Pergakis Melissa B, Chang Wan-Tsu W, Gutierrez Camilo A, Neustein Benjamin, Podell Jamie E, Parikh Gunjan, Badjatia Neeraj, Motta Melissa, Lerner David P, Morris Nicholas A
From the Department of Neurology (M.B.P., C.A.G., J.E.P., G.P., N.B., M.M., N.A.M.), Program in Trauma (M.B.P., W.-T.W.C., B.N., J.E.P., G.P., N.B., M.M., N.A.M.), and Department of Emergency Medicine (W.-T.W.C.), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (D.P.L.), Lahey Hospital and Medical Center, Burlington, MA.
Neurol Educ. 2022 Nov 17;1(2):e200020. doi: 10.1212/NE9.0000000000200020. eCollection 2022 Dec.
Delays in treatment of both herpes simplex virus (HSV) encephalitis and seizures are associated with poor patient outcomes, but many physicians fail to recognize HSV despite classic presenting symptoms. Our goal was to assess trainee performance in a simulation-based case to recognize HSV encephalitis as the underlying etiology of refractory status epilepticus.
This is a prospective, observational, single-center simulation-based study of participants ranging from subinterns to attending physicians managing a patient with viral encephalitis complicated by nonconvulsive status epilepticus. Using a modified Delphi approach, we developed a list of critical actions. The primary outcome measure was critical action item sum score. We compared level of training and performance using analysis of variance as validity evidence to support our findings.
Fifty-nine trainees completed the simulation. The mean sum of critical actions completed was 13.9/25 (56%). Eighty percent of trainees administered an appropriately dosed benzodiazepine, and 97% administered a second-line agent. Despite 88% of trainees obtaining a lumbar puncture, only 47% recognized viral encephalitis as the most likely diagnosis with 36% starting appropriate treatment. There was significant effect of training level on critical action sum score (level 1 mean score [SD] = 10.8 [1.5] vs level 2 mean score [SD] = 12.2 [2.5] vs level 3 mean score [SD] = 13.9 [3.0] vs level 4 mean score [SD] = 18.2 [3.2], < 0.001, = 0.38).
Although initial seizure treatment was sufficient, failure to recognize HSV encephalitis was common with few trainees initiating appropriate treatment potentially leading to poor outcomes in real-life scenarios. High-fidelity simulation holds promise as an assessment tool in identifying trainee knowledge gaps and why classic clinical cases escape trainee diagnosis.
单纯疱疹病毒（HSV）脑炎及癫痫发作治疗的延迟均与患者不良预后相关，但许多医生即便面对典型的症状表现，仍无法识别HSV。我们的目标是评估学员在基于模拟病例中识别HSV脑炎作为难治性癫痫持续状态潜在病因的表现。
这是一项前瞻性、观察性、单中心基于模拟的研究，参与者包括从实习医生到主治医生，他们负责管理一名患有病毒性脑炎并发非惊厥性癫痫持续状态的患者。我们采用改良的德尔菲法制定了一系列关键操作清单。主要结局指标是关键操作项目总分。我们使用方差分析比较培训水平和表现，以此作为支持我们研究结果的效度证据。
59名学员完成了模拟。完成的关键操作平均总分是13.9/25（56%）。80%的学员给予了适当剂量的苯二氮䓬类药物，97%的学员给予了二线药物。尽管88%的学员进行了腰椎穿刺，但只有47%的学员将病毒性脑炎识别为最可能的诊断，36%的学员开始了适当的治疗。培训水平对关键操作总分有显著影响（1级平均得分[标准差]=为10.8[1.5]，2级平均得分[标准差]=12.2[2.5]，3级平均得分[标准差]=13.9[3.0]，4级平均得分[标准差]=18.2[3.2]，<0.001，=0.38）。
虽然初始癫痫治疗是充分的，但未能识别HSV脑炎很常见，很少有学员开始适当治疗，这在现实场景中可能导致不良后果。高保真模拟有望作为一种评估工具，用于识别学员的知识差距以及经典临床病例为何未被学员诊断出来。
