American Academy Of Neurology Guidelines Research Articles

Identification, prevalence, and treatment of painful diabetic neuropathy in patients from a rural area in South Carolina.

Diabetic peripheral neuropathy (DPN) represents significant burdens to many patients and the public health-care system. Patients with diabetes in rural areas have higher risk of developing complications and having less access to proper treatment. We studied a rural population of patients with diabetes who attended a pharmacist-led free clinic for a diabetic education program. Our objectives were to 1) determine the prevalence of DPN and painful diabetic neuropathy (p-DN) in patients with type 2 diabetes; 2) assess the proportion of patients with DPN and p-DN left undocumented upon physician referral to a pharmacist-led free clinic; and 3) determine the appropriateness of pain medication regimen. We performed a retrospective analysis of clinical records of patients from the Presbyterian College School of Pharmacy (PCSP) Wellness Center located in Clinton, SC. Diagnoses of DPN and/or p-DN were obtained from referral notes in the clinical records and compared with results from foot examinations performed in the free clinic and clinical features. Medication regimens were also obtained and compared using American Academy of Neurology (AAN) treatment guidelines. Within our study population (n=111), the prevalence of DPN was 62.2% (national average of 28%–45%) and that of p-DN was 23.4% (national average of 11%–24%). In p-DN patients (n=26), 53.8% (n=14) had a documented diagnosis of p-DN by the referring physician, and 46.2% (n=12) were identified by the pharmacists. A total of 95% (19 of 20) of the patients treated for p-DN received adequate pharmacological agents, though suboptimal as per clinical guidelines. More than 50% of the patients used subtherapeutic doses of their medications. Gabapentin was the most frequently used medication in our population (65.4%). Patients in rural South Carolina had a higher prevalence of DPN and p-DN with >60% undocumented cases of p-DN. More than 95% of treated patients did not receive optimum therapy according to AAN guidelines.

Variability in Diagnosing Brain Death at an Academic Medical Center.

Objective. Research continues to highlight variability in hospital policy and documentation of brain death. The aim of our study was to characterize how strictly new guidelines of American Academy of Neurology (AAN) for death by neurological criteria were practiced in our hospital prior to appointment of neurointensivists. Method. This is a retrospective study of adults diagnosed as brain dead from 2011 to 2015. Descriptive statistics compared five categories: preclinical testing, neurological examination, apnea tests, ancillary test, and documentation of time of death. Strict adherence to AAN guidelines for brain death determination was determined. Result. 76 patients were included in this study. Preclinical prerequisites were fulfilled in 53.9% and complete neurological examinations were documented in 76.3%. Apnea test was completed in 39.5%. Ancillary test was completed in 29.8%. Accurate documentation of time of death occurred in 59.2%. Overall, strict adherence to current AAN guidelines for death by neurological criteria was correctly documented in 38.2%. Conclusion. Our study shows wide variability in diagnosing brain death. These findings led us to update our death by neurological criteria policy and increase awareness of brain death determination with the goal of improving our documentation following current AAN guidelines.

Naturalistic study of guideline implementation tool use via evaluation of website access and physician survey

BackgroundClinical guidelines support decision-making at the point-of-care but the onus is often on individual users such as physicians to implement them. Research shows that the inclusion of implementation tools in or with guidelines (GItools) is associated with guideline use. However, there is little research on which GItools best support implementation by individual physicians. The purpose of this study was to investigate naturalistic access and use of GItools produced by the American Academy of Neurology (AAN) to inform future tool development.MethodsWebsite accesses over six months were summarized for eight AAN guidelines and associated GItools published between July 2012 and August 2013. Academy members were surveyed about use of tools accompanying the sport concussion guideline. Data were analyzed using summary statistics and the Chi-square test.ResultsThe clinician summary was accessed more frequently (29.0%, p < 0.001) compared with the slide presentation (26.8%), patient summary (23.2%) or case study (20.9%), although this varied by guideline topic. For the sport concussion guideline, which was accompanied by a greater variety of GItools, the mobile phone quick reference check application was most frequently accessed, followed by the clinician summary, patient summary, and slide presentation. For the sports concussion guideline survey, most respondents (response rate 21.8%, 168/797) were aware of the guideline (88.1%) and had read the guideline (78.6%). For GItool use, respondents indicated reading the reference card (51.2%), clinician summary (45.2%), patient summary (28.0%), mobile phone application (26.2%), and coach/athletic trainer summary (20.2%). Patterns of sports concussion GItool use were similar between respondents who said they had and had not yet implemented the guideline.ConclusionsDevelopers faced with resource limitations may wish to prioritize the development of printable or mobile application clinician summaries, which were accessed significantly more than other types of GItools. Further research is needed to understand how to optimize the design of such GItools.

Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter): Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.

To update the 2004 American Academy of Neurology guideline for patients with stroke and patent foramen ovale (PFO) by addressing whether (1) percutaneous closure of PFO is superior to medical therapy alone and (2) anticoagulation is superior to antiplatelet therapy for the prevention of recurrent stroke. Systematic review of the literature and structured formulation of recommendations. Percutaneous PFO closure with the STARFlex device possibly does not provide a benefit in preventing stroke vs medical therapy alone (risk difference [RD] 0.13%, 95% confidence interval [CI] -2.2% to 2.0%). Percutaneous PFO closure with the AMPLATZER PFO Occluder possibly decreases the risk of recurrent stroke (RD -1.68%, 95% CI -3.18% to -0.19%), possibly increases the risk of new-onset atrial fibrillation (AF) (RD 1.64%, 95% CI 0.07%-3.2%), and is highly likely to be associated with a procedural complication risk of 3.4% (95% CI 2.3%-5%). There is insufficient evidence to determine the efficacy of anticoagulation compared with antiplatelet therapy in preventing recurrent stroke (RD 2%, 95% CI -21% to 25%). Clinicians should not routinely offer percutaneous PFO closure to patients with cryptogenic ischemic stroke outside of a research setting (Level R). In rare circumstances, such as recurrent strokes despite adequate medical therapy with no other mechanism identified, clinicians may offer the AMPLATZER PFO Occluder if it is available (Level C). In the absence of another indication for anticoagulation, clinicians may routinely offer antiplatelet medications instead of anticoagulation to patients with cryptogenic stroke and PFO (Level C).

Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: an update.

To investigate the impact of new evidence for weight-bearing, bisphosphonates, and vitamin D and calcium interventions, towards updating the systematic review and clinical practice guidelines for osteoporosis in children with cerebral palsy (CP) published in 2011. Computer-assisted literature searches were conducted for articles published from 2010 to 2016. Searches focused on children with CP functioning at Gross Motor Function Classification System levels III to V and limited to weight-bearing activities, bisphosphonates, and vitamin D and/or calcium supplementation. Articles were classified according to the American Academy of Neurology guidelines to update the grading of the evidence for improving bone mineral density (BMD) and decreasing fragility fractures. Six new articles underwent full-text review and data abstraction. These included one weight-bearing, three bisphosphonate, and two mixed intervention studies (bisphosphonate and vitamin D/calcium supplementation). Overall, there continues to be 'probable' evidence for bisphosphonates, 'possible' evidence for vitamin D/calcium, and 'insufficient' evidence for weight-bearing activities as effective interventions to improve low BMD in children with CP. There is 'possible' evidence for bisphosphonates in reducing fragility fractures. The grading of evidence to support the use of weight-bearing activities, bisphosphonates, and vitamin D and calcium supplementation in pediatric CP osteoporosis clinical practice guidelines remained the same.

Educational Intervention Improves Compliance With AAN Guidelines for Return Epilepsy Visits: A Quality Improvement Project.

In 2011, the American Academy of Neurology (AAN) released guidelines for return seizure visits detailing 8 points that should be addressed during such visits. These guidelines are designed to improve routine follow-up care for epilepsy patients. The authors performed a quality improvement project aimed at increasing compliance with these guidelines after educating providers about them. The authors performed a chart review before and after an intervention which included: education regarding the guidelines, providing materials to remind providers of the guidelines, and templates to facilitate compliance. The authors reviewed charts at 2 and 6 months after the intervention. Significant improvement in documentation of 4 of the 8 measures was observed after this educational intervention. This suggests that simple educational interventions may help providers change practice and can improve compliance with new guidelines while requiring minimal time and resources to implement.

A migraine management training program for primary care providers: An overview of a survey and pilot study findings, lessons learned, and considerations for further research.

There are five to nine million primary care office visits a year for migraine in the United States. However, migraine care is often suboptimal in the primary care setting. A prior study indicated that primary care physicians (PCPs) wanted direct contact with headache specialists to improve the migraine care they provide. We sought to further examine PCPs' knowledge of migraine management and assess the feasibility of a multimodal migraine education program for PCPs. We conducted a survey assessing PCPs' knowledge about migraine. We then held three live educational sessions and developed an email consultative service for PCPs to submit questions they had about migraine. We report both quantitative and qualitative findings. Twenty-one PCPs completed the survey. They were generally familiar with the epidemiology of migraine (mean prevalence of migraine reported was 12.6% ± 10.1), the psychiatric comorbidities (mean prevalence of comorbid depression was 24.5% ± 16.7, mean prevalence of comorbid anxiety was 24.6% ± 18.3), and evidence-based behavioral treatments. Fifty-six percent cited cognitive behavioral therapy, 78% cited biofeedback, and 61% cited relaxation therapy as evidence based treatments. Though most were aware of the prevalence of psychiatric comorbidities, they did not routinely assess for them (43% did not routinely assess for anxiety, 29% did not routinely assess for depression). PCPs reported frequently referring patients for non-level A evidence based treatments: special diets (60%), acupuncture (50%), physical therapy (30%), and psychoanalysis (20%). Relaxation therapy was a therapy recommended by 40% of the PCPs. Only 10% reported referring for cognitive behavioral therapy or biofeedback. Nineteen percent made minimal or no use of migraine preventive medications. Seventy-two percent were unaware of or only slightly aware of the American Academy of Neurology guidelines for migraine. There was variable attendance at the educational sessions (N=22 at 1st session, 6 at 2nd session, 15 at 3rd session). Very few PCPs used the email consultative service (N=4). Though PCPs are familiar with many aspects of migraine care, there is a need and opportunity for improvement. The three live sessions were poorly attended and the email consultative service was rarely used. We provide an in depth discussion of targeted areas for educational intervention, of the challenges in developing a migraine educational program for PCPs, and areas for future study.

Computer-Based Cognitive Rehabilitation for Individuals With Traumatic Brain Injury: A Systematic Review

PurposeThe purpose of this review is to evaluate the efficacy of computer-based cognitive rehabilitation (CCR) for improving cognitive and cognitive-communication skills in individuals with traumatic brain injury (TBI).MethodA systematic search using key words related to CCR and TBI was conducted in 11 databases. Studies investigating CCR in children, adolescents, and adults with TBI were identified using a set of predetermined clinical questions, inclusion/exclusion criteria, and search parameters. Studies were evaluated for methodological quality according to American Academy of Neurology guidelines (AAN, 2011).ResultsThirteen studies were included in this review. One study was classified as AAN Class II and 12 were rated as AAN Class III. Results across studies were inconsistent. In addition, studies contained a range of limitations that reduced the confidence of the reported findings.ConclusionAt this time, there is insufficient evidence to support or refute the efficacy of CCR in improving the cognitive or cognitive-communication skills of individuals with TBI. Additional, high-quality research is needed to determine if individuals with TBI will benefit from CCR. Until this occurs, clinicians are encouraged to review existing expert recommendations and engage in practice-based evidence to determine if CCR is appropriate for their individual clients with TBI.

Racial disparities in the diagnosis and management of trigeminal neuralgia.

OBJECTIVE A number of studies have documented inequalities in care and outcomes for a variety of clinical conditions. The authors sought to identify racial and socioeconomic disparities in the diagnosis and treatment of trigeminal neuralgia (TN), as well as the potential underlying reasons for those disparities, which could serve as areas of focus for future quality improvement initiatives. METHODS The medical records of patients with an ICD-9 code of 350.1, signifying a diagnosis of TN, at the Henry Ford Medical Group (HFMG) in the period from 2006 to 2012 were searched, and clinical and socioeconomic data were retrospectively reviewed. Analyses were conducted to assess potential racial differences in subspecialty referral patterns and the specific type of treatment modality undertaken for patients with TN. RESULTS The authors identified 652 patients eligible for analysis. Compared with white patients, black patients were less likely to undergo percutaneous ablative procedures, stereotactic radiosurgery, or microvascular decompression (p < 0.001). However, there was no difference in the likelihood of blacks and whites undergoing a procedure once they had seen a neurosurgeon (67% vs 70%, respectively; p = 0.712). Blacks and whites were equally likely to be seen by a neurologist or neurosurgeon if they were initially seen in either the emergency room (38% vs 37%, p = 0.879) or internal medicine (48% vs 50%, p = 0.806). Among patients diagnosed (268 patients) after the 2008 publication of the European Federation of Neurological Societies and the American Academy of Neurology guidelines for medical therapy for TN, fewer than 50% were on medications sanctioned by the guidelines, and there were no statistically significant racial disparities between white and black patients (p = 0.060). CONCLUSIONS According to data from a large database from one of the nation's largest comprehensive health care systems, there were significant racial disparities in the likelihood of a patient undergoing a procedure for TN. This appeared to stem from outside HFMG from a difference in referral patterns to the neurologists and neurosurgeons.

Variability of Brain Death Policies in the United States.

Brain death is the irreversible cessation of function of the entire brain, and it is a medically and legally accepted mechanism of death in the United States and worldwide. Significant variability may exist in individual institutional policies regarding the determination of brain death. It is imperative that brain death be diagnosed accurately in every patient. The American Academy of Neurology (AAN) issued new guidelines in 2010 on the determination of brain death. To evaluate if institutions have adopted the new AAN guidelines on the determination of brain death, leading to policy changes. Fifty-two organ procurement organizations provided US hospital policies pertaining to the criteria for determining brain death. Organizations were instructed to procure protocols specific to brain death (ie, not cardiac death or organ donation procedures). Data analysis was conducted from June 26, 2012, to July 1, 2015. Policies were evaluated for summary statistics across the following 5 categories of data: who is qualified to perform the determination of brain death, what are the necessary prerequisites for testing, details of the clinical examination, details of apnea testing, and details of ancillary testing. We compared these data with the standards in the 2010 AAN update on practice parameters for brain death. A total of 508 unique hospital policies were obtained, representing the majority of hospitals in the United States that would be eligible and equipped to evaluate brain death in a patient. Of these, 492 provided adequate data for analysis. Although improvement with AAN practice parameters was readily apparent, there remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies [56.2%]) and hypothermia (181 of 228 policies [79.4%]), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed. Of the 492 policies, 163 (33.1%) required specific expertise in neurology or neurosurgery for the health care professional who determines brain death, and 212 (43.1%) stipulated that an attending physician determine brain death; 150 policies did not mention who could perform such determination. Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death.

Analysis of the Adherence to Seizure Prophylaxis Guidelines in Neurosurgery Patients

Background: In 2000, the American Academy of Neurology guidelines recommended that long-term seizure prophylaxis should not be routine in patients with newly diagnosed brain tumours and that if anti-epileptic drugs (AEDs) are used, they should be tapered and discontinued after 7 days post-operatively. Recent data shows that most newly diagnosed brain tumour patients continue to receive prophylactic AED. Aim: This study aimed to examine the seizure prophylaxis practices at Trillium Health Partners – Mississauga Hospital, a regional neurosurgery centrelocated in Mississauga, Ontario, Canada. Materials and Methods: A retrospective chart review was performed in adult patients with a newly diagnosed brain tumour who underwent neurosurgery between January 2010 and December 2014. Results: 690 patient charts were screened and 235 patients were excluded, most commonly due to seizure on admission. Overall, 28% (N=129) of 455 included patients over 5 years received seizure prophylaxis. Phenytoin was the most common prophylactic agent used. The average post-operative length of stay was 7.98 days and the average duration of therapy was 8.73 days. In 61% of patients who received prophylaxis, it was unknown whether the AED was continued in the long-term. The drug cost savings to Trillium over 5 years if patients had not received seizure prophylaxis was $4287.52. The patient characteristics most strongly correlated with receiving seizure prophylaxis were increasing tumour size and decreasing number of tumours. Conclusion: 1 in 3 patients at Trillium received seizure prophylaxis. Increased awareness of the organization's practice patterns may help prevent unnecessary long-term AED use.

Routine cognitive screening in a neurology practice

Alzheimer disease is one of the most prevalent and costly neurologic disorders. American Academy of Neurology guidelines call for diagnosis and treatment when dementia is present, but provide no specific instruction relating to cognitive screening. Our center piloted a cognitive screening initiative using the Mini-Cog, which was administered to all neurology patients aged ≥70 years without a history of a cognitive disorder. There was a 37.4% screen positive rate on the Mini-Cog. The percentage of patients with subjective memory complaints did not differ between patients screening positive vs negative on the Mini-Cog. Prospective analysis over an 18-month postscreening period showed that individuals screening positive for cognitive impairment were 10 times more likely to have follow-up cognitive assessment by the provider (p < 0.0001), almost 3 times more likely to be referred for neuropsychological testing (p = 0.003), and 3 times more likely to receive a diagnosis of cognitive impairment or dementia (p < 0.0001) compared to those screening negative. Diagnosis of a cognitive disorder, referral to a cognitive specialty clinician, and prescription of cognitive-enhancing medications were no more frequent than was observed in a randomized trial of screening in primary care, and evidence of neurologists' actions relevant to cognitive impairment was found in a minority of individuals screening positive. Further studies are needed to better understand factors influencing neurologist actions in the evaluation and treatment of cognitive impairment.

Botulinum Toxin for Neuropathic Pain: A Review of the Literature.

Botulinum neurotoxin (BoNT), derived from Clostridium botulinum, has been used therapeutically for focal dystonia, spasticity, and chronic migraine. Its spectrum as a potential treatment for neuropathic pain has grown. Recent opinions on the mechanism behind the antinociceptive effects of BoNT suggest that it inhibits the release of peripheral neurotransmitters and inflammatory mediators from sensory nerves. There is some evidence showing the axonal transport of BoNT, but it remains controversial. The aim of this review is to summarize the experimental and clinical evidence of the antinociceptive effects, mechanisms, and therapeutic applications of BoNT for neuropathic pain conditions, including postherpetic neuralgia, complex regional pain syndrome, and trigeminal neuralgia. The PubMed and OvidSP databases were searched from 1966 to May 2015. We assessed levels of evidence according to the American Academy of Neurology guidelines. Recent studies have suggested that BoNT injection is an effective treatment for postherpetic neuralgia and is likely efficient for trigeminal neuralgia and post-traumatic neuralgia. BoNT could also be effective as a treatment for diabetic neuropathy. It has not been proven to be an effective treatment for occipital neuralgia or complex regional pain syndrome.

Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics.

Evidence-based guidelines, or recommendations, for the management of infants with seizures are lacking. A Task Force of the Commission of Pediatrics developed a consensus document addressing diagnostic markers, management interventions, and outcome measures for infants with seizures. Levels of evidence to support recommendations and statements were assessed using the American Academy of Neurology Guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The report contains recommendations for different levels of care, noting which would be regarded as standard care, compared to optimal care, or "state of the art" interventions. The incidence of epilepsy in the infantile period is the highest of all age groups (strong evidence), with epileptic spasms the largest single subgroup and, in the first 2years of life, febrile seizures are the most commonly occurring seizures. Acute intervention at the time of a febrile seizure does not alter the risk for subsequent epilepsy (class 1 evidence). The use of antipyretic agents does not alter the recurrence rate (class 1 evidence), and there is no evidence to support initiation of regular antiepileptic drugs for simple febrile seizures (class 1 evidence). Infants with abnormal movements whose routine electroencephalography (EEG) study is not diagnostic, would benefit from video-EEG analysis, or home video to capture events (expert opinion, level U recommendation). Neuroimaging is recommended at all levels of care for infants presenting with epilepsy, with magnetic resonance imaging (MRI) recommended as the standard investigation at tertiary level (level A recommendation). Genetic screening should not be undertaken at primary or secondary level care (expert opinion). Standard care should permit genetic counseling by trained personal at all levels of care (expert opinion). Genetic evaluation for Dravet syndrome, and other infantile-onset epileptic encephalopathies, should be available in tertiary care (weak evidence, level C recommendation). Patients should be referred from primary or secondary to tertiary level care after failure of one antiepileptic drug (standard care) and optimal care equates to referral of all infants after presentation with a seizure (expert opinion, level U evidence). Infants with recurrent seizures warrant urgent assessment for initiation of antiepileptic drugs (expert opinion, level U recommendation). Infantile encephalopathies should have rapid introduction and increment of antiepileptic drug dosage (expert opinion, level U recommendation). There is no high level evidence to support any particular current agents for use in infants with seizures. For focal seizures, levetiracetam is effective (strong evidence); for generalized seizures, weak evidence supports levetiracetam, valproate, lamotrigine, topiramate, and clobazam; for Dravet syndrome, strong evidence supports that stiripentol is effective (in combination with valproate and clobazam), whereas weak evidence supports that topiramate, zonisamide, valproate, bromide, and the ketogenic diet are possibly effective; and for Ohtahara syndrome, there is weak evidence that most antiepileptic drugs are poorly effective. For epileptic spasms, clinical suspicion remains central to the diagnosis and is supported by EEG, which ideally is prolonged (level C recommendation). Adrenocorticotropic hormone (ACTH) is preferred for short-term control of epileptic spasms (level B recommendation), oral steroids are probably effective in short-term control of spasms (level C recommendation), and a shorter interval from the onset of spasms to treatment initiation may improve long-term neurodevelopmental outcome (level C recommendation). The ketogenic diet is the treatment of choice for epilepsy related to glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency (expert opinion, level U recommendation). The identification of patients as potential candidates for epilepsy surgery should be part of standard practice at primary and secondary level care. Tertiary care facilities with experience in epilepsy surgery should undertake the screening for epilepsy surgical candidates (level U recommendation). There is insufficient evidence to conclude if there is benefit from vagus nerve stimulation (level U recommendation). The key recommendations are summarized into an executive summary. The full report is available as Supporting Information. This report provides a comprehensive foundation of an approach to infants with seizures, while identifying where there are inadequate data to support recommended practice, and where further data collection is needed to address these deficits.

Migraine diagnosis and treatment: A knowledge and needs assessment among primary care providers.

Studies reveal that migraine is often under-recognized, misdiagnosed and inadequately treated in the primary care setting. The objective of this article is to assess primary care providers' (PCP) knowledge and needs regarding migraine diagnosis and management. We held semi-structured group interviews and distributed a brief questionnaire to PCPs in our hospital network. Building on the information from the interviews, we developed a comprehensive survey assessing PCPs' knowledge about migraine. Descriptive analyses were performed. The initial interviews and brief questionnaires revealed that PCPs are aware of the prevalence of migraine but are uncertain about the details of management. Eighty-three of 120 physicians completed the comprehensive survey. Only 47% would order imaging for a new type of headache, 31% for worsening headache, and 35% for a headache unresponsive to treatment. Only 28% were familiar with the American Academy of Neurology guidelines on preventive treatment and 40% were familiar with the Choosing Wisely Campaign recommendations on migraine treatment. Just 34% were aware that opioids can cause medication-overuse headache. Non-pharmacologic treatment was not usually recommended. PCPs favored educational opportunities involving direct contact with headache physicians (56%). PCPs are not universally aware of the specific recommendations for managing migraine patients. Future work should focus on innovative ways to provide decision support and education for PCPs caring for migraineurs.

Prophylactic anticonvulsants for gliomas: a seven-year retrospective analysis.

The American Academy of Neurology (AAN) does not recommend routine use of prophylactic antiepileptic drugs (pAEDs) in patients with newly diagnosed brain tumors. If used in the perioperative setting, discontinuation is suggested after the first postoperative week. It is unclear whether such recommendations are followed. Our objective was to compare our perioperative and long-term pAED use in glioma patients with AAN practice parameters. Retrospective chart review was performed on 578 glioma patients from 2006 to 2013. Seizures and AED use were assessed at surgery, 3 months postoperatively and death, last visit or 16 months postoperatively. Patients were divided into three groups at surgery: seizure-free with pAED, seizure-free without pAED, and seizure patients. Long-term pAED use was defined as continued use at 3 months postsurgery without seizures. pAEDs efficacy, factors influencing its use, and survival were examined. Out of 578 patients identified, 330 (57.1%) were seizure-naïve preoperatively. There were no significant differences in age, histology, tumor location or resection status between seizure-free populations with and without prophylaxis. Of 330 seizure-naïve patients, 205 (62.1%) received pAEDs at surgery. Ninety-six (46.9%) of those patients were still on pAEDs 3 months postsurgery (median use = 58 days). Rate of long-term prophylaxis use decreased by 13.5% over 6 years (70.3% in 2006; 56.8% in 2012). Phenytoin was preferred in 2006 (98.2%) with increasing use of levetiracetam over 6 years (44.6% in 2012). The only predictive factor for pAED use was complete resection (P = .0069). First seizure prevalence was similar in both seizure-free populations (P = .91). The seizure population had more men (P = .007), younger patients (P < .0001), lower-grade gliomas (P = .0003) and survived longer (P = .001) compared with seizure-free populations. In our center, long-term prophylactic AED use is high, deviating from current AAN Guidelines. Corrective measures are warranted.

Emergent diagnostic testing for pediatric nonfebrile seizures

BackgroundGuidelines from the American Academy of Neurology recommend laboratory studies or computed tomography (CT) for children who experience a nonfebrile seizure if anything in their history suggests a clinically significant abnormality. ObjectiveTo ascertain if any patient or seizure characteristics are associated with a greater likelihood that laboratory studies or CT scan will yield clinically significant results. MethodsThis retrospective case series reviewed 93 children with nonfebrile seizure, who were evaluated in an urban pediatric emergency department (ED) between July 2007 and June 2011. ResultsLaboratory studies were performed in 87% of the study group; 7% of those tests gave clinically significant results. Computed tomographic scans were obtained in 35% of our patients; 9% showed clinically significant findings. Presence of an active seizure in the ED or a first nonfebrile seizure had an 8% and 11% difference, respectively, for clinically significant laboratory abnormality. Children younger than 2 years showed a 7% difference of clinically significant laboratory abnormality. ConclusionThis study did not identify statistically significant predictors of laboratory or CT abnormalities for children with nonfebrile seizure presenting to the ED. Age less than 2years, having an active seizure in the ED, and experiencing a first-time seizure showed a trend toward an increased yield of laboratory testing. In accordance with the American Academy of Neurology guidelines, we conclude that the history of a child's present illness preceding the nonfebrile seizure, not characteristics of the seizure, should be used to determine the need for further testing.

The Relationship Between Coping and Psychological Adjustment in Family Caregivers of Individuals With Traumatic Brain Injury: A Systematic Review

A systematic review was conducted to evaluate the association between coping (as measured by the Ways of Coping Questionnaire [WOCQ]) and psychological adjustment in caregivers of individuals with traumatic brain injury (TBI). A search conducted using the CINAHL, Medline, and PsycINFO databases yielded 201 citations between 1974 and 2014. A total of seven articles met the inclusion criteria; namely, the respondents who completed the WOCQ were family caregivers of individuals with TBI (including 66-item, 42-item, or 21-item versions). Reviews were conducted in accordance with the American Academy of Neurology guidelines (2011) for classifying evidence. The results found no Class 1 or Class II studies but only four Class III and three Class IV studies. The major finding across the better-rated Class III studies was that the use of emotion-focused coping and problem-focused coping was possibly associated with psychological adjustment in caregivers. The Class IV studies were determined to be inadequate or conflicting in determining the association between coping and psychological adjustment. Future studies need to employ carefully crafted designs, adhere to statistical procedure, apply advanced analytic techniques, and employ explicit models of coping, which will increase the accuracy and generalizability of the findings.

Brain death guidelines explained.

Brain death is diagnosed in the minority of patients with acute severe brain injury. Guidelines have been developed in many countries in the world and physicians usually work through a set of criteria. The clinical evaluation starts with determination of futility of any medical or surgical intervention and an unmistakable certainty that the underlying diagnosis is correct. The actual neurologic evaluation in a patient suspected of being brain dead requires 25 tests and verifications. Brain death determination demands perfect diagnostic accuracy and thus requires skill and expertise. The overriding principle is simple: establish cause, exclude confounders, determine futility of interventions, examine brainstem reflexes, and test for apnea. In this review, the author revisits the American Academy of Neurology guidelines, and examines the details behind the guidelines. The 2010 guidelines have eliminated unnecessary tests and observation delays, and maintain a principle of simplicity.

Does adherence to epilepsy quality measures correlate with reduced epilepsy-related adverse hospitalizations? A retrospective experience.

In 2011, the American Academy of Neurology (AAN) established eight epilepsy quality measures (EQMs) for chronic epilepsy treatment to address deficits in quality of care. This study assesses the relationship between adherence to these EQMs and epilepsy-related adverse hospitalizations (ERAHs). A retrospective chart review of 475 new epilepsy clinic patients with an ICD-9 code 345.1-9 between 2010 and 2012 was conducted. Patient demographics, adherence to AAN guidelines, and annual number of ERAHs were assessed. Fisher's exact test was used to assess the relationship between adherence to guidelines (as well as socioeconomic variables) and the presence of one or more ERAH per year. Of the eight measures, only documentation of seizure frequency, but not seizure type, correlated with ERAH (relative risk [RR] 0.343, 95% confidence interval [CI] 0.176-0.673, p=0.010). Among patients in the intellectually disabled population (n=70), only review/request of neuroimaging correlated with ERAH (RR 0.128, 95% CI 0.016-1.009, p=0.004). ERAHs were more likely in African American patients (RR 2.451, 95% CI 1.377-4.348, p=0.008), Hispanic/Latino patients (RR 4.016, 95% CI 1.721-9.346, p=0.016), Medicaid patients (RR 2.217, 95% CI 1.258-3.712, p=0.009), and uninsured patients (RR 2.667, 95% CI 1.332-5.348, p=0.013). In this retrospective series, adherence to the eight AAN quality measures did not strongly correlate with annual ERAH.