American Academy Of Neurology Guidelines Research Articles

Association of the Area Deprivation Index With Dementia Basic Workup and Diagnosis in Central and Western Virginia: A Cross-Sectional Study.

The Area Deprivation Index (ADI) provides a validated and multidimensional metric of areal disadvantage. Our goals were to determine if the ADI influences the likelihood of receiving workup based on published guidelines and an etiologic diagnosis of dementia in Central and Western Virginia. We collected deidentified data from the electronic health record of individuals aged 50-105 years diagnosed with dementia at the University of Virginia (UVA) Medical Center (2016-2021) and at Carillion Clinic (2018-2021). Visit-specific ICD-10 codes were used to classify each dementia diagnosis as "disease-specific" (e.g., Alzheimer disease) or "general" (e.g., unspecified dementia). Following the American Academy of Neurology guidelines, we considered the evaluation performed as "adequate" if patients had vitamin B12, thyroid-stimulating hormone, and brain CT or magnetic resonance imaging within 6 months of the initial diagnosis. Census tract ADI was linked to study participants using the unique census tract identifier derived from the participants' home addresses at the time of diagnosis. Statistical modeling occurred under a Bayesian paradigm implemented using a standard code in R. The study included 13,431 individuals diagnosed with dementia at UVA (n = 7,152) and Carillion Clinic (n = 6,279). Of those, 32.5% and 20.4% received "disease-specific" diagnoses at UVA and Carillion Clinic and 8.2% and 20.4% underwent "adequate" workup, respectively. The adjusted relationship between census tract ADI and the likelihood of a disease-specific diagnosis was U-shaped: Residence in moderately disadvantaged areas was associated with the lowest likelihood of disease-specific diagnosis. Most patients diagnosed with dementia did not receive an adequate evaluation or an etiologic diagnosis. Those living in locations just above the national median ADI levels had the lowest likelihood of receiving an etiologic diagnosis, lower than those in the least and most deprived areas. Renewed awareness efforts among providers are needed to increase compliance with diagnostic guidelines.

The effectiveness of group music reminiscence therapy for people thriving with dementia: A systematic review of randomized controlled trials

AbstractDementia is characterized by a progressive decline in cognition, behavioral and psychological symptoms (BPSD), and quality of life (QoL). The lack of curative therapies has led to a psychosocial discourse prioritizing QoL of people thriving with dementia (PTD). Group reminiscence therapy (RT) is a relatively inexpensive intervention, with music prompts being a preferred choice, owing to robust musical memory in the early disease stage. However, a synthesis of current evidence is needed to inform research and clinical use of group music RT in dementia care. Therefore, we conducted a systematic review on PubMed, Scopus, CINAHL, APA PsycInfo, and APA PsycArticles to critically appraise published randomized controlled trials examining group music RT to improve cognition, BPSD, and QoL in PTD. Of 14,725 articles, two RCTs involving 102 PTD were included. All studies used prerecorded music for group music RT. All studies were deemed of good quality, adhering to intention‐to‐treat analysis and assessor blinding. Based on the American Academy of Neurology guidelines, we assigned a Level C recommendation for group music RT for cognition and Level B recommendations for BPSD and QoL (ineffective). In conclusion, group music RT may be useful for symptomatic management in PTD. However, heterogeneous study designs, disease severity, dementia subtype, and outcome measures are likely barriers to meaningful clinical translation. Therefore, the rating of recommendations only serves as a point of reference. Future avenues include live performances as prompts for group music RT.

Role of Clinical and Multimodality Neuroimaging in the Evaluation of Brain Death/Death by Neurologic Criteria and Recent Highlights from 2023 Updated Guidelines.

Purpose of Review: This review aims to provide a comprehensive overview of the diagnosis of brain death/death by neurologic criteria (BD/DNC) by emphasizing the clinical criteria established by the American Academy of Neurology (AAN) in light of their updated guidelines released in 2023. In this review, we will focus on the current implementation of ancillary tests including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler, which provide support in diagnoses when clinical examination and apnea tests are inconclusive. Finally, we will also provide examples to discuss the implementation of certain imaging studies in the context of diagnosing BD/DNC. Recent Findings: Recent developments in the field of neurology have emphasized the importance of clinical criteria for diagnosing BD/DNC, with the AAN providing clear updated guidelines that include coma, apnea, and the absence of brainstem reflexes. Current ancillary tests, including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler play a crucial role in confirming BD/DNC when the clinical assessment is limited. The role of commonly used imaging studies including computed tomography and magnetic resonance angiographies of the brain as well as CT/MR perfusion studies will also be discussed in the context of these new guidelines. Summary: BD/DNC represents the permanent cessation of brain functions, including the brainstem. This review article provides the historical context, clinical criteria, and pathophysiology that goes into making this diagnosis. Additionally, it explores the various ancillary tests and selected imaging studies that are currently used to diagnose BD/DNC under the newly updated AAN guidelines. Understanding the evolution of how to effectively use these diagnostic tools is crucial for healthcare professionals who encounter these BD/DNC cases in their practice.

Interventions to Improve Medication Adherence in Children With Epilepsy: A Systematic Review.

Low medication adherence remains a major challenge in the treatment of epilepsy, particularly in children. In recent years, several approaches and interventions have been employed to promote medication adherence in children with epilepsy (CWE). In this study, we aimed to summarize the evidence on these interventions. In this systematic review, major medical electronic databases were searched for relevant literature from January 2005 till July 2023, including PsycINFO, Medline (via PubMed), Google Scholar, Taylor & Francis databases, and CENTRAL by the Cochrane Library. We planned to include observational studies (with a control arm) and clinical trials involving children/adolescents (<19 years) with epilepsy and/or their caregivers/families who underwent any intervention to improve adherence to anti-seizure medications. Out of 536 articles searched, eight (six randomized trials and two non-randomized intervention studies) were included in the systematic review. A total of 2,685 children/adolescents along with their caregivers participated in these studies. Six studies used educational and two used behavioral interventions to improve adherence to anti-seizure medications. Four studies showed variable levels of adherence improvement, ranging from 2-20% up to 73.9% post-intervention. To conclude, the findings suggest the potential for educational interventions to promote medication adherence in CWE. The class of evidence was II to III among the included studies, as per American Academy of Neurology guidelines.

Escalation Versus Induction/High-Efficacy Treatment Strategies for Relapsing Multiple Sclerosis: Which is Best for Patients?

After more than 2decades of recommending an escalating strategy for the treatment of most patients with multiple sclerosis, there has recently been considerable interest in the use of high-efficacy therapies in the early stage of the disease. Early intervention with induction/high-efficacy disease-modifying therapy may have the best risk-benefit profile for patients with relapsing-remitting multiple sclerosis who are young and have active disease, numerous focal T2 lesions on spinal and brain magnetic resonance imaging, and no irreversible disability. Although we have no curative treatment, at least seven classes of high-efficacy drugs are available, with two main strategies. The first strategy involves the use of high-efficacy drugs (e.g., natalizumab, sphingosine 1-phosphate receptor modulators, or anti-CD20 drugs) to achieve sustained immunosuppression. These can be used as a first-line therapy in many countries. The second strategy entails the use of one of the induction drugs (short-term use of mitoxantrone, alemtuzumab, cladribine, or autologous hematopoietic stem cell transplant) that are mainly recommended as a second-line or third-line treatment in patients with very active or aggressive multiple sclerosis disease. Early sustained immunosuppression exposes patients to heightened risks of infection and cancer proportionate to cumulative exposure, and induction drugs expose patients to similar risks during the initial post-treatment period, although these risks decrease over time. Their initial potential safety risks should now be revisited, taking account of long-term data and some major changes in their regimens: natalizumab with the long-term monitoring of John Cunningham virus; use of monthly courses of mitoxantrone with maximum cumulative doses of 36-72 mg/m2, followed by a safer disease-modifying drug; cladribine with only 2-weekly treatment courses required in years 1 and 2 and no systematic treatment for the following 2 years; alemtuzumab, whose safety and clinical impacts have now been documented for more than 6 years after the last infusion; and autologous haematopoietic stem cell transplant, which dramatically reduces transplantation-related mortality with a new regimen and guidelines. Escalation and induction/high-efficacy treatments need rigorous magnetic resonance imaging monitoring. Monitoring over the first few years, using the MAGNIMS score or American Academy of Neurology guidelines, considerably improves prediction accuracy and facilitates the selection of patients with relapsing-remitting multiple sclerosis requiring aggressive treatment.

Challenges in determining death by neurologic criteria in extracorporeal membrane oxygenation - A single center experience.

Apnea test (AT) in patients on extracorporeal membrane oxygenation (ECMO) support is challenging, leading to variation in determining death by neurologic criteria (DNC). We aim to describe the diagnostic criteria and barriers for DNC in adults on ECMO in a tertiary care center. A retrospective review of a prospective observational standardized neuromonitoring study was conducted in adult VA- and VV-ECMO patients at a tertiary center from June 2016 to March 2022. Brain death was defined according to the 2010 American Academy of Neurology guidelines and following the 2020 World Brain Death Project recommendations for performing AT in ECMO patients. Eight (2.7%) ECMO patients (median age = 44years, 75% male, 50% VA-ECMO) met criteria for DNC, six (75%) of whom were determined with AT. In the other two patients who did not undergo AT due to safety concerns, ancillary tests (transcranial doppler and electroencephalography) were consistent with DNC. An additional seven (2.3%) patients (median age = 55years, 71% male, 86% VA-ECMO) were noted to have absent brainstem reflexes but failed to complete determination of DNC as they underwent withdrawal of life-sustaining treatment (WLST) before a full evaluation was completed. In these patients, AT was never performed, and ancillary tests were inconsistent with either neurological exam findings and/or neuroimaging supporting DNC, or with each other. AT was used safely and successfully in 6 of the 8 ECMO patients diagnosed with DNC and was always consistent with the neurological exam and imaging findings, as opposed to ancillary tests alone.

Impact of Updates in Headache Quality Measures on Adherence to Best Practices in a Neurology Resident Clinic (P8-12.001)

<h3>Objective:</h3> To assess the impact of a quality-improvement initiative on adherence to updated American Academy of Neurology (AAN) headache quality measures. <h3>Background:</h3> As an important resource for headache care, the AAN publishes quality measures, which were most recently updated in 2019. This single-site study at a large, academic tertiary referral center aimed to apply the AAN measures to its cohort of neurology resident physicians and evaluate adherence changes (primary outcome) as well as utilization of appropriate diagnostic criteria, patient education, and confidence in following AAN guidelines (secondary outcomes). <h3>Design/Methods:</h3> A pre-intervention (pre-QI) survey based on retrospective analysis of five clinic notes for adherence to the measures was designed and distributed to all neurology residents at our center. The intervention included creation of an electronic medical record template to aid residents in following the measures during clinical encounters as well as provision of direct feedback based on pre-QI results. Finally, a post-intervention (post-QI) survey was distributed for completion based on notes written during the intervention period. Significance testing of differences between pre- and post-QI values was performed using Chi-squared analysis. Analysis was limited to migraine headaches given a low percentage of cluster headaches seen in clinic. <h3>Results:</h3> An increase in adherence was seen in three of the four migraine-related quality measures, with two – utilization of migraine abortive therapies and counseling of modifiable lifestyle and chronification factors – showing significant improvement (p &lt; 0.01). For secondary outcomes, increases in utilization of appropriate diagnostic criteria and patient education were both significant (p &lt; 0.05), and a positive trend in self-assessed confidence rating for adherence to AAN guidelines was significant (p &lt; 0.0001). <h3>Conclusions:</h3> This study provided evidence that our QI intervention led to increased adherence to the AAN migraine-related measures. It is anticipated that increased adherence may lead to improved patient outcomes. <b>Disclosure:</b> Mr. Cascella has nothing to disclose. Dr. Anderson has nothing to disclose. Dr. Perez Martinez has nothing to disclose.

Simulation-based Assessment of Brain Death Determination for ACGME Milestones of Adult Neurology Residents (P8-2.004)

<h3>Objective:</h3> Determining the utility of simulation-based training in assessment of the ACGME milestone for brain death determination in adult Neurology residents. <h3>Background:</h3> Recent updates to the ACGME milestones require proficiency in brain death determination. Because brain death occurs rarely, there is limited opportunity to observe and perform a brain death exam during residency. Simulation-based training is a useful tool for teaching management of infrequently encountered scenarios such as brain death. Prior studies have shown simulation improves practitioner knowledge base and comfort level with diagnosing brain death. No studies have demonstrated its utility as an assessment tool. <h3>Design/Methods:</h3> We created a simulation using a SimMan 3G manikin for brain death determination. Using the American Academy of Neurology guidelines, we created a validated checklist scoring four categories: pre-requisites and confounders, neurologic examination, apnea test, and determination of the need for ancillary testing. Adult neurology residents completed a survey before participating in the simulation. After the simulation, residents participated in a group debriefing and completed a post-simulation survey identical to the pre-simulation survey. The ACGME milestone for determination of brain death was assessed based on participants’ scores on the simulation. <h3>Results:</h3> All UF neurology residents performed the brain death determination simulation and were objectively scored on the ACGME milestone. Residents reported improved comfort level with determining brain death and scored higher on knowledge-based questions after the simulation and debriefing session. <h3>Conclusions:</h3> We successfully created a simulation designed to assess residents’ progress on the ACGME milestones in determining death by neurologic criteria. Variations of these scenarios exposed residents to commonly-encountered confounders, barriers to completing the exam, and situations where interventions may be required to continue testing safely. Additionally, residents reported increased comfort level and scored higher on knowledge-based questions after the simulation and debriefing. <b>Disclosure:</b> Dr. Wasserstrom has nothing to disclose. Dr. Maciel has received research support from American Heart Association. Dr. Maciel has received research support from National Institute of Health. The institution of an immediate family member of Dr. Wilson has received research support from NIH. An immediate family member of Dr. Wilson has received intellectual property interests from a discovery or technology relating to health care. Dr. Wilson has received publishing royalties from a publication relating to health care. Dr. Ford has nothing to disclose.

The Neurologist’s Role in Patients with Mild Cognitive Impairment and Mild Alzheimer’s Disease Dementia

AbstractBackgroundAlzheimer’s disease (AD) is a progressive neurodegenerative disease and the most common cause of dementia. Mild cognitive impairment (MCI) affects &gt;10% of US adults over the age of 70 and represents a transitional stage between healthy aging and dementia. Multiple factors influence the path to care through the health system. This study sought to better understand the medical journey of patients with all‐cause MCI and mild AD dementia (ADD) to identify opportunities for improvement.MethodAn anonymous online survey was conducted in a cross‐sectional US‐population of 103 patients with self‐reported diagnosis of MCI/mild ADD, 150 care partners of patients with MCI/mild ADD, and 75 neurologists.ResultIn the most common medical journey for patients (73% of patients), half of patients/care partners (51%) reported they received their diagnosis from a neurologist. The most common reasons patients/care partners initiated discussions with a healthcare provider were symptoms interfering with activities of daily life (51%), symptoms not resolving (46%), encouragement from family or friends (44%), and symptoms worsening in degree of discomfort/frequency (43%). Most patients/care partners (23%) reported receiving a misdiagnosis prior to receiving a formal diagnosis of MCI/mild ADD. Half of neurologists (52%) view themselves as the coordinator of care for patients with MCI/mild ADD; whereas 35% of patients/care partners view them as such.At the time of diagnosis, most neurologists (83%) reported discussing with patients the potential causes of MCI/mild ADD. Most neurologists (84%) reported following American Academy of Neurology guidelines (AAN) for treatment and management of patients with MCI/mild ADD. For ongoing care, treatments most commonly prescribed/recommended by neurologists included mental exercises (84%), general improvements in lifestyle (84%), acetylcholinesterase (AChE) inhibitors (78%), social interaction (75%), and NMDA antagonists (73%).ConclusionNeurologists are often the healthcare provider diagnosing MCI/mild ADD however patients frequently experience misdiagnosis in their medical journey. Neurologists are not viewed as coordinators of care by most patients. Positioning neurologists as coordinators of MCI/mild ADD care and equipping them with the right resources may help patients obtain a diagnosis and treatment sooner.

Hypertensive Retinopathy Is Associated With Worse Cognitive Function in Women: The SWAN Study

Based on the 2018 American Academy of Neurology guideline, the prevalence of mild cognitive impairment (CI) increases from 6.7% at 60-64 years to 25.2% at 80-84 years. There is interest to identify potential biomarkers in the retina for CI and dementia. The aims of this analysis was to test whether hypertensive retinopathy (HR) was associated with cognitive function using data from the Study of Women’s Health Across the Nation (SWAN), Michigan cohort. SWAN, launched in 1996/97, is a longitudinal study of women traversing midlife and into late adulthood. Starting in 2000, cognitive function tests were administered: East Boston Memory Test immediate (EBMTi) and 10-minute delay (EBMTd) for verbal episodic memory; digit span backwards (DSB) for working memory; and symbol digits modalities test (SDMT) for perception speed, motor speed, and visual scanning. Z-scores were calculated for EBMTi, EBMTd, DSB and SDMT and averaged at follow-up visit 15 (2015/16). Eye exams were performed on 255 women (66 + 2.6 years) at follow-up visit 16 (2016/17). HR was based on presence/absence of arteriovenous nicking. Logistic regression showed a statistically significant association of lower average cognitive Z-score with HR (p-value 0.03, beta=-0.21 [95% confidence interval: -0.40 to -0.02]) adjusting for measured hypertension or anti-hypertensive drugs, years of measured hypertension, race, education, and age. Preliminary results indicate that HR is associated with lower cognitive test scores in women in their 60s-70s. This association between a simple ophthalmic exam finding of systemic hypertension, i.e., arteriovenous nicking, and lower cognitive function is consistent with a cerebrovascular mechanism of CI.

Repository corticotropin injection improves quality metrics in an observational study of multiple sclerosis relapse.

Aim: To determine whether clinicians evaluate American Academy of Neurology (AAN) quality metrics for patients with multiple sclerosis (MS) relapse and whether repository corticotropin injection (RCI) improves clinical and patient-reported outcomes associated with these metrics at 2 and 6 months after treatment. Methods: A multicenter, prospective, observational registry evaluating patients receiving RCI for MS relapse (N=125) categorized data according to AAN quality metrics involving diagnosis, disability, fatigue, cognitive impairment, depression, and quality of life. Results: Clinicians assessed all 11 AAN quality metrics in patients with MS relapse. Disability, fatigue, cognitive impairment, depression, and quality of life outcomes improved with RCI therapy. Conclusion: RCI was associated with improved quality metrics, and AAN guidelines were followed during routine RCI treatment for MS relapse.

How often is EEG used as part of routine dementia evaluation in community practice?

AbstractBackgroundRecommendations for evaluation of patients with dementia have changed little in the last thirty years. The guideline for diagnosis of dementia published by the American Academy of Neurology (AAN) in 1984 recommended against routine use of EEG for evaluation of dementia, and in the updated guideline from 2001 EEG is not specifically mentioned. Some authors continue to argue for use of EEG in dementia research, though mostly this focuses on specialized EEG techniques like quantitative EEG. There are few reports, however, on the frequency of EEG use in community neurological evaluations for dementia.MethodAll new patient referrals to the Novant Health Memory Clinic in Charlotte, NC, for 2020 were reviewed. Information was tabulated for those patients who had been previously evaluated by a neurologist in the community, specifically to determine how often EEG was included as part of the routine evaluation. Results of the EEG as taken from the clinician’s report were tabulated, though there was no opportunity to examined the EEG tracing itself. The author made a judgement as to whether the results of the EEG affected the clinical diagnosis or provided useful information for management of the patient in each case, and these data were tabulated.ResultDuring the year of observation, there were a total of 845 new patient evaluations in the Memory Clinic. Of those, 274 patients met clinical criteria for “Probable” Alzheimer Disease, 237 met criteria for Mild Cognitive Impairment, and 207 for Subjective Cognitive Decline. Out of these patients, 89 had been previously evaluated by a community neurologist. In 63 of the evaluations, EEG was obtained as part of the routine evaluation. Of these, 16 were read as “normal,” and 47 were read as “abnormal” due to slowing of background rhythm. In 2 of the 47, the reader also reported finding “sharp waves” in temporal leads, and these 2 patients were treated by the reading neurologist with anticonvulsants, later discontinued in both cases. In no case did the EEG provide useful information for either diagnosis of management of dementia.ConclusionThese data support the AAN guideline’s recommendation against routine use of EEG for dementia evaluation.

Simulation-Based Training Improves Fellows' Competence in Brain Death Discussion and Declaration.

Despite well-defined American Academy of Neurology guidelines for death by whole brain criteria (brain death), there is marked variability in national practice, which some have attributed to lack of formal education. Further, communication with surrogates and families about brain death is integral to brain death declaration. As such, we developed a targeted brain death curriculum combining didactics and simulation-based education to improve examination and subsequent communication skills with families. Multidisciplinary critical care fellows participated in (1) didactic and case-based curriculum, (2) brain death simulated examination (SimMan3G mannequin), and (3) a standardized family scenario with delivery of a brain death diagnosis to a surrogate "family member". Fellows completed a precurriculum and postcurriculum multiple choice knowledge test and survey (Likert 1 to 10 scale) evaluating measures regarding diagnosis and communication of brain death. t Test and 2-tailed Wilcoxon signed rank test were used for statistical analysis (P<0.05). Thirteen critical care fellows participated in the curriculum. Most fellows [80% (N=12)] had only participated in 0 to 5 brain death declarations before this intervention. There was significant improvement across all measures: self-rated knowledge (P=0.004), perceived knowledge relative to peers (P=0.002), confidence (P=0.001), and comfort (P=0.001) with performing a brain death exam, and comfort with family discussion (P=0.01). Objective test scores improved from 56 to 73% after simulation (P=0.004). All fellows found the curriculum beneficial. Trainees may lack sufficient exposure to brain death education. Didactics with simulation-based education can improve objective knowledge and subjective measures of comfort with brain death declaration and surrogate communication.

Changes in Antibiotic Treatment for Children With Lyme Meningitis 2015-2020.

Although ceftriaxone has been the first-line treatment of Lyme meningitis, the 2020 Infectious Disease Society of America, American College of Rheumatology, and American Academy of Neurology guideline recommends either doxycycline or ceftriaxone. Our objective was to explore recent trends in enteral antibiotic treatment of children with Lyme meningitis. Using International Classification of Diseases, 10th Revision codes for case identification, we performed a multicenter retrospective study of patients ≤21 years of age presenting to a pediatric hospital contributing to the Pediatric Health Information System who were diagnosed with Lyme meningitis from 2015 to 2020. Our primary outcome was treatment with parenteral antibiotics, defined by either a procedure code for indwelling catheter placement or >7 days of inpatient parenteral Lyme disease-specific therapy. To examine trends over the study period, we used a generalized estimating equation, with parenteral antibiotics as the dependent variable and study year as the independent variable, adjusted for patient age, sex, race, ethnicity, and insurance status clustered by hospital. We identified 239 patients with Lyme meningitis treated at 24 participating centers. Overall, 48 (20.0%) were treated with parenteral antibiotics, with a declining rate over the study period (43.8% in 2015 to 8.9% in 2020). After adjustment, the odds of treatment with a parenteral antibiotic decreased over the study period (adjusted odds ratio 0.57; 95% confidence interval 0.41-0.80). Parenteral antibiotic treatment of children with Lyme meningitis has been on the decline in advance of the published clinical guideline. Carefully designed comparative effectiveness studies are needed to examine the effect of oral versus parenteral treatment regimens on clinical outcomes.

Survey of Pain Medicine Specialists' Familiarity with Migraine Management.

Pain specialists treat patients with headache and interface with those who use opioids more so than neurologists and headache specialists. We assessed the headache medicine knowledge and needs of pain specialists. Cross-sectional online survey. Members of the American Academy of Pain Medicine. Survey was based on a prior survey of primary care providers' knowledge and needs and was iteratively updated by four headache specialists, two with pain medicine affiliations. Of the 105 respondents, 71.4% were physicians, 34.3% were women, and they averaged 20.0 ± 13.6 years in practice. The most common specialty was anesthesia (36.1%, n = 35/97) followed by neurology (14.4%, n = 14/97). About half of providers (55.7%, n = 34/61 and 53.3%, n = 32/60) were familiar with the American Academy of Neurology Guidelines for pharmacological migraine prevention and the Choosing Wisely Campaign recommendations for limiting neuroimaging and opioids. Less than half of all providers (39.7%, n = 23/58) were familiar with the American Headache Society guidelines for emergency management of migraine. Providers were aware of Level A evidence-based nonpharmacological therapies, with over three-fourths recognizing cognitive behavioral therapy (80.7%, n = 50/62) and biofeedback (75.8%, n = 47/62) as evidence-based interventions. About 80% of providers (n = 50/64) estimate making migraine diagnoses in ≤50% of their patients with headache. Providers consider starting preventive headache therapy at 7.1 ± 3.9 days/month and report referring 34.3%±34.2% of patients to behavioral interventions. Dissemination and implementation of headache guidelines is needed for pain medicine specialists. Providers may need help diagnosing migraine based on currently accepted guidelines and referring for evidence-based behavioral therapies.

Is jaw muscle activity impaired in adults with persistent temporomandibular disorders? A systematic review and meta-analysis.

Understanding jaw muscle activity changes in temporomandibular disorders (TMD) is crucial to guide clinical management. The nature of these changes is currently unclear. Explore changes in jaw muscle activity in TMD. Electronic databases (PubMed, EMBASE, CINAHL, Scopus, Web of Science, Cochrane) and bibliographies were searched from inception to 9 July 2020 for eligible studies, including grey literature. Case-control and interventional studies reporting time-domain and frequency-domain electromyographic measures of jaw muscle activity in TMD and control groups were included. SIGN checklist for case-control studies was used to evaluate risk of bias. Results were pooled for meta-analysis using random-effects model. Confidence in cumulative evidence was established using American Academy of Neurology guidelines. Forty-five studies were included. Most were rated moderate risk of bias. Activity of four muscles (masseter, temporalis, lateral pterygoid, suprahyoids) was assessed across six domains (resting, clenching, chewing, swallowing, concentrating, resisted mandibular movements), with partial meta-analysis scope. Masseter and temporalis activity were significantly higher at rest (P=.05, P<.0001), but lower during brief maximal clenching (P=.005, P=.04) in TMD vs controls. Insufficient data precluded meta-analysis of remaining outcomes and subgroup analysis. Confidence in cumulative evidence ranged from moderate to very low. Changes in jaw muscle activity exist in TMD, which are both task-specific and muscle-specific. It remains unclear whether jaw muscle activity changes vary between TMD subgroups. Muscle function should be considered in clinical management of TMD. Insufficient subgroup data highlight future direction for research.

Migraine diagnosis and treatment: A knowledge and needs assessment of women's healthcare providers.

Studies suggest that migraine is often underdiagnosed and inadequately treated in the primary care setting, despite many patients relying on their primary care provider (PCP) to manage their migraine. Many women consider their women's healthcare provider to be their PCP, yet very little is known about migraine knowledge and practice patterns in the women's healthcare setting. The objective of this study was to assess women's healthcare providers' knowledge and needs regarding migraine diagnosis and treatment. The comprehensive survey assessing migraine knowledge originally developed for PCPs was used in this study, with the addition of a section regarding the use of hormonal medications in patients impacted by migraine. Surveys were distributed online, and primarily descriptive analyses were performed. The online survey was completed by 115 women's healthcare providers (response rate 28.6%; 115/402), who estimated that they serve as PCPs for approximately one-third of their patients. Results suggest that women's healthcare providers generally recognize the prevalence of migraine, but experience some knowledge gaps regarding migraine management. Despite 82.6% (95/115) of survey respondents feeling very comfortable or somewhat comfortable with diagnosing migraine, only 57.9% (66/114) reported routinely asking patients about headaches during annual visits. Very few were familiar with the American Academy of Neurology guidelines on preventative treatment (6.3%; 7/111) and the Choosing Wisely Campaign recommendations on migraine treatment (17.3%; 19/110), and many prescribed medications known to contribute to medication overuse headache. In addition, only 24.3% (28/115) would order imaging for a new type of headache, 35.7% (41/115) for worsening headache, and 47.8% (55/115) for headache with neurologic symptoms; respondents cited greater tendency with sending patients to an emergency department for the same symptoms. Respondents had limited knowledge of evidence-based, non-pharmacological treatments for migraine (i.e., biofeedback or cognitive behavioral therapy), with nearly none placing referrals for these services. Most providers were comfortable prescribing hormonal contraception (mainly progesterone only) to women with migraine without aura (80.9%; 89/110) and with aura (72.5%; 79/109), and followed American College of Obstetricians and Gynecologists (ACOG) guidelines to limit combination hormonal contraception for patients with aura. When queried, 6.3% or less (5/79) of providers would prescribe estrogen-containing contraception for women with migraine with aura. Only 37.3% (41/110) of respondents reported having headache/migraine education. Providers indicated interest in education pertaining to migraine prevention and treatment (96.3%; 105/109), migraine-associated disability (74.3%; 81/109), and diagnostic testing (59.6%; 65/109). Women's healthcare providers appear to have several knowledge gaps regarding the management of migraine in their patients. These providers would likely benefit from access to a headache-specific educational curriculum to improve provider performance and patient outcomes.

Differential Diagnosis of Childhood Apraxia of Speech Compared to Other Speech Sound Disorders: A Systematic Review.

Purpose The aim of this study was to determine the discriminative features that might contribute to differentiation of childhood apraxia of speech (CAS) from other speech sound disorders (SSDs). Method A comprehensive literature search was conducted for articles or doctoral dissertations that included ≥ 1 child with CAS and ≥ 1 child with SSD. Of 2,071 publications screened, 53 met the criteria. Articles were assessed for (a) study design and risk of bias; (b) participant characteristics and confidence in diagnosis; and (c) discriminative perceptual, acoustic, or kinematic measures. A criterion was used to identify promising studies: American Academy of Neurology study design (Class III+), replicable participant descriptions and adequate confidence in diagnosis (≥ 3), and ≥ 1 discriminative and reliable measure. Results Over 75% of studies were retrospective, case-control designs and/or assessed English-speaking children. Many studies did not fully describe study design and quality. No studies met the Class I (highest) quality rating according to American Academy of Neurology guidelines. CAS was mostly compared to speech delay/phonological disorder. Only six studies had diagnostic confidence ratings of 1 (best). Twenty-six studies reported discriminative perceptual measures, 14 reported discriminative acoustic markers, and four reported discriminative kinematic markers. Measures were diverse, and only two studies directly replicated previous findings. Overall, seven studies met the quality criteria, and another eight nearly met the study criteria to warrant further investigation. Conclusions There are no studies of the highest diagnostic quality. There are 15 studies that can contribute to further diagnostic efforts discriminating CAS from other SSDs. Future research should utilize careful diagnostic design, support replication, and adhere to standard reporting guidelines. Supplemental Material https://doi.org/10.23641/asha.13158149.

Are jaw range of motion, muscle function and proprioception impaired in adults with persistent temporomandibular disorders? A systematic review and meta-analysis.

The nature of certain musculoskeletal impairments associated with temporomandibular disorders (TMD) is unclear. Understanding impairments within TMD subgroups is important to guide management. Characterise local musculoskeletal impairments in adults with persistent TMD. PubMed, EMBASE, CINAHL, Scopus, Web of Science and Cochrane databases were searched from inception to 12 January 2020. Bibliographies were searched for additional articles, including grey literature. Case-control and interventional studies reporting temporomandibular range of motion (ROM), muscle function (MF) or proprioception in TMD and control groups were included. Risk of bias was assessed using SIGN checklist for case-control studies. Results were pooled using random-effects model. Confidence in cumulative evidence was determined using American Academy of Neurology guidelines. Sixty-six studies were included, most rated moderate risk of bias. Twelve primary outcomes were assessed, with partial scope for meta-analysis. Significant reductions were found for active maximal mouth opening (P<.00001, MD=-4.65mm), protrusion (P<.0001, MD=-0.76mm) and maximum bite force (P<.00001) in TMD versus controls. Subgroup analysis scope was limited. Reduced AMMO was found in myogenic TMD subgroups versus controls (P=.001, MD= -3.28mm). Few studies measured proprioception, with high methodological variability. Confidence in cumulative evidence ranged from high to very low. ROM and bite force impairments accompany TMD. Insufficient data were available to investigate impairments within TMD subgroups. Several musculoskeletal impairments have been identified, which may guide clinical management of TMD. Lack of subgroup data, and data for proprioception and MF, highlights future direction for research. CRD42020150734.

Allied Muslim Healthcare Professional Perspectives on Death by Neurologic Criteria.

We sought to evaluate how Muslim allied healthcare professionals view death by neurologic criteria (DNC). We recruited participants from two listservs of Muslim American health professionals to complete an online survey questionnaire. Survey items probed views on DNC and captured professional and religious characteristics. Comparative statistical analyses were performed after dichotomizing the sample based on religiosity, and Chi-squared, Fisher's exact tests, likelihood ratios and the Kruskal-Wallis test were used to assess differences between the two cohorts. There were 49 respondents (54%) in the less religious cohort and 42 (46%) in the more religious cohort. The majority of respondents (84%) believed that if the American Academy of Neurology guidelines are followed and a person is declared brain dead, they are truly dead; there was no difference on this view based on religiosity. Less than a quarter of respondents believed that outside of organ donation, mechanical ventilation, hydration, nutrition or medications should be continued after DNC; again, there was no difference based on religiosity of the sample. Importantly, half of all respondents believed families should be able to choose whether an evaluation for DNC is performed (40% of the less religious cohort and 60% of the more religious cohort, p = 0.09) and whether organ support is discontinued after DNC (49% of both cohorts, p = 1). Although the majority of allied Muslim healthcare professionals we surveyed believe DNC is death, half believe that families should be able to choose whether an evaluation for DNC is performed and whether organ support should be discontinued after DNC. This provides insight that can be helpful when making medical practice policy and addressing legal controversies surrounding DNC.