Objective: To determine the incidence and mortality rates and predictors of death in myasthenia gravis (MG) and MG crisis in a large US cohort. Methods: Our cohort was identified from the Nationwide Inpatient Sample database for the years 2000 through 2005 using ICD-9-CM codes. MG crisis was identified by the principal diagnosis code or by the presence of respiratory failure. The incidence of MG was stratified by age, ethnicity, and gender. Multivariate logistic regression analysis was used to identify predictors of mortality in MG. For trend analyses of immune intervention, we used the Cochrane-Armitage test. Results: After data cleansing, 5,502 patients with MG were included. In women, the incidence of admission was two to three times higher during the first 5 decades. In men, the incidence of admission was higher during the sixth, seventh, and eighth decades. The annual incidence rate of MG was higher in black women (0.01 per 1,000 persons/year) compared to white women and white and black men (0.009, 0.008, and 0.007 per 1,000 persons/year). The overall in-hospital mortality rate was 2.2%, being higher in MG crisis (4.47%). Older age and respiratory failure were the predictors of death, with adjusted odds ratios of 9.28 (95% confidence interval [CI], 3.31, 26.0) and 3.58 (95% CI, 2.01, 6.38). The trend of IV immunoglobulin utilization has increased compared to plasma exchange and thymectomy (p < 0.0001). Conclusion: Myasthenia gravis (MG) is still a disease of young women and old men, as reflected by the hospital admission rates. In-hospital mortality of MG is low. Hospital utilization of IV immunoglobulin has significantly increased compared to plasma exchange and thymectomy.

Though high-frequency alternating current (HFAC) can block nerve conduction, the block is invariably preceded by an onset response which is a period of repetitive nerve firing. We tested the hypothesis that slowly ramping up the amplitude of the HFAC waveform could produce block without this initial onset response. Computer simulations were performed, using the McIntyre-Richardson-Grill (MRG) model of myelinated mammalian axon. A ramped-amplitude HFAC was applied to axons of diameters ranging from 7.3 microm to 16 microm and at frequencies ranging from 3125 Hz to 40 kHz. The ramped-amplitude HFAC was also investigated in vivo in preparations of rat sciatic nerve. Sinusoidal voltage-regulated waveforms, at frequencies between 10 kHz and 30 kHz, were applied with initial amplitudes of 0 V, linearly increasing with time to 10 V. Ramp durations ranged from 0 s to 60 s. In both the MRG model simulations and the experiments, ramping the HFAC waveform did not eliminate the onset response. In the rat experiments, the peak amplitude of the onset response was lessened by ramping the amplitude, but both the onset response duration and the amount of onset activity as measured by the force-time integral were increased.

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.