A diverse workforce is critical to providing high-quality, equitable neurologic care. Many neurologic conditions disproportionately affect Black and Latinx people, but these populations have limited access to neurologic care.1,2 Although healthcare disparities can be reduced with a diverse workforce,3-7 just 2.8% of neurologists are Black and 7.2% are Latinx, compared with the most recent US census with 12.8% of individuals identifying as Black and 18.4% as Latinx.8,9 The gap also exists at the trainee level; 4.4% of neurology residents are Black and 7.2% are Latinx.10 Recruitment of an inclusive residency class is paramount to addressing these inequities.3,5,7,11 A record of 42,508 medical students and physicians applied for residency positions in the United States in 2020–2021, as the application season moved to a virtual format because of the COVID-1912 pandemic. Future residency application seasons will likely be a hybrid of in-person and virtual recruitment. This change presents both unique opportunities and challenges for the recruitment of a diverse and inclusive residency class.13
arental leave policies have major effects on resident well-being, gender disparities in academic medicine, 1 and maternal, child, and family health. 2 The increasing occurrence of parenthood during residency training underscores the critical importance of policies that are clear and supportive. Recent surveys have shown that approximately 40% of respondents plan to have children during residency. 3 A recent editorial in the New England Journal of Medicine recommended that parental leave during graduate medical education (GME) should include a minimum of 6 weeks of paid leave with the goal of increasing to 12 weeks, applicable to all trainees, without automatic extension of training. 4 A policy statement from the American Board of Medical Specialties (ABMS) in July 2020 issued similar recommendations. 5 Unfortunately, a majority of institutions lack consistent policies that meet these goals. 6 The successful revision of a parental leave policy requires understanding of and compliance with the relevant laws and regulations in GME. Clear, concise resources summarizing this information are lacking. In order to facilitate the creation of modern parental leave policies at all institutions, we summarize the pertinent regulations in this article (TABLE ). Specialtyand institution-specific factors are paramount. Accordingly, we use the field of neurology as an illustrative example for the creation of a residency program parental leave policy. However, most issues discussed here are relevant to all fields of medicine.
Similar to Saturday night palsy, Saturday night retinopathy (SNR) is a condition in which an intoxicated patient falls asleep in an unusual position leading to injury. Direct compression of the orbit leads to increased intraocular pressure, optic nerve edema, and intraorbital arterial and venous vessel compression with vision loss due to ischemia. 1 Bilateral hippocampal ischemia leading to anterograde amnestic syndrome is a new phenomenon that has been described in the setting of multiple drugs of abuse. Our patient developed SNR and anterograde amnestic syndrome after using intranasal fentanyl. Case report A 36-year-old man with a history of substance abuse for intranasal heroin, presented with right eye (OD) ptosis, complete ophthalmoplegia, amaurosis, and confusion. He reported intranasal heroin use a few days before his presentation but denied trauma, fever, chills, weight loss, or intravenous drug use. On examination, the patient was afebrile with normal vital signs, he had no light perception OD, 20/20 vision left eye, an afferent pupillary defect, global restriction of extraocular movements, and periorbital swelling with chemosis. Fundoscopic examination showed diffuse pallor OD without disc swelling, cherry red spot, or choroidal flush. He was oriented to place but not date, and his speech was fluent without any paraphasic errors. Calculations were intact but delayed recall was 0/3 at 5 minutes. During the examination, he repeatedly asked "am I going to die?" During reevaluation 4 hours later, the patient did not recognize any of the neurologists on the team. He was not able to remember a simple story, phrase, or series of words beyond 30 seconds. He had a leukocytosis of 11.78 K/μL and aspartate aminotransferase was elevated at 57 U/L. The rest of his complete blood count, coagulation studies, comprehensive metabolic profile, and blood cultures were normal. CSF analysis showed 1 white blood cell, protein of 42 mg/dL, and glucose of 77 mg/dL. Toxicology screen was positive for fentanyl. CT orbits were notable for preseptal soft-tissue swelling without extension into the orbit with no associated orbital fat stranding. MRI showed diffusion-weighted imaging restriction along the length of the right optic nerve with increased T2/fluid-attenuated inversion recovery signal, enlarged right extraocular muscles, and extensive soft-tissue swelling along the right frontal, preseptal, and premaxillary soft tissues. Extensive bilateral symmetric diffusion restriction and swelling with apparent diffusion coefficient correlate was noted in the hippocampal gyri (figure 1). Magnetic resonance angiography demonstrated normal flow within the ophthalmic arteries and magnetic resonance venography did not show any venous sinus thrombosis. Fluorescein angiography showed early minimal filling, with rapid washout and diffuse choroidal nonperfusion (figure 2).
Appropriate parental leave policies remain an unmet need in graduate medical education. Although current legal and institutional guidelines allow for policies that support parental leave, there are many challenges and perceived barriers to consider in developing and implementing a successful policy. In 2018, we revised the parental leave policy for our neurology residency. Here we describe the development of our policy, measure its impact, and offer guidelines for other programs to develop a similar approach. We propose solutions to commonly encountered problems, focusing on training and education, staffing of clinical services, evolving legal requirements, resident wellbeing and equity, and financial support.
reports no disclosures. Joseph Rosenthal reports no disclosures. Erika Williams reports no disclosures. Tracey Milligan reports no disclosures.
No abstract
reports no disclosures. Kathryn Holroyd reports no disclosures. Denis Balaban reports no disclosures. Wai-Ying Wendy Yau reports no disclosures.
BACKGROUND The neurologic assessment in neuro-oncology (NANO) scale was developed as a standardized metric to objectively measure neurologic function in patients with brain tumors and complement radiographic assessment in defining overall outcome. The scale has been incorporated in clinical trials. Early data is suggestive of feasibility and that NANO contributes to overall outcome assessment. However, real-world use of the NANO scale to drive clinical-decision making and the predictive value of the NANO scale to determine overall survival remains unclear in IDH-wt GBM. METHODS We report on an ongoing study using the NANO scale to evaluate neurologic function in patients with IDH-wt GBM, seen at Dana-Farber Cancer Institute (DFCI). Patient demographics, tumor histology and molecular status, treatment history and progression dates are being captured. NANO score, as collected by a built-in scale in our institutional electronic medical record (EMR), functional status (Karnofsky performance status) and corticosteroid dose are collected at prespecified time points (prior to start of therapy, and during each subsequent MRI visit). Changes in the NANO score will be correlated to overall survival. Statistical analyses including descriptive data analysis and generalized linear models will be performed using R (version 3.4.3). RESULTS Since June 2020, 50 patients have been enrolled in this study, including 42 (84%) with ≥2 follow up visits. Study accrual was initially impacted by the COVID-19 pandemic, but adaptation to a virtual platform for NANO allowed for improved recruitment and follow up of patients. Study results will be available for discussion at the 2021 SNO conference. CONCLUSIONS Evaluation of neurologic function by NANO is feasible in a virtual framework in a prospective study in patients with GBM, aided by integration of the scale in our institutional EMR. NANO is able to objectively track neurologic function throughout disease course in IDH-wt GBM.
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