J. Douglas Miles

BACKGROUND The occurrence of multiple autoimmune neurological disorders in one patient is rare. Here, we present the case of a woman who exhibited clinical features and antibody titers consistent with myasthenia gravis (MG), neuromyelitis optica (NMO), and anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. CASE REPORT A 37-year-old woman with a 10-year history of MG presented with a sudden loss of central vision in her right eye. Magnetic resonance imaging (MRI) revealed new enhancement of the right optic nerve, and additional cervical and thoracic spine scans showed continuous demyelination of the central cord. Given these findings, a primary demyelinating condition was suspected, and an NMO antibody test confirmed the diagnosis. Two years later, the patient developed significant behavioral changes, including neglecting her usual activities and displaying diminished responsiveness. She became mute and uncooperative with commands. Based on clinical suspicion of anti-NMDAR encephalitis, a comprehensive work-up revealed the presence of NMDAR antibodies, confirming the diagnosis. The patient was treated with plasma exchange, resulting in a marked improvement in her encephalopathy. CONCLUSIONS Over 12 years, this patient developed clinical manifestations of 3 distinct neurological autoimmune disorders. This case underscores the critical need for clinicians to remain alert to overlapping neurological conditions, enabling timely diagnoses and interventions that can help improve clinical outcomes and prevent unnecessary delays in treatment.

How can educators foster a passion for teaching in a health sciences student who has never considered education as a career? The author recounts 5 experiences that were instrumental in shaping his own career as an educator. These experiences illustrate principles which may be used to encourage students to consider careers in education. Principles discussed include exposure to teaching opportunities while students are still studying the health sciences, recognition of students showing promise as teachers, role models, mentorship, and appropriate compensation for those in education careers.

Introduction: In Hawaiʻi, there are 367,000 Native Hawaiian and Pacific Islanders. Native Hawaiians experience health disparities in a variety of conditions, including stroke, diabetes, and cancer.  Ethnic minorities are underrepresented among physicians; this lack of physician-patient racial concordance may contribute to the disparities, as recent studies suggest that racial discordance resulted in poorer healthcare quality. This study aims to assess the current status of neurological health disparities in the Native Hawaiian population in Hawaiʻi, with a focus on identifying neurologist ethnic representation, neurological diseases, and healthcare-related challenges disproportionately affecting Native Hawaiians. Methods: An anonymous survey on physician’s attitudes and practice was emailed to all neurologists in the Hawaiʻi Neurological Society from February 2019 to June 2019. Findings: Twenty-three full responses and one partial response was received. No participants self-identified as Native Hawaiian nor did they know of any Native Hawaiian neurologists in Hawaiʻi, yet all who completed the survey reported treating Native Hawaiians in their practice (n = 23), which identifies a gap in Native Hawaiian representation in the field of neurology in Hawaiʻi. In addition, majority of participants perceived that Native Hawaiians are disproportionately affected by neurological diseases and have difficulty accessing neurology services and obtaining quality care. Conclusions: Future focus on creating opportunities to improve racially discordant physician-patient relationships and to increase Native Hawaiian representation in neurology may help narrow the gap in health disparities experienced by Native Hawaiians.

Gauging medical education quality has always remained challenging. Many studies have examined predictors of standardized exam performance; however, data sets do not distinguish by institution or curriculum. Our objective is to present a summary of variables associated with the United States Medical Licensing Examination (USMLE) scores, and thus identify institutions (and therefore curriculums) which deviate from trend lines by producing higher USMLE scores despite having lower entrance grade point averages and medical college admissions test (MCAT) scores. Data was obtained from U.S. News and World Report’s 2014 evaluation of allopathic U.S. medical schools. A univariate analysis was performed first for each variable using two sample t-test or Wilcoxon rank sum test for categorical variables, and Pearson or Spearman correlation coefficients for continuous variables. A multivariable linear regression model was developed to identify the factors contributing to USMLE scores. All statistical analyses were two-sided and performed using SAS software version 9.4 (SAS Institute Inc., Cary, NC). Univariate analysis reveals a significant association between USMLE Step 1 and 2 scores with medical college admissions test scores, grade point averages, school type (private vs. public), full-time faculty-to-student ratio, National Institute of Health funds, residency director assessment score, peer assessment score, and class size. Of these nine variables, MCAT scores and Step 1 scores display the strongest correlation (corr = 0.72, P < .0001). Multivariable analysis also supports a significant association between MCAT scores and Step scores, meanwhile National Institute of Health funding size demonstrates a negative correlation with USMLE Step 2 scores. Although MCAT scores and National Institute of Health funds are significantly associated with USMLE performance, six outlier institutions were identified, producing higher USMLE scores than trend line predictions. Outlier institutions produce USMLE scores that do not follow expected trend lines. Their performance might be explainable by differences in curriculum. Having identified these institutions, their curriculums can be further studied to determine what factors enhance student learning.

Wegener granulomatosis (WG) is an uncommon, idiopathic disorder that is characterized by granulomatous inflammation of the upper and lower respiratory tract, disseminated vasculitis involving small and medium-sized vessels, and focal segmental glomerulonephritis. Approximately 25% to 50% of patients have nervous system involvement. The brain is less frequently involved. We report a case of a 74 year-old previously well woman who presented with rapidly progressing WG that culminated in subarachnoid hemorrhage. Only six cases of subarachnoid hemorrhage in the setting of WG have previously been reported. We review the common presenting signs and symptoms, diagnosis, treatment, and complications of WG.