasthenia gravis in a patient with melanoma treated with pembrolizumab

INTRODUCTION

While anticancer immunotherapies have traditionally focused on activation of the immune system, there is recent interest in disinhibition of the natural antitumor immune response by targeting immune checkpoints such as cytotoxic T-lymphocyte associated antigen-4 (CTLA-4) and programmed death-1 (PD-1). One humanized monoclonal antibody against PD-1, pembrolizumab, was recently approved for treatment of metastatic malignant melanoma.

METHODS

We report exacerbation of myasthenia gravis (MG) after treatment with pembrolizumab and provide a brief literature review.

RESULTS

We describe a 75-year-old man with stable MG who experienced myasthenic crisis in the setting of pembrolizumab treatment. A concurrent azathioprine taper was a possible although unlikely contributor given the short time interval between taper and exacerbation.

CONCLUSIONS

As long-term data become available regarding the adverse immune effects of novel checkpoint inhibitors, clinicians should be mindful of their risks/benefits and of possible autoimmune disease exacerbation. Muscle Nerve 54: 157-161, 2016.

Computer-based teaching module design: principles derived from learning theories

CONTEXT

The computer-based teaching module (CBTM), which has recently gained prominence in medical education, is a teaching format in which a multimedia program serves as a single source for knowledge acquisition rather than playing an adjunctive role as it does in computer-assisted learning (CAL). Despite empirical validation in the past decade, there is limited research into the optimisation of CBTM design. This review aims to summarise research in classic and modern multimedia-specific learning theories applied to computer learning, and to collapse the findings into a set of design principles to guide the development of CBTMs.

METHODS

Scopus was searched for: (i) studies of classic cognitivism, constructivism and behaviourism theories (search terms: 'cognitive theory' OR 'constructivism theory' OR 'behaviourism theory' AND 'e-learning' OR 'web-based learning') and their sub-theories applied to computer learning, and (ii) recent studies of modern learning theories applied to computer learning (search terms: 'learning theory' AND 'e-learning' OR 'web-based learning') for articles published between 1990 and 2012. The first search identified 29 studies, dominated in topic by the cognitive load, elaboration and scaffolding theories. The second search identified 139 studies, with diverse topics in connectivism, discovery and technical scaffolding. Based on their relative representation in the literature, the applications of these theories were collapsed into a list of CBTM design principles.

RESULTS

Ten principles were identified and categorised into three levels of design: the global level (managing objectives, framing, minimising technical load); the rhetoric level (optimising modality, making modality explicit, scaffolding, elaboration, spaced repeating), and the detail level (managing text, managing devices).

CONCLUSIONS

This review examined the literature in the application of learning theories to CAL to develop a set of principles that guide CBTM design. Further research will enable educators to take advantage of this unique teaching format as it gains increasing importance in medical education.

Competing causes of death in patients with oropharyngeal cancer treated with radiotherapy

Radiation with or without chemotherapy is considered the mainstay of treatment for the majority of patients with oropharyngeal cancer. The goal of this study was to analyze competing causes of mortality in patients with oropharyngeal cancer with long-term follow-up. We queried the Surveillance, Epidemiology and End Results (SEER) database and identified 3728 patients with oropharyngeal cancer treated between 1988 and 2001 with definitive radiotherapy. We analyzed predictors of overall survival and risks of mortality from index oropharyngeal cancer, second primary cancer, cardiovascular disease and other causes using a cumulative incidence analysis and Cox multivariate analysis. With a median follow-up of 6.8 years, the 5- and 10-year overall survival was 37 and 22%, respectively. At 5 years, the risk of mortality from primary oropharyngeal cancer was 35%. Between years 3 and 10, 69% of mortalities were attributed to causes other than the index cancer. Despite advances in the non-surgical treatment of oropharyngeal cancer, patients remain at significant risk of cancer- and non-cancer-related mortality.

Phase II trial of concurrent sunitinib and image-guided radiotherapy for oligometastases

Background

Preclinical data suggest that sunitinib enhances the efficacy of radiotherapy. We tested the combination of sunitinib and hypofractionated image-guided radiotherapy (IGRT) in a cohort of patients with historically incurable distant metastases.

Methods

Twenty five patients with oligometastases, defined as 1–5 sites of active disease on whole body imaging, were enrolled in a phase II trial from 2/08 to 9/10. The most common tumor types treated were head and neck, liver, lung, kidney and prostate cancers. Patients were treated with the recommended phase II dose of 37.5 mg daily sunitinib (days 1–28) and IGRT 50 Gy (days 8–12 and 15–19). Maintenance sunitinib was used in 33% of patients. Median follow up was 17.5 months (range, 0.7 to 37.4 months).

Results

The 18-month local control, distant control, progression-free survival (PFS) and overall survival (OS) were 75%, 52%, 56% and 71%, respectively. At last follow-up, 11 (44%) patients were alive without evidence of disease, 7 (28%) were alive with distant metastases, 3 (12%) were dead from distant metastases, 3 (12%) were dead from comorbid illness, and 1 (4%) was dead from treatment-related toxicities. The incidence of acute grade ≥ 3 toxicities was 28%, most commonly myelosuppression, bleeding and abnormal liver function tests.

Conclusions

Concurrent sunitinib and IGRT achieves major clinical responses in a subset of patients with oligometastases.

Trial Registration

ClinicalTrials.gov NCT00463060

Liver fibrosis in elderly cadavers: localization of collagen types I, III, and IV, α-smooth muscle actin, and elastic fibers

We have shown a high prevalence of liver fibrosis in elderly cadavers with diverse causes of death by Sirius red stain; however, the various collagen types in these samples have yet to be evaluated. To further characterize the histopathology of the fibrotic lesions in the livers of these elderly cadavers, this study used immunohistochemistry and histochemistry to identify the principal collagens produced in liver fibrosis, fibrogenic cells and elastic fibers. Collagen I and III immunoreactions were found to colocalize in collagen fibers of fibrotic central veins, perisinusoidal fibrotic foci, portal tract stroma, and fibrous septa. α-Smooth muscle actin-expressing perisinusoidal hepatic stellate cells (HSCs), as well as perivenular, portal, and septal myofibroblasts, were closely associated with collagen fibers, reflecting their fibrogenic functions. HSCs and myofibroblasts were also noted to express collagen IV, which may contribute to production of basal lamina-like structures. In fibrotic livers, the sinusoidal lining showed variable immunostaining for collagen IV. Collagen IV immunostaining revealed vascular proliferation and atypical ductular reaction at the portal-septal parenchymal borders, as well as capillary-like vessels in the lobular parenchyma. While elastic fibers were absent in the space of Disse, they were found to codistribute with collagens in portal tracts, fibrous septa and central veins. Our combined assessment of collagen types, HSCs, myofibroblasts, and elastic fibers is significant in understanding the histopathology of fibrosis in the aging liver.

Prognostic significance of p16 in locoregionally advanced head and neck cancer treated with concurrent 5-fluorouracil, hydroxyurea, cetuximab and intensity-modulated radiation therapy

A phase II trial was conducted to evaluate the tolerability and efficacy of incorporating cetuximab and simultaneous integrated boost intensity-modulated radiation therapy (SIB-IMRT) into a well-described 5-fluorouracil (5-FU) and hydroxyurea (HU)-based chemoradiation regimen. Patients with stage IVa-IVb or high-risk stage III squamous cell carcinomas were enrolled. Prior organ-conserving surgery or induction chemotherapy was allowed. IMRT was administered in 1.5 Gy fractions twice daily on days 1-5 of weeks 1, 3, 5, 7±9 for a total dose of 60-73.5 Gy. Concurrent systemic therapy consisted of 5-FU (600 mg/m2), HU (500 mg BID) and cetuximab (250 mg/m2). p16INK4A expression was assessed by immunohistochemistry. From January 2007 to January 2010, 65 patients (61 with stage IV disease; 31 with oropharyngeal primaries) were enrolled. At a median follow-up of 28 months, 2-year locoregional control, distant control, progression-free survival, event-free survival and overall survival were 79, 83, 72, 63 and 80%, respectively. In 48 patients with available pre-treatment tissue, p16 overexpression was associated with significantly increased distant control (p=0.03), progression-free survival (p=0.02), event-free survival (p=0.007) and overall survival (p=0.03). The most common grade 3-4 toxicities were mucositis (46%), leukopenia (18%), anemia (18%) and dermatitis (17%). Concurrent 5-FU, HU, cetuximab and SIB-IMRT is a highly active regimen, particularly in patients with p16-positive disease.