Child Neurology Research Articles

An Approach to Successful Development of Clinician-Scientists in Neurology: The NINDS R25 Experience.

Training clinician-scientists is a primary objective of many academic neurology departments, as these individuals are uniquely positioned to perform insightful clinical or laboratory-based research informed both by clinical knowledge and their own experiences caring for patients. Despite its importance, training clinician-scientists has perhaps never been so challenging. The National Institute of Neurologic Disorders and Stroke (NINDS) R25 program was designed in an attempt to support these individuals, decrease the time needed to obtain National Institutes of Health K awards, and to help educate a cohort of trainees preparing for a career in academic neurology. We endeavored to describe the structure and features of the program while examining its outcomes. R25 outcome data from 2009 to 2024 were reviewed. Statistical comparisons were made using 2-sided Mann-Whitney U testing. A total of 67% of adult neurologists who received an R25 had a successful application for a National Institutes of Health K award compared with 45% of adult neurologists who had not received R25 support (p < 0.0001). Among child neurologists, 73% who applied went on to receive K funding after R25 support, compared with 45% who had not been part of the R25 program (p < 0.001). The average time between completion of residency and obtaining a K award for R25 participants was decreased by 26 months among those with an MD/PhD degree, and 32 months for those with an MD degree compared with non-R25 individuals. The R25 program has been successful in achieving its training goals, but stands as only one component of support for aspiring clinician-scientists. Investments and commitments made by academic neurology departments are key to supporting this success. ANN NEUROL 2024.

Neuroimaging Findings in Children with Cerebral Palsy – Risk Assessment for Symptomatic Epilepsy

Neuroimaging plays a key role in the diagnosis of cerebral palsy (CP), as it helps to understand the etiology and pathogenesis of neurological impairment. The aim of the study is to demonstrate the role of neuroimaging in assessing the risk for epilepsy in children with CP with various lesions in CT and MRI with a focus on neuroimaging findings in full-term and premature children and their risk for epilepsy. The study includes 521 children with CP, diagnosed in the Clinic of Child Neurology, UMHATNP “St. Naum” between 2008 and 2018. Two hundred and twenty children underwent MRI of the brain, 464 of the cases had CT, and 127 had both MRI and CT. Various pathological lesions in MRI (brain malformations, lesions in the white or gray matter, lesions in the basal ganglia, cystic lesions, cortical atrophy, ventriculomegaly) were found in all patients with CP and symptomatic epilepsy, while 5.8% of those children with CP without epilepsy had normal MRI. Normal findings were observed in CT in 7.5% of the children with CP and epilepsy, while this result reached 12.1% when children did not have epilepsy. Among the abnormal findings in MRI with the highest relative risk for symptomatic epilepsy were ventriculomegaly RR – 1.296 (95% CI 1.149–1.463), cortical atrophy RR – 1.235 (95% CI 1.082–1.410) and lesions in the gray matter RR – 1.210 (95% CI 1.056–1.387). When comparing the types of the lesions in MRI in full-term and premature children with CP, we observed that white matter lesions predominated in premature children, while grey matter lesions in full-term children, which explains the higher incidence of epilepsy in full-term children. We found a higher incidence of pathological lesions in neuroimaging studies in patients with CP and concomitant epilepsy compared to those without epilepsy, as well as a high relative risk for epilepsy in patients with ventriculomegaly, cortical atrophy, and gray matter lesions.

Design and Interrater Reliability of the Pediatric Version of the Race Scale: PedRACE.

Acute ischemic stroke is a leading cause of pediatric death and disability. A clinical scale adapted for children can ensure early detection of candidates for urgent acute ischemic stroke treatment. The Rapid Arterial Occlusion Evaluation (RACE) scale for adults, which scores 5 items (facial palsy 0-2; arm motor function 0-2; leg motor function 0-2; head/gaze deviation 0-1; and aphasia or agnosia 0-2), has good sensitivity and specificity in detecting large vessel occlusion. We adapted the previously validated RACE scale for use in children as the Pediatric RACE scale. This adapted scale was tested by prehospital/emergency room staff attending to patients covered by the Catalan Pediatric Stroke Code and child neurologists for its correlation with the Pediatric National Institutes of Health Stroke Scale and for interrater reliability. The study included 50 children, 18 with confirmed strokes (7 acute ischemic strokes and 11 hemorrhagic strokes). Prehospital/emergency staff and child neurologists agreed fully regarding 82% of patients and 100% regarding head/gaze deviation and agnosia. The Pediatric RACE scale correlated strongly with the Pediatric National Institutes of Health Stroke Scale in evaluations by child neurologists (Spearman ρ, 0.852; P<0.001) and prehospital/emergency staff (Spearman ρ, 0.781; P<0.001). The median Pediatric RACE score was significantly higher in patients with large vessel occlusion (6.5; interquartile range, 6-7) than with other etiologies. Pediatric RACE, showing good interrater reliability and correlation with the Pediatric National Institutes of Health Stroke Scale, is a simple scale to detect candidates for pediatric acute stroke treatment, designed for both prehospital and in-hospital use by non-neurologist medical staff.

Opioid neurotoxicity: A case series and review from members of the Child Neurology Society Neurocritical Care Special Interest Group

Opioid neurotoxicity: A case series and review from members of the Child Neurology Society Neurocritical Care Special Interest Group

Brazilian consensus recommendations on the diagnosis and treatment of autoimmune encephalitis in the adult and pediatric populations.

Autoimmune encephalitis (AIE) is a group of inflammatory diseases characterized by the presence of antibodies against neuronal and glial antigens, leading to subacute psychiatric symptoms, memory complaints, and movement disorders. The patients are predominantly young, and delays in treatment are associated with worse prognosis. With the support of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, ABN) and the Brazilian Society of Child Neurology (Sociedade Brasileira de Neurologia Infantil, SBNI), a consensus on the diagnosis and treatment of AIE in Brazil was developed using the Delphi method. A total of 25 panelists, including adult and child neurologists, participated in the study. The panelists agreed that patients fulfilling criteria for possible AIE should be screened for antineuronal antibodies in the serum and cerebrospinal fluid (CSF) using the tissue-based assay (TBA) and cell-based assay (CBA) techniques. Children should also be screened for anti-myelin oligodendrocyte glucoprotein antibodies (anti-MOG). Treatment should be started within the first 4 weeks of symptoms. The first-line option is methylprednisolone plus intravenous immunoglobulin (IVIG) or plasmapheresis, the second-line includes rituximab and/or cyclophosphamide, while third-line treatment options are bortezomib and tocilizumab. Most seizures in AIE are symptomatic, and antiseizure medications may be weaned after the acute stage. In anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, the panelists have agreed that oral immunosuppressant agents should not be used. Patients should be evaluated at the acute and postacute stages using functional and cognitive scales, such as the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Modified Rankin Scale (mRS), and the Clinical Assessment Scale in Autoimmune Encephalitis (CASE). The present study provides tangible evidence for the effective management of AIE patients within the Brazilian healthcare system.

Transition Is Not Enough: How Child Neurologists can Help Improve the Care for Adults With Neurodevelopmental Disabilities

Transition Is Not Enough: How Child Neurologists can Help Improve the Care for Adults With Neurodevelopmental Disabilities

Kind of a Big Dill: An Innovative Adult and Child Neurology Resident-Versus-Faculty Pickleball Tournament.

Kind of a Big Dill: An Innovative Adult and Child Neurology Resident-Versus-Faculty Pickleball Tournament.

Impact of clinical clerkship integrated with clinical ladder on attending physicians’ teaching self-efficacy

BackgroundSelf-efficacy plays an important role in enhancing the teaching capabilities of attending physicians (APs). The clinical ladder (CL) is an educational approach developed in the field of nursing education that increases difficulty in an incremental manner. However, no previous study has confirmed the effectiveness of CL in medical education. Therefore, this study aimed to examine the effect of clinical clerkship integrated with clinical ladder (CC-CL) on the self-efficacy of APs.MethodsSixth-year medical students participated in CC-CL for 6 months starting from April 2023, and the changes in the self-efficacy of APs were retrospectively evaluated. The students were trained by the APs concurrently, and the achievement levels of each student were shared. The primary outcome measure was the physician teaching self-efficacy questionnaire (PTSQ) score. The PTSQ scores before and after CC-CL were analyzed using the Wilcoxon matched-pair signed-rank test.ResultsFifteen APs from the Department of Pediatric and Child Neurology were included in this study. No significant difference was observed in the total PTSQ scores of the APs before and after CC-CL. However, a significant increase was observed in the PTSQ score of APs who participated for at least 2 h per week over a period of more than 3 months (n = 8) after CC-CL (p = 0.022). Furthermore, APs who had received their pediatrician certification < 10 years ago (n = 8) showed a significant increase in the total PTSQ score after CC-CL (p = 0.022).ConclusionsCC-CL may play an important role in cultivating the self-efficacy of less experienced APs. Further comparative studies must be conducted in the future to validate the findings of this study.

A Qualitative Analysis of Communication-focused Feedback Provided to Child Neurology Residents During an Objective Structured Clinical Exam (OSCE) (P4-7.003)

A Qualitative Analysis of Communication-focused Feedback Provided to Child Neurology Residents During an Objective Structured Clinical Exam (OSCE) (P4-7.003)

@NMatch2024: A Student-led Social Media-based Initiative to Guide Adult and Child Neurology Residency Applicants and Programs in a Digital Era (P5-7.005)

@NMatch2024: A Student-led Social Media-based Initiative to Guide Adult and Child Neurology Residency Applicants and Programs in a Digital Era (P5-7.005)

Expert Accuracy and Inter-rater Agreement of “Must-know” EEG Findings for Adult and Child Neurology Residents (P11-1.001)

Expert Accuracy and Inter-rater Agreement of “Must-know” EEG Findings for Adult and Child Neurology Residents (P11-1.001)

Focality in childhood absence epilepsy

ABSTRACT Background and purpose Childhood absence epilepsy (CAE) has a typical electroencephalography (EEG) pattern of generalized 3 Hz spike and wave discharges (SWD). Focal interictal discharges were also documented in a small number of documents. The aim was to investigate the amplitudes of interictal 3 Hz SWD within the 1st second in drug-naïve CAE patients. In this way, areas with maximal electronegativity at the beginning of clinically generalized discharges will be documented. Methods The EEG records of children with drug-naïve CAE were evaluated retrospectively by two child neurologists first for 3 Hz SWD. Then, a machine-learning model evaluated the amplitudes of 3 Hz in the 1st second of SWD. Maximum electronegativity areas were documented and classified as focal, bilateral, and generalized. Results One hundred and twelve 3 Hz SWD were evaluated in 11 patients. Among discharges within the 1st second, maximum electronegativity areas were documented as focal for 44 (39.2%), bilateral for 8 (7.1%), generalized for 60 (53.5%). Among focal electronegativity areas, mostly right central, left occipital and midline parietal areas were documented in 12 (10.7%), 7 (6.2%), and 6 (5.3%), respectively. Eight (7.1%) of the maximum electronegativity areas were detected bilaterally, of which 7 (6.2%) originated from the frontopolar areas. Conclusions Focal maximal electronegativity areas were frequently observed in drug-naïve CAE patients, comprising approximately half of non-generalized discharges. Focal discharges might be misleading in diagnosis. Focal areas within the brain may be responsible for and contribute to absence seizures that appear bilaterally symmetrical and generalized clinically. Although its clinical implication is unknown, this warrants further study.

Effects of explainable artificial intelligence in neurology decision support.

Artificial intelligence (AI)-based decision support systems (DSS) are utilized in medicine but underlying decision-making processes are usually unknown. Explainable AI (xAI) techniques provide insight into DSS, but little is known on how to design xAI for clinicians. Here we investigate the impact of various xAI techniques on a clinician's interaction with an AI-based DSS in decision-making tasks as compared to a general population. We conducted a randomized, blinded study in which members of the Child Neurology Society and American Academy of Neurology were compared to a general population. Participants received recommendations from a DSS via a random assignment of an xAI intervention (decision tree, crowd sourced agreement, case-based reasoning, probability scores, counterfactual reasoning, feature importance, templated language, and no explanations). Primary outcomes included test performance and perceived explainability, trust, and social competence of the DSS. Secondary outcomes included compliance, understandability, and agreement per question. We had 81 neurology participants with 284 in the general population. Decision trees were perceived as the more explainable by the medical versus general population (P < 0.01) and as more explainable than probability scores within the medical population (P < 0.001). Increasing neurology experience and perceived explainability degraded performance (P = 0.0214). Performance was not predicted by xAI method but by perceived explainability. xAI methods have different impacts on a medical versus general population; thus, xAI is not uniformly beneficial, and there is no one-size-fits-all approach. Further user-centered xAI research targeting clinicians and to develop personalized DSS for clinicians is needed.

Utility of camp for children with epilepsy: a retrospective

Objective: The aim of this study was to evaluate the benefits of educational and recreational camping programs for children with epilepsy. Method: A retrospective review of data collected from all children attending annual epilepsy camps organized by the Croatian Epilepsy Association and the Zagreb City Office for Health during 8 years was performed. Children included were between 6 and 18 years of age. The staff of the camp includes child neurologists, a psychologist, neurology nurses and trained volunteers. Educational activities are designed to improve children’s knowledge of epilepsy, importance of taking medication, academic choices, suggested employment, and regulations regarding driving laws. These issues were discussed in groups or in single sessions, depending on the case. Other activities included supervised swimming, team sports, fun activities and games, arts and crafts and entertainment such as disco or movie night. Each of the participants filled out three questionnaires 1. General data questionnaire and pre-camp knowledge test; 2. Camp satisfaction questionnaire and post-camp knowledge test; 3. Questionnaire on adaptation to epilepsy in young people. Results: The analyses of surveys and tests showed that only 75% of children in camp knew that they had epilepsy. In 10% of children, friends and distant family members did not know about epilepsy. Comparing the knowledge test before and after the camp, the average percentage of correctly solved tasks on the first test is 65%, and on the second 87%. The answers in the questionnaire on adaptation to life with epilepsy are indicators of strong stigma in children with epilepsy. Conclusions: The main accomplishment of the camp was for children to gain confidence that they can reach their full potential in life and to feel equal to their peers in every aspect of life.

Access to Pediatric Neurology Training and Services Worldwide: A Survey by the International Child Neurology Association.

Access to Pediatric Neurology Training and Services Worldwide: A Survey by the International Child Neurology Association.

Education Research: Observational Study of Educational Debt Among US Medical Graduates Entering Neurology, 2010-2021.

To identify trends in educational debt for US medical school graduates entering neurology and compare debt to anticipated compensation. Data of 148 accredited medical schools were obtained from the Association of American Medical Colleges Graduation and Matriculating Student Questionnaires to identify self-reported educational debt for graduates pursuing neurology training. Trends were assessed in a 2-year interval from 2010 to 2021. Descriptive statistics were used to assess characteristics associated with debt. Dollar amounts were adjusted to 2021 US dollars. Total compensation by subspecialty from the 2021 American Academy of Neurology Compensation and Productivity Survey was used to calculate debt-to-income ratios by subspecialty. There were 182,738 responses recorded from medical graduates from 2010 to 2021, of which 4,466 planned on neurology training. The percentage of medical graduates entering neurology with debt decreased from 82% in 2010-2011 to 71% in 2020-2021. Among indebted, the median educational debt increased 9% from $192,613 (interquartile range [IQR] $140,908) in 2010-2011 to $209,396 (IQR $159,128) in 2020-2021 (p < 0.001). Medical graduates with debt more often reported family income in the bottom 3 quintiles of US household income (18% with debt vs 7% without debt; p < 0.001). Graduates from self-identified race and ethnicity groups who are underrepresented in medicine (URiM) were more likely to have debt (15% vs 9%; p < 0.001) and had greater debt when compared with graduates not self-identifying as URiM (median $211,616 [IQR $152,760] vs $202,379 [IQR $153,340]; p < 0.001). In 2021, 46% of indebted neurology-bound graduates indicated plans to use Public Service Loan Forgiveness, which increased from 16% in 2010. In 2021, the median debt for neurology graduates represented between 70% and 93% of total annual compensation with the highest debt-to-income ratios among behavioral neurology (0.93), child neurology (0.91), and movement disorders (0.89). The burden of educational debt for neurology-bound graduates is increasingly concentrated among those from lower-income families and racial and ethnic groups who are URiM. Subspecialties that often manage patients in the outpatient setting, as compared with those that are primarily inpatient/procedural, may have greater debt with respect to their compensation. Nearly half of 2021 graduates pursuing neurology plan to use tax-payer funds for loan forgiveness.

Education Research: EEG Education in Child Neurology and Neurodevelopmental Disabilities Residencies: A Survey of US and Canadian Program Directors.

In the United States, many child neurologists (CNs) and neurodevelopmental disability (NDD) specialists who read EEGs in clinical practice had no additional EEG training other than what was received during residency. This practice highlights the importance of ensuring that CN/NDD residents achieve EEG competence before graduation. However, prior survey-based evidence showed that roughly a third of graduating CN residents in the United States do not feel confident interpreting EEGs independently. As part of a needs assessment, we conducted a descriptive study characterizing EEG practices in CN and NDD residency programs in the United States and Canada. A 30-question e-survey focused on characteristics of residency programs and their EEG teaching practices was sent to all 88 CN and NDD residency program directors listed in the Accreditation Council for Graduate Medical Education, Child Neurology Society, and Canadian Residency Matching Service websites. Twenty-nine (n = 29/88; 33%) residency programs completed the survey, most of which were CN (90%), academic (90%), and located in the United States (83%). The mean number of weeks dedicated to EEG training required to graduate was 7.3 ± 4 (mean ± SD). EEG rotations involved the clinic/outpatient setting (83%), epilepsy monitoring unit (EMU) (76%), and inpatient setting (excluding EMU) (72%). During a 4-week EEG rotation, residents typically read 16-45 EEGs (62%). The most common methods of EEG teaching in CN/NDD programs were teaching during EEG rotation and yearly didactics. The mean number of EEGs read per rotation had a significant positive correlation with the average percentage of residents who reportedly achieve EEG competence by graduation (coefficient 0.461; p = 0.007). Barriers to EEG education were reported by 28% of the programs; the most common barrier identified was insufficient EEG exposure. Possible solutions were primarily related to increasing quality and quantity of EEG exposure. Almost two-thirds of programs reported not using objective measures to assess EEG competence. Our results characterize resident EEG education in a third of CN/NDD residency programs in the United States and Canada. We suggest that residency leaderships consider standardization of EEG learning along with establishment and implementation of objective measures in training requirements and competence assessment.

Education Research: Educating Child Neurology Residents About Psychogenic Nonepileptic Seizures

Background and Objectives Psychogenic nonepileptic seizures (PNES) are difficult to differentiate from epileptic seizures (ES) even for neurologists who see these conditions frequently. This difficulty is due to overlapping semiologic findings between the 2 diagnoses. Previous studies have shown that trainees, including neurology trainees, are not accurate in differentiating PNES from ES. Neurologists often find the communication of PNES difficult. Despite these challenges, most programs do not have formal curricula for teaching PNES, and there are no standards for residency curricula in this topic. The aim of this study was to understand the gaps in resident education on PNES. Methods This study was accomplished through a needs assessment of current pediatric neurology residents and residency program directors (PDs). Two unique surveys were distributed, 1 for child neurology trainees and 1 for PDs. Questions were designed to understand trainees' self-reported knowledge, confidence, current education received, and desired teaching. Similarly for PDs, questions were designed to assess the state of education on PNES at their programs, sufficiency of education, and their desire for standardized curriculum. Results Sixty-eight trainees and 21 PDs responded to the survey. Approximately one-quarter of trainees reported neutral to low levels of confidence and 38% reported neutral to low levels of knowledge in caring for patients with PNES. Trainees reported that directing patients with PNES to appropriate management was the most challenging aspect of care, followed by communicating the diagnosis, with 60% and 46% reporting difficulty, respectively. Only 21% of residents felt their current PNES education needs no improvement. One-fifth of PDs felt their current PNES education is not sufficient, and all reported they would incorporate a standardized curriculum. Trainees reported preferring to learn about this topic through lectures and simulation, while PDs preferred online modules and simulation. Discussion While residents and PDs report high confidence and knowledge in treating pediatric patients with PNES, respondents felt improvement is needed to their curricula regarding this topic. Multiple learning methods are preferred, with emphasis on communicating the diagnosis and management of patients once the diagnosis has been made. PDs desire a standardized curriculum and would incorporate one into their programs. Findings of this study could be used to create a national curriculum.

Clearance for Driving in Genetic Generalized Epilepsy.

A key aspect of management of genetic generalized epilepsy involves assessing seizure control and deciding suitability for driving motor vehicles. We surveyed child neurologists and pediatric epileptologists on key questions that practitioners should ask prior to providing clearance for driving. The results showed a wide variability of practice among responders. We propose a likely appropriate process necessary to determine seizure control.

Managing pediatric-onset multiple sclerosis in an austere setting: A case report.

Pediatric-onset multiple sclerosis (POMS) is the most common demyelinating disease in children. Patients suffer from physical disability, cognitive impairment, and psychosocial challenges. Management requires a multidisciplinary care team. Here we present a case of an 11-year-old boy with POMS who relocated to Guam prior to initiation of a disease-modifying treatment and who experienced a flare without immediate access to an MRI or a child neurologist. Care required the combined efforts of ophthalmology, pediatrics, and emergency medicine in Guam, real-time remote guidance by child neurology, and asynchronous collaboration with cardiology and child neurology. As a result, the immediate flare was accurately diagnosed and treated with steroids, the patient was started on Fingolimod, and an emergency management plan for future flares was constructed. This case illustrates the nuances of both the acute and chronic management of multiple sclerosis in a resource-limited setting and how a combination of synchronous and asynchronous telemedicine was able to achieve a satisfactory treatment plan.