American Academy Of Neurology Research Articles

Principles of Neurologic Ethics

Many neurologic diseases affect the brain and thus cognition and personality. Many people consider some neurologic conditions “worse than death” and would prefer not to be kept alive using medical technology if there is no reasonable chance of recovery. The clinician caring for patients with neurologic disease will frequently be confronted with decisions about whether to initiate or continue life-sustaining therapies. And because neurologic disease often impairs the ability to understand and to decide, clinicians are more often called on to make decisions for patients who cannot decide for themselves. This chapter covers general principles, including respect for autonomy, beneficence, nonmaleficence, justice, informed consent, and implied consent. Discussion about making decisions for others includes competence and decision-making capacity, advance directives (powers of attorney and living wills), substituted judgment, and best interests. Decisions about life-sustaining treatment include withholding versus withdrawing, acts versus omissions, and limiting life-sustaining treatment for the patient with no surrogate. Also covered are decisions in the face of prognostic uncertainty, and futility, as well as commonly encountered problems such as states of severely disordered consciousness, coma, vegetative state, minimally conscious state, and brain death (including ethical controversies). Organ donation after both brain death and cardiac death is discussed. The section on dementia covers feeding tubes for patients with advanced dementia, the locked-in state, and neuroenhancement. Tables include elements of informed consent, elements of competence, assumed ethical priority of potential surrogates, steps that aid decision making in the face of prognostic uncertainty, and the American Academy of Neurology’s criteria for determination of brain death. This chapter includes 23 references.

American Academy of Neurology, 2015 Annual Meeting: Advisor's Introduction

American Academy of Neurology, 2015 Annual Meeting: Advisor's Introduction

Education research: a case-based bioethics curriculum for neurology residents.

In 2012, the American Academy of Neurology (AAN) updated and expanded its ethics curriculum into Practical Ethics in Clinical Neurology, a case-based ethics curriculum for neurologists. We piloted a case-based bioethics curriculum for neurology residents using the framework and topics recommended by the AAN, matched to clinical cases drawn from Columbia's neurologic services. Our primary outcome was residents' ability to analyze and manage ethically complex cases as measured on precurriculum and postcurriculum multiple-choice quizzes. Secondary outcomes included precurriculum and postcurriculum self-assessed comfort in discussing and managing ethically complex cases, as well as attendance at ethics discussion sessions as compared to attendance at other didactic sessions. Resident performance on quizzes improved from 75.8% to 86.7% (p = 0.02). Comfort in discussing ethically complex cases improved from 6.4 to 7.4 on a 10-point scale (p = 0.03). Comfort in managing such cases trended toward improvement but did not reach statistical significance. Attendance was significantly better at ethics discussions (73.5%) than at other didactic sessions (61.7%, p = 0.04). Our formal case-based ethics curriculum for neurology residents, based on core topics drawn from the AAN's published curricula, was successfully piloted. Our study showed a statistically significant improvement in residents' ability to analyze and manage ethically complex cases as measured by multiple-choice tests and self-assessments.

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.

Treatment responsiveness in CIDP patients with diabetes is associated with unique electrophysiological characteristics, and not with common criteria for CIDP

Objectives: Characterize treatment responsiveness in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) patients with diabetes mellitus (DM). Methods: We performed a retrospective chart review of CIDP subjects assessed between 1997 and 2013 and compared treatment response rates in those with and without DM, using different sets of criteria. Results: 99 CIDP patients were included, 34 CIDP+DM and 65 CIDP−DM patients, both having similar treatment response rates. CIDP patients fulfilling European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria had higher treatment response rates. Responders fulfilled a higher number of American Academy of Neurology (AAN) and EFNS/PNS criteria and had a higher number of demyelinating features in the total cohort and in CIDP−DM but not in CIDP+DM patients. CIDP+DM responders, however, had unique electrophysiologic characteristics. Conclusion: Fulfilling EFNS/PNS and AAN criteria, and higher number of demyelinating features, are associated with higher treatment response rates in CIDP−DM but not in CIDP+DM patients, implying the need for adjusting current criteria to predict treatment response rates in CIDP−DM patients.

Treatment for Acquired Apraxia of Speech: A Systematic Review of Intervention Research Between 2004 and 2012.

The aim was for the appointed committee of the Academy of Neurological Communication Disorders and Sciences to conduct a systematic review of published intervention studies of acquired apraxia of speech (AOS), updating the previous committee's review article from 2006. A systematic search of 11 databases identified 215 articles, with 26 meeting inclusion criteria of (a) stating intention to measure effects of treatment on AOS and (b) data representing treatment effects for at least 1 individual stated to have AOS. All studies involved within-participant experimental designs, with sample sizes of 1 to 44 (median = 1). Confidence in diagnosis was rated high to reasonable in 18 of 26 studies. Most studies (24/26) reported on articulatory-kinematic approaches; 2 applied rhythm/rate control methods. Six studies had sufficient experimental control for Class III rating according to the Clinical Practice Guidelines Process Manual (American Academy of Neurology, 2011), with 15 others satisfying all criteria for Class III except use of independent or objective outcome measurement. The most important global clinical conclusion from this review is that the weight of evidence supports a strong effect for both articulatory-kinematic and rate/rhythm approaches to AOS treatment. The quantity of work, experimental rigor, and reporting of diagnostic criteria continue to improve and strengthen confidence in the corpus of research.

Benign paroxysmal positional vertigo: opportunities squandered.

Benign paroxysmal positional vertigo (BPPV) presentations are unique opportunities to simultaneously improve the effectiveness and efficiency of care. The test and treatment for BPPV--the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM), respectively--are supported by two evidence-based guidelines (American Academy of Otolaryngology--Head and Neck Surgery and American Academy of Neurology). With these processes, patients can be readily identified and treated at the bedside, quickly and without expensive tests. Patients randomized to the CRM have a cure rate of 80% at 24 h, compared to only 10% of controls. Despite this large effect size, less than 10% of affected patients receive the treatment, which shows that the management of BPPV in routine care is suboptimal. Future research is necessary to disseminate and implement the DHT and the CRM into routine practice.

Investigating the necessity of computed tomographic scans in children with headaches: a retrospective review.

Headaches are a common problem in the pediatric population. In 2002, the American Academy of Neurology (AAN) developed guidelines on neuroimaging for patients presenting with headache. Our objective was to determine the frequency of computed tomographic (CT) scanning ordered by a range of medical practitioners for pediatric patients presenting with primary headache. A retrospective chart review was conducted at the Children's Hospital of Eastern Ontario (CHEO), a tertiary care centre in Ontario. One hundred fifty-one records of patients referred to the outpatient neurology clinic at CHEO with ''headache'' or ''migraine'' as the primary complaint from 2004 to 2009 were randomly selected. Ninety-nine patients with normal neurologic examinations were ultimately included. Thirty-four patients (34%; 95% CI 25-45) had undergone CT scanning. None of the 34 CT scans (0%; 95% CI 0-10) showed significant findings, and none changed the headache diagnosis or management. Eleven (32%) of the CT scans were ordered by CHEO neurologists, 15 (44%) by community physicians, and 8 (24%) by CHEO emergency physicians. A high proportion of children presenting with primary headaches and a normal neurologic examination undergo CT scanning, despite well-established AAN guidelines regarding neuroimaging. Most of these CT scans do not appear to alter diagnosis and management. A variety of non-evidencebased factors may be encouraging physicians to overinvestigate this population and, as a result, increasing the risk of adverse events due to radiation exposure. Implementing initiatives at a site-based level that promote the use of established guidelines before performing CT scanning in this population may be beneficial.

The internationalization of the American Academy of Neurology.

The American Academy of Neurology (AAN), established in March 1948, was born out of a desire to create an inclusive professional society for neurologists, particularly for those nascent in their careers as young neurologists and those in training. This was in deliberate contrast to the more established American Neurological Association (ANA), at that time a 75-year-old association whose restrictive membership comprised only senior, mostly male leaders of American academic neurology predominantly in Northeast American institutions.1 The AAN's agenda for inclusivity was reflected not only in its relatively open membership requirements but also in the creation of a woman's auxiliary.

Where to go to find patient organizations, help for all neurologic conditions, and for the American Academy of Neurology's “Find-a-Neurologist” tool.

Where to go to find patient organizations, help for all neurologic conditions, and for the American Academy of Neurology's “Find-a-Neurologist” tool.

Developing guidelines for return to play: Consensus and evidence-based approaches

Background: Sports-related concussions are commonplace at all levels of play and across all age groups. The dynamic, evolving nature of this injury coupled with a lack of objective biomarkers creates a challenging management issue for the sports medicine team. Athletes who return to play following a concussion are known to be at higher risk for an additional brain injury, which necessitates a careful, informed return to play (RTP) process.Aim: The goal of this paper is to outline historical attempts at developing RTP guidelines and trace their evolution over time, culminating in a discussion of the process and outcomes of the most recent consensus statements/guidelines published by the international Concussion In Sport Group (CISG), the American Academy of Neurology (AAN), the National Athletic Trainers’ Association, and the 2013 Team Physician Consensus Statement Update.Method: An evaluation of the pros and cons of these guidelines is presented along with suggestions for future directions. In addition, the Institute of Medicine recently conducted a comprehensive report outlining the current state of evidence regarding youth concussions, which provides specific recommendations for future research.Conclusions: The different methodologies utilized in the development of consensus statements have distinct advantages and disadvantages, and both approaches add value to the everyday management of sports concussions. Importantly, the overall approach for management of sports concussion is remarkably similar using either consensus-based or formal evidence-based methods, which adds confidence to the current guidelines and allows practitioners to focus on accepted standards of clinical care. Moving forward, careful study designs need to be utilized to avoid bias in selection of research subjects, collection of data, and interpretation of results. Although useful, clinicians must venture beyond consensus statements to examine reviews of the literature that are published in much greater frequency than consensus statements

Inability to Consent Does not Diminish the Desirability of Stroke Thrombolysis: Chiong W, Kim AS, Huang IA, et al. Ann Neurol 2014;76:296−304.

Recently, the American Academy of Neurology and the American Heart Association/American Stroke Association have endorsed the use of thrombolysis in incapacitated persons without surrogate decision makers. The rationale for this position is that a reasonable person would consent to treatment if asked. The goal of this study was to evaluate the influence of the inability to consent and of personal health-related values on older adults’ emergency treatment preferences for both ischemic stroke and cardiac arrest.

Where to go for more information on the topics discussed in this issue of Neurology Now and for the American Academy of Neurology's “Find-a-Neurologist” tool.

Where to go for more information on the topics discussed in this issue of Neurology Now and for the American Academy of Neurology's “Find-a-Neurologist” tool.

Hallux Abducto valgus in relation to ankle equinus: A literature review

s / The Foot 24 (2014) 217–219 219 recommends tricyclic antidepressants as first line agents, anticonvulsants as second line and opioids as third line therapy [16] and as mentioned in Bril et al., the American Academy of Neurology advocates pregabalin as thefirst line treatment and states venlafaxine, duloxetine, amitriptyline, gabapentin, opioids and capsaicin as probably effective [14]. Given the variety of medications available for DPN, obtaining a complete history and physical and understanding the patients’ medical needs will help guide which type of medication will be optimal.

ED-15 * LONG-TERM PROPHYLACTIC ANTIEPILEPTIC DRUGS USE IN PATIENTS WITH GLIOMAS: A 7 YEAR RETROSPECTIVE ANALYSIS IN A TERTIARY CARE CENTER

BACKGROUND: American Academy of Neurology's 2000 practice parameter do not support routine use of prophylactic antiepileptic drugs (AEDs) in newly diagnosed brain tumors. If used in the perioperative setting, they should be discontinued after the first postoperative week. However, it remains unclear whether such recommendations are followed. OBJECTIVE: To compare our use of long-term prophylactic AEDs in patients with gliomas to published practice guidelines by the AAN. METHODS: A retrospective chart review was performed on 578 glioma cases evaluated in a single tertiary care center from 2006-2013. Data collected included demographic factors, surgical procedure and tumor characteristics. Seizures and AED use were assessed at surgery, 3 months post-operatively and death/last visit/16 months. Long-term prophylactic AED use was defined as continued use of AED at 3 months post-surgery in the absence of seizures. Patients were divided into three groups at surgery: seizure-free with and without prophylactic AEDs, and seizure-patients. Survival, prophylaxis efficacy and factors influencing its use were calculated. RESULTS: Out of 578 patients operated between 2006-2013, 330(57.1%) were seizure-naive pre-operatively. 205/330(62.1%) received prophylactic AED at surgery. 96/205(46.9%) 95%CI(40.2-54.7) were still on AED 3 months post-surgery (median use = 58 days; 95%CI(31-152)). Rate of long-term prophylaxis use decreased by 13.5% over 6 years (70.3%-2006;56.8%-2012). Dilantin was the preferred agent in 2006(98.2%) with increasing use of Keppra over the years (44.6%-2012). There were no significant differences in age, histology, localisation and resected status between the seizure-free populations with and without prophylaxis. However, seizure-population had more men (p = 0.0068), younger patients (p < 0.0001), lower-grade gliomas (p = 0.0003) and lived longer (p = 0.0012,HR = 0.5423,95%CI(0.3742, 0.7859)) compared to seizure-free populations. The only predictive factor for prophylactic AEDs use was complete resection (p = 0.0069,OR = 2.0292,95%CI(1.2202, 3.4177)). Prevalence of first seizure was similar in both seizure-free populations (p = 0.9104, HR = 0.9627, 95%CI(0.5153, 1.806)). CONCLUSIONS: In our centre, long-term prophylactic AED use is high, deviating from current AAN Guidelines. Corrective measures are warranted.

PO275 BENEFICIAL EFFECTS OF AN ORIENTAL PHYTOMEDICINE BOFUTSUSHOSAN ON OBESITY-RELATED METABOLIC DISTURBANCES IN HIGH-FAT DIET-INDUCED OBESE C57BL/6J MICE

Reference(s) [1] Bril V, England J, Franklin GM, Backonja M, et al. American Academy of Neurology; American Association of Neuromuscular and Electrodiagnostic Medicine; American Academy of Physical Medicine and Rehabilitation. Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011; 76(20): 1758–65. [2] O’Connor AB, Noyes K, Holloway RG. A cost-utility comparison of four first-line medications in painful diabetic neuropathy. Pharmacoeconomics. 2008; 26(12): 1045–64. [3] Bansal D, Bhansali A, HotaD, Chakrabarti A, et al. Amitriptyline vs. pregabalin in painful diabetic neuropathy: a randomized double blind clinical trial. Diabet Med. 2009; 26(10): 1019–26.

SM-02 * LEVETIRACETAM USAGE IN POST-OPERATIVE SEIZURE MANAGEMENT IN MALIGNANT GLIOMA

BACKGROUND: There is a lack of consensus in the use of newer-generation anti-epileptic drugs (AEDs) as prophylaxis in patients with malignant glioma (MG) who undergo surgical resection. The rate of seizure occurrence in MG is less than low-grade gliomas, but due to the debilitating nature of seizures, clinicians routinely prescribe prophylactic AEDs. Recommendations were last published in 2000 by the American Academy of Neurology based on research of older generation AEDs. Levetiracetam (LEV) is a newer generation AED with an improved safety profile and proven efficacy in heterogeneous patient populations, but its efficacy has yet to be determined in MG patients. METHODS: A retrospective analysis of AED usage was conducted among 114 patients diagnosed with MG (WHO Grade III-IV) who underwent initial resection at a single institution during 2011-2012. Demographics, comorbidities, tumor and surgical characteristics, AED usage, toxicity and seizure occurrence were reviewed. Seizure history was characterized prior to and up to 6 months after surgery. Logistic regression was used to evaluate the association of LEV prophylaxis and other risk factors with post-operative seizure occurrence. RESULTS: Patients were male (58%), had a gross total resection (88%), a history of seizures (44%), and received LEV pre-operatively (45%). Post-operatively, 91% received LEV of which 25% experienced a seizure. Side effects of LEV use were rare (n = 10, 10%), and included irritability, somnolence, psychiatric disturbances, and thrombocytopenia. Patient's age was a significant predictor of seizure occurrence. Older patients had a higher risk of seizure in the 6 months post-operatively (OR = 2.6, 95% CI 1.10-6.35, p = 0.0327). CONCLUSIONS: LEV is well tolerated in MG patients undergoing resection. Older age is associated with post-operative seizure occurrence. Future studies need to assess the effectiveness of LEV in reducing post-operative seizure recurrence in this population in comparison to other AEDs.

Opioids for Chronic Noncancer Pain: The Need for Balance

In this position paper, the American Academy of Neurology reviews the rise in opioid-associated harms, the lack of evidence for long-term

A systematic review of stress-management interventions for multiple sclerosis patients.

The objective of this study was to identify stress-management interventions used for people with multiple sclerosis (MS) and systematically evaluate the efficacy of these interventions. Several strategies were used to search for studies reported in articles published up to 2013. Our initial search retrieved 117 publications, of which 8 met our criteria for review. Of the eight studies, one provided Class I evidence, five provided Class III evidence, and two provided Class IV evidence for the efficacy of stress-management interventions according to the evidence classification established by the American Academy of Neurology. Most studies showed positive changes in outcomes assessed; however, the range of methodological quality among the published studies made it difficult to draw conclusions. The promising findings for stress-management interventions highlight the need for future studies. Additional large, prospective, multicenter studies will help to define the role of stress-management interventions in the treatment and course of MS. Furthermore, including outcome measures based on biological and clinical markers of disease will prove useful in understanding potential underlying mechanisms.

Where to go for more information on the topics discussed in this issue of Neurology Now and for the American Academy of Neurology's “Find-a-Neurologist” tool.

Where to go for more information on the topics discussed in this issue of Neurology Now and for the American Academy of Neurology's “Find-a-Neurologist” tool.