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Biomedical subjects

S Andrew Josephson

Publications and source records attributed to S Andrew Josephson.

8 recordsLinked to original sources
PubMed2006

NIH Stroke Scale reliability in ratings from a large sample of clinicians.

OBJECTIVE: The NIH Stroke Scale (NIHSS) is widely used in stroke clinical care and trials. Certification in its use, most commonly through rating of video vignettes, is routinely required. To investigate the reliability of the NIHSS in a representative sample of raters, we examined the results of the most frequently used certification examination. METHODS: At the invitation of the National Stroke Association, we analyzed the results of all raters who completed one of two multiple patient videotaped certification examinations from 1998 to 2004. Total scores for each vignette were calculated and ratings were compared based on percentile of responses and modified kappa scores. RESULTS: There were 7,405 unique raters with 38,148 individual NIHSS item responses; median scores for each vignette ranged from 0 to 31. Total NIHSS scores varied widely between raters; scoring for 7 of the 11 patients (64%) had a four or more point difference in NIHSS score from the 5th to 95th percentile. The aphasia (kappa = 0.60) and facial palsy (0.65) items on the test contributed most to the variance in the total NIHSS score. Nurses agreed with the most common response on scoring more frequently than physicians (p < 0.0001). Taking the certification examination multiple times did not improve agreement. CONCLUSIONS: In a large diverse sample of clinicians, inter-rater reliability for individual elements of the NIHSS on videotaped vignettes was generally good, but overall scoring was inconsistent and could impact clinical trial results. Whether additional training, modification of examination elements, or clearer definitions for scoring could improve reliability requires further study.

Certification↗
PubMed2006

National Stroke Association guidelines for the management of transient ischemic attacks.

OBJECTIVE: Transient ischemic attacks are common and important harbingers of subsequent stroke. Management varies widely, and most published guidelines have not been updated in several years. We sought to create comprehensive, unbiased, evidence-based guidelines for the management of patients with transient ischemic attacks. METHODS: Fifteen expert panelists were selected based on objective criteria, using publication metrics that predicted nomination by practitioners in the field. Prior published guidelines were identified through systematic review, and recommendations derived from them were rated independently for quality by the experts. Highest quality recommendations were selected and subsequently edited by the panelists using a modified Delphi approach with multiple iterations of questionnaires to reach consensus on new changes. Experts were provided systematic reviews of recent clinical studies and were asked to justify wording changes based on new evidence and to rate the final recommendations based on level of evidence and quality. No expert was allowed to contribute to recommendations on a topic for which there could be any perception of a conflict of interest. RESULTS: Of 257 guidelines documents identified by systematic review, 13 documents containing 137 recommendations met all entry criteria. Six iterations of questionnaires were required to reach consensus on wording of 53 final recommendations. Final recommendations covered initial management, evaluation, medical treatment, surgical treatment, and risk factor management. INTERPRETATION: The final recommendations on the care of patients with transient ischemic attacks emphasize the importance of urgent evaluation and treatment. The novel approach used to develop these guidelines is feasible, allows for rapid updating, and may reduce bias.

Health Planning Guidelines↗
PubMed2006

Complex visual hallucinations as post-ictal cortical release phenomena.

Visual hallucinations can be elementary or complex and appear in a wide variety of neurological disorders. Hallucinations associated with seizures can either be ictal or part of a post-ictal cortical release phenomenon, and their features may help distinguish their etiology. We describe two patients with suspected ictal occipital lobe lesions with elementary hallucinations that were followed by post-ictal complex hallucinations.The pathophysiologies of elementary and complex hallucinations are reviewed. The sequential occurrence of these two distinct types of hallucinations in these patients emphasizes the observation that hallucinations associated with seizures can result from both irritative and cortical release mechanisms.

Adolescent↗
PubMed2005

Incidence of contrast nephropathy from cerebral CT angiography and CT perfusion imaging.

The incidence of contrast-induced nephropathy was examined in 1,075 patients receiving routine CT angiography and CT perfusion brain imaging at a single institution. Fifty-two patients had a creatinine rise of > or =0.5 mg/dL. In four patients (0.37%), the administration of IV contrast medium possibly contributed to renal failure. Two patients (0.19%) received temporary hemodialysis during hospitalization. The incidence of contrast nephropathy in neurovascular patients is low.

Cohort Studies↗
PubMed2004

Continuous bleeding from a basilar terminus aneurysm imaged with CT angiography and conventional angiography.

We report a case of fatal subarachnoid hemorrhage from nontraumatic rupture of an aneurysm at the basilar terminus in which both computed tomography angiography and conventional angiography showed evidence of active bleeding. The time period from initial ictus to CT angiography was 30-50 minutes and to conventional angiography was 120-140 minutes. This case illustrates that aneurysmal bleeding is not necessarily as brief as a few seconds and can last up to 30 to 50 minutes and perhaps longer. Continued bleeding from an intracranial aneurysm is a rare event that can be recognized using computed tomography angiography and likely indicates a poor prognosis.

Adult↗
PubMed2002

A new first-year course designed and taught by a senior medical student.

Senior medical students have been utilized at some institutions in limited teaching roles for first-year medical students. The authors describe a pilot program in which a motivated senior medical student completely designed and taught an original course to a group of first-year students in academic year 2000-01. The 16-hour course was offered as a selective for first-year students. This course concentrated on clinically-focused topics, evidence-based medicine, and physical examination skills. Evaluations from the students in the course, as well as from a faculty advisor, were uniformly positive. This unique course filled an existing need in the first-year curriculum, and could be permanently integrated in various settings. This novel approach of a senior medical student's developing and teaching an entire first-year course benefited both the senior and first-year students and could be implemented at other institutions using similar methods or a number of suggested variations.

Curriculum↗