Abstract Background and aims Prehospital triage of patients with suspected large vessel occlusion (LVO) stroke is crucial for timely recanalization and favorable functional outcome. Selecting the optimal transport strategy (mothership vs. drip-and-ship) and transport modality remains challenging, particularly in regions with heterogeneous geography and stroke unit workflows. This study aimed to evaluate the influence of helicopter transport on prehospital triage by quantifying its impact on the probability of good functional outcome. Methods A previously described conditional probability model was applied to estimate the probability of good functional outcome in patients with suspected LVO stroke in a district of South Baden, Germany. The model incorporated prehospital triage strategy, transport modality (ground vs. helicopter), time from symptom onset to emergency call, and heterogeneity in clinical workflows among participating stroke units. The impact of helicopter transport on triage-dependent outcome probabilities was assessed. Regionally superior triage strategies were visualized using a high-resolution spatial grid map. Results Helicopter transport substantially increased the absolute probability of good functional outcome in geographically remote areas and significantly changed prehospital triage decision thresholds. Its use reduced the spatial extent in which the drip-and-ship strategy was superior. The benefit was most pronounced in regions with prolonged ground transport times and extended in-hospital workflows at primary stroke centers. Overall, helicopter availability modified the superior triage strategy across large parts of the region. Conclusions Helicopter transport significantly influences prehospital triage in suspected LVO stroke. Probability-based models incorporating this modality may enable individualized, geography- and workflow-sensitive triage decisions and optimize regional stroke systems of care. Conflict of interest Max Henningsen: nothing to disclose; Jochen Brich: nothing to disclose

Identifying suspected anterior circulation large-vessel occlusion (aLVO) strokes during emergency calls could enhance dispatch efficiency, particularly in rural areas. However, data on emergency medical dispatchers’ (EMDs) ability to recognize aLVO symptoms remain limited. This simulation study aimed to evaluate the feasibility of identifying side-specific arm paresis, side-specific conjugate eye deviation (CED), and aphasia during emergency calls by instructing layperson callers to perform brief, standardized examination steps. Two communication methods were compared: (1) telephone calls and (2) video calls. Forty-eight laypersons interacted with simulated patients presenting various stroke syndromes. Simulated EMDs conducted standardized assessments during simulated emergency calls, guiding laypersons through patient examinations. In 96 telephone-assisted and 95 video-assisted calls, EMDs identified aLVO stroke symptoms with high accuracy. In telephone calls, accuracy was 0.92 for side-specific arm paresis, 0.98 for side-specific CED, and 0.88–0.99 for aphasia. In video calls, accuracy was 0.97 for side-specific arm paresis, 0.97 for side-specific CED, and 0.94-1.00 for aphasia. These findings suggest that EMDs can identify stroke symptoms indicative for aLVO via both telephone and video calls using a standardized dispatch protocol to guide lay bystanders. This study provides a foundation for future real-world research on implementing aLVO detection protocols in emergency dispatch.

Falls in elderly people are becoming increasingly important in acute and emergency medicine, also because of demographic change. Due to physiological conditions and comorbidities, the initial treatment already has a strong impact on the short-term, but also on the long-term course of the disease. This article will take a closer look at the acute treatment of elderly trauma patients in order to improve the care of this vulnerable patient group.

Background Detecting an anterior circulation large-vessel occlusion (aLVO) as a cause of stroke during emergency calls could optimise dispatch, particularly in rural areas. Numerous stroke severity scales assessing motor and cortical signs have been designed for direct patient contact; however, none have been purposely designed for emergency calls. This study aimed to prospectively validate the novel Freiburg Neurointerventional Score (FRENS) in patients presenting with a suspected acute stroke to detect aLVO.Methods Patients aged ≥18 years with suspected acute stroke brought directly to our tertiary hospital by paramedics, between May 2021 and 2022, were included in this study. We used the FRENS and National Institutes of Health Stroke Scale (NIHSS) to analyse the FRENS convergent validity. We evaluated and compared the predictive ability and test characteristics of the FRENS and five established NIHSS-based stroke severity scales for the detection of an aLVO stroke. We analysed the number of steps required for the completion of the FRENS algorithm.Results Among the 1042 analysed patients, the FRENS items showed high convergent validity with corresponding NIHSS items. A positive FRENS was statistically significantly correlated with an aLVO stroke. The FRENS had the highest sensitivity and negative predictive values for an aLVO stroke and the highest sensitivity value for M2 occlusions. The FRENS provided results after two and all four steps, in 71% and <3% of cases, respectively.Conclusions The FRENS enabled the rapid, sensitive detection of an aLVO in patients with suspected acute stroke. Designed for use in emergency calls, the FRENS requires translation and validation in a prehospital setting.

AbstractIntroductionAphasia and neglect in combination with hemiparesis are reliable indicators of large anterior vessel occlusion (LAVO). Prehospital identification of these symptoms is generally considered difficult by emergency medical service (EMS) personnel. Therefore, we evaluated the simple non‐paretic‐hand‐to‐opposite‐ear (NPE) test to identify aphasia and neglect with a single test. As the NPE test includes a test for arm paresis, we also evaluated the diagnostic ability of the NPE test to detect LAVO in patients with suspected stroke.MethodsIn this prospective observational study, we performed the NPE test in 1042 patients with suspected acute stroke between May 2021 and May 2022. We analyzed the correlation between the NPE test and the aphasia/neglect items of the National Institutes of Health Stroke Scale. Additionally, the predictive values of the NPE test for LAVO detection were calculated.ResultsThe NPE test showed a strong, significant correlation with both aphasia and neglect. A positive NPE test result predicted LAVO with a sensitivity of 0.70, a specificity of 0.88, and an accuracy of 0.85. Logistic regression analysis showed an odds ratio of 16.14 (95% confidence interval 10.82–24.44) for predicting LAVO.ConclusionThe NPE test is a simple test for the detection of both aphasia and neglect. With its predictive values for LAVO detection being comparable to the results of LAVO scores in the prehospital setting, this simple test might be a promising test for prehospital LAVO detection by EMS personnel. Further prospective prehospital validation is needed.

Background Endovascular thrombectomy (ET), combined with intravenous thrombolysis if possible, is an effective treatment option for patients with stroke who have confirmed anterior large vessel occlusion (aLVO). However, ET is mainly limited to comprehensive stroke centers (CSCs), resulting in a lack of ET capacity in remote, sparsely populated areas. Most stroke networks use the “Drip and Ship” or “Mothership” strategy, resulting in either delayed ET or intravenous thrombolysis, respectively. Objective This study protocol introduces the Leitstellen-Basierte Erkennung von Schlaganfall-Patienten für eine Thrombektomie und daraufhin abgestimmte Optimierung der Rettungskette (LESTOR) strategy, developed to optimize the preclinical part of the stroke chain of survival to improve the clinical outcome of patients with suspected aLVO stroke. This involves refining the dispatch strategy for identifying patients with acute aLVO stroke using a phone-based aLVO query. This includes dispatching emergency physicians and emergency medical services (EMS) to urban emergency sites, as well as dispatching helicopter EMS to remote areas. If a highly suspected aLVO is identified after a standardized aLVO score evaluation during a structured examination at the emergency scene, prompt transport to a CSC should be prioritized. Methods The LESTOR study is a controlled, nonrandomized study implementing the LESTOR strategy, with a stepped-wedge, cluster trial design in 6 districts in southwest Germany. In an interprofessional, iterative approach, an aLVO query or dispatch protocol intended for use by dispatchers, followed by a coordinated aLVO examination score for use by EMS, is being developed, evaluated, and pretested in a simulation study. After the training of all participating health care professionals with the corresponding final aLVO query, the LESTOR strategy is being implemented stepwise. Patients otherwise receive usual stroke care in both the control and intervention groups. The primary outcome is the modified Rankin Scale at 90 days in patients with stroke receiving endovascular treatment. We will use a generalized linear mixed model for data analysis. This study is accompanied by a cost-effectiveness analysis and a qualitative process evaluation. Results This paper describes and discusses the protocol for this controlled, nonrandomized LESTOR study. Enrollment was completed in June 2023. Data analysis is ongoing and the first results are expected to be submitted for publication in 2024. The project started in April 2020 and will end in February 2024. Conclusions We expect that the intervention will improve the clinical outcome of patients with aLVO stroke, especially outside the catchment areas of CSCs. The results of the accompanying process evaluation and the cost-effectiveness analysis will provide further insights into the implementation process and allow for a better interpretation of the results. Trial Registration German Clinical Trials Register DRKS00022152; https://drks.de/search/de/trial/DRKS00022152 International Registered Report Identifier (IRRID) DERR1-10.2196/51683

When stroke patients with suspected anterior large vessel occlusion (aLVO) happen to live in rural areas, two main options exist for prehospital transport: (i) the drip-and-ship (DnS) strategy, which ensures rapid access to intravenous thrombolysis (IVT) at the nearest primary stroke center but requires time-consuming interhospital transfer for endovascular thrombectomy (EVT) because the latter is only available at comprehensive stroke centers (CSC); and (ii) the mothership (MS) strategy, which entails direct transport to a CSC and allows for faster access to EVT but carries the risk of IVT being delayed or even the time window being missed completely. The use of a helicopter might shorten the transport time to the CSC in rural areas. However, if the aLVO stroke is only recognized by the emergency service on site, the helicopter must be requested in addition, which extends the prehospital time and partially negates the time advantage. We hypothesized that parallel activation of ground and helicopter transportation in case of aLVO suspicion by the dispatcher (aLVO-guided dispatch strategy) could shorten the prehospital time in rural areas and enable faster treatment with IVT and EVT. As a proof-of-concept, we report a case from the LESTOR trial where the dispatcher suspected an aLVO stroke during the emergency call and dispatched EMS and HEMS in parallel. Based on this case, we compare the provided aLVO-guided dispatch strategy to the DnS and MS strategies regarding the times to IVT and EVT using a highly realistic modeling approach. With the aLVO-guided dispatch strategy, the patient received IVT and EVT faster than with the DnS or MS strategies. IVT was administered 6 min faster than in the DnS strategy and 22 min faster than in the MS strategy, and EVT was started 47 min earlier than in the DnS strategy and 22 min earlier than in the MS strategy. In rural areas, parallel activation of ground and helicopter emergency services following dispatcher identification of stroke patients with suspected aLVO could provide rapid access to both IVT and EVT, thereby overcoming the limitations of the DnS and MS strategies.

Introduction Stroke detection in the preclinical setting is challenging, resulting in more than 1/3 of missed strokes by EMS personnel. Recently, prehospital identification of anterior large vessel occlusion (LVO) stroke has come into focus. Cortical signs have a high predictive value for the presence of LVO stroke but are often missed. Simulated patients (SPs) could be an excellent tool to train EMS personnel in the evaluation of stroke syndromes with cortical symptoms but it has not been studied whether they can simulate these important signs convincingly. The main objective of this study was thus to examine whether SPs can simulate stroke syndromes and symptoms so that stroke experts can identify them correctly and reliably, applying the NIH stroke scale (NIHSS). Methods Lay actors were trained to simulate one of 8 stroke syndromes either typical of a lacunary stroke or of an anterior LVO stroke and then videotaped during an examination according to the NIHSS. Stroke experts were asked to rate each item of the NIHSS based on the videos, determine which stroke syndrome was being demonstrated, and rate the quality of the simulation. The primary outcome was the correct identification of the target stroke syndrome by the expert raters. Secondary outcomes were the agreement of the rating of the NIHSS score with the target NIHSS score and the expert raters' assessment of the quality of the simulation. Results Seven of eight syndromes were rated correctly by at least twelve of fifteen raters and the mean rated NIHSS score was within one point of the target score for six of eight syndromes. The mean rating for the quality of simulation was between 3.54 and 3.98 (as rated on a scale from 1 to 4) for each syndrome. Discussion/Conclusion SPs are capable of simulating acute stroke symptoms and syndromes accurately and convincingly. They thus represent a great resource to improve educational interventions that improve stroke recognition.

Introduction Stroke detection in the preclinical setting is challenging, resulting in more than 1/3 of missed strokes by EMS personnel. Recently, prehospital identification of anterior large vessel occlusion (LVO) stroke has come into focus. Cortical signs have a high predictive value for the presence of LVO stroke but are often missed. Simulated patients (SPs) could be an excellent tool to train EMS personnel in the evaluation of stroke syndromes with cortical symptoms but it has not been studied whether they can simulate these important signs convincingly. The main objective of this study was thus to examine whether SPs can simulate stroke syndromes and symptoms so that stroke experts can identify them correctly and reliably, applying the NIH stroke scale (NIHSS). Methods Lay actors were trained to simulate one of 8 stroke syndromes either typical of a lacunary stroke or of an anterior LVO stroke and then videotaped during an examination according to the NIHSS. Stroke experts were asked to rate each item of the NIHSS based on the videos, determine which stroke syndrome was being demonstrated, and rate the quality of the simulation. The primary outcome was the correct identification of the target stroke syndrome by the expert raters. Secondary outcomes were the agreement of the rating of the NIHSS score with the target NIHSS score and the expert raters’ assessment of the quality of the simulation. Results Seven of eight syndromes were rated correctly by at least twelve of fifteen raters and the mean rated NIHSS score was within one point of the target score for six of eight syndromes. The mean rating for the quality of simulation was between 3.54 and 3.98 (as rated on a scale from 1 to 4) for each syndrome. Discussion/Conclusion SPs are capable of simulating acute stroke symptoms and syndromes accurately and convincingly. They thus represent a great resource to improve educational interventions that improve stroke recognition.

Timely treatment of stroke is critical to minimize brain damage. Therefore, efforts are being made to educate the public on detecting stroke symptoms, e.g., face, arms, and speech test (FAST). In this position paper, we propose to perform the arm weakness test using the integrated video tracking from an iPhone - some general tests to assess the tracking quality and discuss potential critical points. The test has been performed on 4 stroke patients. The result is compared with the report of the clinician. Although presenting some limitations, the system proved to be able to detect arm weakness as a symptom of stroke. We envisage that introducing a portable body tracking system in such clinical tests will provide advantages in terms of objectivity, repeatability, and the possibility to record and compare groups of patients.

Abstract BackgroundLarge vessel occlusions (LVO) cause up to 30% of acute ischemic strokes. Mechanical thrombectomy is the first line treatment performed by neurointerventionalists. In Germany, neurointerventionalists are mostly situated in comprehensive stroke centres (CSC). Thus, long transport distances to CSCs may be necessary. The aim of this study is to implement and evaluate an intervention that involves lay first responders in the early identification of LVO, followed by a direct assignment to a CSC.Methods This controlled study with a stepped-wedge design and clustering of six emergency control centres in southwest Germany will stepwise implement LVO screening performed during the emergency call. Individuals with suspected LVO in both the control and intervention group (n=250) will undergo the usual treatment. In addition, emergency medical service dispatchers will screen patients in the intervention group for cortical stroke symptoms. For those with suspected LVO, air rescue is initiated immediately by the dispatchers. If the emergency medical service on scene confirms the suspected LVO, the patient benefits from accelerated transportation to the CSC. The primary endpoint is the clinical outcome measured by the modified Rankin Scale 90 days post-stroke. In addition, we will perform a qualitative process evaluation.Discussion We will assess the feasibility and cost-effectiveness of a systematic screening for symptoms of acute LVO implemented at the emergency control centre. The process evaluation will provide additional insight into how the participating emergency professionals perceive the intervention and the psychological impact on lay first responders. We hypothesize that early, pre-hospital identification of LVO patients and an optimized rescue chain will enable earlier treatment - especially in rural areas. We expect improved clinical outcomes of LVO patients and a better understanding for future studies with larger sample sizes.Trial registrationDRKS (German Clinical Trials Register), DRKS-ID: DRKS00022152. Registered 19th October 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022152; WHO UTN: U1111-1253-5758.

Background Large vessel occlusions (LVO) cause up to 30% of acute ischemic strokes. Mechanical thrombectomy is the first line treatment performed by neurointerventionalists. In Germany, neurointerventionalists are mostly situated in comprehensive stroke centres (CSC). Thus, long transport distances to CSCs may be necessary. The aim of this study is to design, implement and evaluate an intervention that involves lay first responders (LFR) in the early identification of LVO, followed by a direct assignment to a CSC. Methods This controlled study with a stepped-wedge design and clustering of six emergency control centres in southwest Germany will stepwise implement LVO screening performed during the emergency call. Individuals with suspected LVO in both the control and intervention group (n=250) will undergo the usual treatment. In addition, emergency medical service dispatchers will screen patients in the intervention group for cortical stroke symptoms and refer those patients with suspected LVO to a CSC, either by ambulance or air rescue. The primary endpoint is the clinical outcome measured by the modified Rankin Scale 90 days post-stroke. In addition, we will perform a qualitative process evaluation. Discussion We will assess the feasibility and cost-effectiveness of a systematic screening for symptoms of LVO stroke implemented at the emergency control centre. The process evaluation will provide additional insight into how the participating emergency professionals perceive the intervention and the psychological impact on LFR. Conclusions We hypothesize that early, pre-hospital identification of LVO patients and an optimized rescue chain will enable earlier treatment - especially in rural areas. We expect improved clinical outcomes for LVO patients and a better understanding for future studies with larger sample sizes. Trial registration DRKS, DRKS-ID: DRKS00022152. Registered 19 th October 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022152; WHO UTN: U1111-1253-5758.

Der Sturz im Alter gewinnt nicht zuletzt aufgrund des demografischen Wandels auch in der Akut- und Notfallmedizin an Bedeutung. Durch physiologische Gegebenheiten und Komorbiditäten hat bereits die Initialbehandlung starke Auswirkungen auf den kurzfristigen, aber auch auf den langfristigen Krankheitsverlauf. In diesem Artikel soll die Akutbehandlung des betagten Traumapatienten näher beleuchtet werden, um die Versorgung dieser vulnerablen Patientengruppe zu verbessern.

Background and Objectives To compare a blended learning approach with traditional face-to-face instruction in terms of their individual effectiveness in imparting neurologic examination (NE) skills in medical students. Methods We conducted a prospective controlled study of 4th-year medical students (n = 163) who were pseudorandomly distributed into 2 groups. Group A (n = 87) was subjected to a traditional teaching method comprising 2 face-to-face sessions. Group B (n = 76) underwent blended learning, which consisted of an individual preparation period using a course handbook and videoclips, plus a single face-to-face session. NE skill acquisition was assessed by an objective structured clinical examination (OSCE). Questionnaires were used for evaluation. Results Comparison of mean OSCE scores in groups A vs B revealed that NE skill acquisition was better in group B (blended learning), with a moderate effect size, a smaller OSCE score variance, and fewer students performing poorly than in group A (face-to-face instruction). Student evaluation revealed that both teaching approaches were well accepted, but a higher level of satisfaction was associated with the blended learning approach. This method also provided more time for practice and feedback. Discussion The blended learning approach is a highly efficacious and valued method for teaching NE skills. It offers instructors and faculty the advantage of successful skill acquisition in students despite the considerably reduced attendance time.

Introduction: Organizing regional stroke care considering thrombolysis as well as mechanical thrombectomy (MTE) remains challenging in light of a wide range of regional population distribution. To compare outcomes of patients in a stroke network covering vast rural areas in southwestern Germany who underwent MTE via direct admission to a single comprehensive stroke center [CSC; mothership (MS)] with those of patients transferred from primary stroke centers [PSCs; drip-and-ship (DS)], we undertook this analysis of consecutive stroke patients with MTE. Materials and Methods: Patients who underwent MTE at the CSC between January 2013 and December 2016 were included in the analysis. The primary outcome measure was 90-day functional independence [modified Rankin score (mRS) 0–2]. Secondary outcome measures included time from stroke onset to recanalization/end of MTE, angiographic outcomes, and mortality rates. Results: Three hundred and thirty-two consecutive patients were included (MS 222 and DS 110). Median age was 74 in both arms of the study, and there was no significant difference in baseline National Institutes of Health Stroke Scale scores (median MS 15 vs. 16 DS). Intravenous (IV) thrombolysis (IVT) rates differed significantly (55% MS vs. 70% DS, p = 0.008). Time from stroke onset to recanalization/end of MTE was 112 min shorter in the MS group (median 230 vs. 342 min, p < 0.001). Successful recanalization [thrombolysis in cerebral infarction (TICI) 2b-3] was achieved in 72% of patients in the MS group and 73% in the DS group. There was a significant difference in 90-day functional independence (37% MS vs. 24% DS, p = 0.017), whereas no significant differences were observed for mortality rates at 90 days (MS 22% vs. DS 17%, p = 0.306). Discussion: Our data suggest that patients who had an acute ischemic stroke admitted directly to a CSC may have better 90-day outcomes than those transferred secondarily for thrombectomy from a PSC.

Background and Objectives To compare a blended learning approach with traditional face-to-face instruction in terms of their individual effectiveness in imparting neurologic examination (NE) skills in medical students. Methods We conducted a prospective controlled study of 4th-year medical students (n = 163) who were pseudorandomly distributed into 2 groups. Group A (n = 87) was subjected to a traditional teaching method comprising 2 face-to-face sessions. Group B (n = 76) underwent blended learning, which consisted of an individual preparation period using a course handbook and videoclips, plus a single face-to-face session. NE skill acquisition was assessed by an objective structured clinical examination (OSCE). Questionnaires were used for evaluation. Results Comparison of mean OSCE scores in groups A vs B revealed that NE skill acquisition was better in group B (blended learning), with a moderate effect size, a smaller OSCE score variance, and fewer students performing poorly than in group A (face-to-face instruction). Student evaluation revealed that both teaching approaches were well accepted, but a higher level of satisfaction was associated with the blended learning approach. This method also provided more time for practice and feedback. Discussion The blended learning approach is a highly efficacious and valued method for teaching NE skills. It offers instructors and faculty the advantage of successful skill acquisition in students despite the considerably reduced attendance time.

Background and Purpose: This study aims to assess the number of patients with acute ischemic cerebrovascular events seeking in-patient medical emergency care since the implementation of social distancing measures in the coronavirus disease 2019 (COVID-19) pandemic. Methods: In this retrospective multicenter study, data on the number of hospital admissions due to acute ischemic stroke or transient ischemic attack and numbers of reperfusion therapies performed in weeks 1 to 15 of 2020 and 2019 were collected in 4 German academic stroke centers. Poisson regression was used to test for a change in admission rates before and after the implementation of extensive social distancing measures in week 12 of 2020. The analysis of anonymized regional mobility data allowed for correlations between changes in public mobility as measured by the number and length of trips taken and hospital admission for stroke/transient ischemic attack. Results: Only little variation of admission rates was observed before and after week 11 in 2019 and between the weeks 1 and 11 of 2019 and 2020. However, reflecting the impact of the COVID-19 pandemic, a significant decrease in the number of admissions for transient ischemic attack was observed (−85%, −46%, −42%) in 3 of 4 centers, while in 2 of 4 centers, stroke admission rates decreased significantly by 40% and 46% after week 12 in 2020. A relevant effect on reperfusion therapies was found for 1 center only (thrombolysis, −60%; thrombectomy, −61%). Positive correlations between number of ischemic events and mobility measures in the corresponding cities were identified for 3 of 4 centers. Conclusions: These data demonstrate and quantify decreasing hospital admissions due to ischemic cerebrovascular events and suggest that this may be a consequence of social distancing measures, in particular because hospital resources for acute stroke care were not limited during this period. Hence, raising public awareness is necessary to avoid serious healthcare and economic consequences of undiagnosed and untreated strokes and transient ischemic attacks.

Background Conflicts of interest (COIs), including those arising from interactions with pharmaceutical companies, may lead to bias in medical data. Although medical students are now requesting more education on COIs and bias, they are still not adequately taught during medical school, and few published courses on this topic exist . The objective of our study was therefore to evaluate the feasibility and effectiveness of a blended-learning course for detecting and avoiding bias in medical data, with a special focus on COIs. Methods We developed a blended learning course on bias detection, COIs, and risk communication. It was piloted in the Fall Semester of 2019/2020 using a pre/post-test design. The primary outcome was a gain in bias detection skills, tested by a novel key feature test. Secondary outcomes were (i) skepticism (tested using an attitude questionnaire), (ii) the intention to manage COIs in a professional way so as to avoid bias (tested using a situational judgment test) and (iii) the course evaluation by the students. Results Seventeen students participated in the study. The key feature test showed a significant improvement in bias detection skills at post-testing, with a difference in means of 3.1 points (95%-CI: 1.7–4.4, p -value: < 0.001; highest possible score: 16 points). The mean score after the course was 6.21 (SD: 2.62). The attitude questionnaire and situational judgment test also showed an improvement in skepticism and intentions to manage COIs, respectively. Students evaluated the course as having been worthwhile (Median: 5, IQR: 0.75, Likert-Scale 1–6, 6 = fully applicable). Conclusions The blended learning format of the course was feasible and effective. The results suggest a relevant learning gain; however, the low mean score on the key feature test after the course reflects the difficulty of the subject matter. Although a single course has the potential to induce significant short-term improvements in bias detection skills, the complexity of this important subject necessitates its longitudinal integration into medical curricula. This concept should include specific courses such as that presented here as well as an integration of the topic into clinical courses to improve context-related understanding of COIs and medical data bias.

OBJECTIVE:To develop an educational framework basis for improving the teaching of the neurologic examination (NE) by asking German neurologists to (1) identify the basic elements of the screening NE and (2) nominate the steps they would deem mandatory for medical students to master.METHODS:We conducted a questionnaire-based survey among neurologists working in a hospital or ambulatory setting in southwest Germany. To define the screening NE, neurologists were asked to list the NE components they normally use in clinical encounters with patients in whom neurologic findings are unlikely. Furthermore, they were asked to identify additional elements of the NE which they would consider mandatory for students to master.RESULTS:Our neurologists nominated a set of 23 elements as being essential for a screening NE. There was high consensus among the 2 groups, and the results were concordant with international data. Furthermore, nearly 60 additional maneuvers of the NE were deemed obligatory for students to master.CONCLUSION:Our results reinforce the international consensus for screening NE components and confirm a large set of additional examination steps that medical students should master, thereby indicating the need for an educational NE teaching concept. To solve this educational challenge, we propose a longitudinal curriculum that incorporates the "core + clusters" framework, thus combining the screening NE (core) with hypothesis-driven sets of maneuvers (clusters). Based on our data, we provide an initial proposal for the core and neurologic diagnostic clusters which is applicable to both novice and advanced learners across the continuum of training.