Individual Neurologists Research Articles

Black Patients Matter in Neurology: Race, Racism, and Race-Based Neurodisparities.

Black people living in the United States suffer disproportionate morbidity and mortality across a wide range of neurologic conditions. Despite common conceptions to the contrary, "race" is a socially defined construct with little genetic validity. Therefore, racial health inequities in neurology ("neurodisparities") are not a consequence of biologic differences between races. Instead, racism and associated social determinants of health are the root of neurodisparities. To date, many neurologists have neglected racism as a root cause of neurologic disease, further perpetuating the problem. Structural racism, largely ignored in current neurologic practice and policy, drives neurodisparities through mediators such as excessive poverty, inferior health insurance, and poorer access to neurologic and preventative care. Interpersonal racism (implicit or explicit) and associated discriminatory practices in neurologic research, workforce advancement, and medical education also exacerbate neurodisparities. Neurologists cannot fulfill their professional and ethical responsibility to care for Black patients without understanding how racism, not biologic race, drives neurodisparities. In our review of race, racism, and race-based disparities in neurology, we highlight the current literature on neurodisparities across a wide range of neurologic conditions and focus on racism as the root cause. We discuss why all neurologists are ethically and professionally obligated to actively promote measures to counteract racism. We conclude with a call for actions that should be implemented by individual neurologists and professional neurologic organizations to mitigate racism and work towards health equity in neurology.

Clinical Features of COVID-19 on Patients With Neuromyelitis Optica Spectrum Disorders.

Background and ObjectivesTo describe the clinical features and disease outcomes of coronavirus disease 2019 (COVID-19) in patients with neuromyelitis optica spectrum disorder (NMOSD).MethodsThe Neuroimmunology Brazilian Study Group has set up the report of severe acute respiratory syndrome (SARS-CoV2) cases in patients with NMOSD (pwNMOSD) using a designed web-based case report form. All neuroimmunology outpatient centers and individual neurologists were invited to register their patients across the country. Data collected between March 19 and July 25, 2020, were uploaded at the REDONE.br platform. Inclusion criteria were as follows: (1) NMOSD diagnosis according to the 2015 International Panel Criteria and (2) confirmed SARS-CoV2 infection (reverse transcription-polymerase chain reaction or serology) or clinical suspicion of COVID-19, diagnosed according to Center for Disease Control / Council of State and Territorial Epidemiologists (CDC/CSTE) case definition. Demographic and NMOSD-related clinical data, comorbidities, disease-modifying therapy (DMT), COVID-19 clinical features, and severity were described.ResultsAmong the 2,061 pwNMOSD followed up by Brazilian neurologists involved on the registry of COVID-19 in pwNMOSD at the REDONE.br platform, 34 patients (29 women) aged 37 years (range 8–77), with disease onset at 31 years (range 4–69) and disease duration of 6 years (range 0.2–20.5), developed COVID-19 (18 confirmed and 16 probable cases). Most patients exhibited mild disease, being treated at home (77%); 4 patients required admission at intensive care units (severe cases); and 1 patient died. Five of 34 (15%) presented neurologic manifestations (relapse or pseudoexacerbation) during or after SARS-CoV2 infection.DiscussionMost NMOSD patients with COVID-19 presented mild disease forms. However, pwNMOSD had much higher odds of hospitalization and intensive care unit admission comparing with the general Brazilian population. The frequency of death was not clearly different. NMOSD disability, DMT type, and comorbidities were not associated with COVID-19 outcome. SARS-CoV2 infection was demonstrated as a risk factor for NMOSD relapses. Collaborative studies using shared NMOSD data are needed to suitably define factors related to COVID-19 severity and neurologic manifestations.

Approach to and Practice of Disc Fenestration in the Management of Intervertebral Disc Extrusions in Dogs: A Questionnaire Survey.

Intervertebral disc fenestration has been shown to reduce the risk of extrusion in the thoracolumbar region in dogs, but use of the technique varies between individual neurologists and surgeons. Our aim was to investigate opinions and practices regarding disc fenestration amongst those involved in neurosurgery in dogs. A web-based survey containing questions relating to the use of fenestration during treatment of intervertebral disc extrusion in dogs was distributed to board-certified neurologists and surgeons. Results were analysed using Microsoft Excel. There were 323 responses from 190 neurologists and 133 surgeons. Seventy-one per cent of respondents routinely used concurrent disc fenestration when performing decompressive surgery in the thoracolumbar region, although the rate was lower amongst surgeons (55%) than neurologists (82%). Only 25% of respondents performed concurrent fenestration in the cervical spine. Forty-five per cent of respondents reported having experienced complications, with haemorrhage being the most common. Fenestration is widely used in the management of thoracolumbar intervertebral disc extrusion, but a universally accepted approach does not exist, and differences are seen between neurologists and surgeons.

Video-Based Pairwise Comparison: Enabling the Development of Automated Rating of Motor Dysfunction in Multiple Sclerosis

ObjectivesTo examine the feasibility, reliability, granularity, and convergent validity of a video-based pairwise comparison technique that uses algorithmic support to enable automated rating of motor dysfunction in patients with multiple sclerosis (MS). DesignFeasibility and larger cross-sectional cohort study. SettingThe outpatient clinic of 2 specialist university medical centers. ParticipantsSelected sample from a cohort of patients with MS participating in the Assess MS study (N=42). Videos were randomly drawn from each strata of the ataxia severity-degrees as defined in the Expanded Disability Status Scale (EDSS). In Basel: 19 videos of 17 patients (mean age, 43.4±11.6y; 10 women). In Amsterdam: 50 videos of 25 patients (mean age, 50.0±10.0y; 15 women). InterventionsNot applicable. Main Outcome MeasuresIn each center, neurologists (n=13; n=10) viewed pairs of videos of patients performing standardized movements (eg, finger-to-nose test) to assess relative performance. A comparative assessment score was calculated for each video using the TrueSkill algorithm and analyzed for intrarater (test-retest; ratio of agreement) and interrater reliability (intraclass correlation coefficient [ICC] for absolute agreement) and convergent validity (Spearman ρ). Granularity was estimated from the average difference in comparative assessment scores at which 80% of neurologists considered performance to be different. ResultsIntrarater reliability was excellent (median ratio of agreement≥0.87). The comparative assessment scores calculated from individual neurologists demonstrated good-excellent ICCs for interrater reliability (0.89; 0.71). The comparative assessment scores correlated (very) highly with their Neurostatus-EDSS equivalent (ρ=0.78, P<.001; ρ=0.91, P<.05), suggesting a more fine-grained rating. ConclusionsVideo-based pairwise comparison of motor dysfunction allows for reliable and fine-grained capturing of clinical judgment about neurologic performance, which can contribute to the development of a consistent quantified metric of motor ability in MS.

Team conflict and the neurologist.

Collaboration within a complicated organization is inherently challenging and can be fraught with discord. Recent emphasis on interdisciplinary and collaborative teamwork in neurology has brought this issue to the forefront of daily practice. The health care system can be complex and opaque, and the stakes-human life-are high. Medical team conflict has been associated with decreased subjective effectiveness, less job satisfaction, and increase in errors. As specialists, neurologists are necessarily embedded within a network of providers and must be adept in the understanding and management of conflictual situations. For the practicing neurologist, it is important to understand team conflict dynamics. Here, management strategies are provided that illustrate how individual neurologists can serve as effective leaders who mitigate harmful effects and capitalize on benefits of team conflict on performance.

Following the patient's orders? Recommending vs. offering choice in neurology outpatient consultations

The UK's Royal College of Surgeons (2016) has argued that health professionals must replace a ‘paternalistic’ approach to consent with ‘informed choice’. We engage with these guidelines through analysis of neurology consultations in two UK-based neuroscience centres, where informed choice has been advocated for over a decade. Based on 223 recorded consultations and related questionnaire data (collected in 2012), we used conversation analysis (CA) to identify two practices for offering choice: patient view elicitors (PVEs) and option-lists. This paper reports further, mixed-methods analyses, combining CA with statistical techniques to compare the ‘choice’ practices with recommendations. Recommendations were overwhelmingly more common. There was little evidence that patient demographics determined whether choice was offered. Instead, decisional practices were associated with a range of clinical considerations. There was also evidence that individual neurologists tended to have a ‘style’, making it partly a matter of chance which decisional practice(s) patients encountered. This variability matters for the perception of choice: neurologists and patients were more likely to agree a choice had been offered if a PVE or option-list was used. It also matters for the outcome of the decision-making process: while recommendations nearly always ended in agreement to undertake the proffered course of action, option-lists and PVEs did so only about two-thirds of the time. While the direction of causality is unknown, this may indicate that patients are better enabled to refuse things they don't want when neurologists avoid recommending. We argue that our findings imply that neurologists tend to view choice as risky – in that the patient might make the ‘wrong’ choice – but that the inter-individual variation indicates that greater use of the more participatory practices is possible.

The transition of young adults with lifelong urological needs from pediatric to adult services: An international children's continence society position statement

Children with urinary tract disorders managed by teams, or individual pediatricians, urologists, nephrologists, gastroenterologists, neurologists, psychologists, and nurses at some point move from child-centered to adult-centered health systems. The actual physical change is referred to as the transfer whilst the process preceding this move constitutes transition of care. Our aims are twofold: to identify management and health-service problems related to children with congenital or acquired urological conditions who advance into adulthood and the clinical implications this has for long-term health and specialist care; and, to understand the issues facing both pediatric and adult-care clinicians and to develop a systems-approach model that meets the needs of young adults, their families and the clinicians working within adult services. Information was gleaned from presentations at an International Children's Continence Society meeting with collaboration from the International Continence Society, that discussed problems of transfer and transitioning such children. Several specialists attending this conference finalized this document identifying issues and highlighting ways to ease this transition and transfer of care for both patients and practitioners. The consensus was, urological patients with congenital or other lifelong care needs, are now entering adulthood in larger numbers than previously, necessitating new planning processes for tailored transfer of management. Adult teams must become familiar with new clinical problems in multiple organ systems and anticipate issues provoked by adolescence and physical growth. During this period of transitional care the clinician or team assists young patients to build attitudes, skills and understanding of processes needed to maximize function of their urinary tract-thus taking responsibility for their own healthcare needs. Preparation must also address, negotiating adult health care systems, psychosocial, educational or vocational issues, and mental wellbeing. Transitioning and transfer of children with major congenital anomalies to clinicians potentially unfamiliar with their conditions requires improved education both for receiving doctors and children's families. Early initiation of the transition process should allow the transference to take place at appropriate times based on the child's development, and environmental and financial factors. Neurourol. Urodynam. 36:811-819, 2017. © 2016 Wiley Periodicals, Inc.

Supply and demand analysis of the current and future US neurology workforce.

This study estimates current and projects future neurologist supply and demand under alternative scenarios nationally and by state from 2012 through 2025. A microsimulation supply model simulates likely career choices of individual neurologists, taking into account the number of new neurologists trained each year and changing demographics of the neurology workforce. A microsimulation demand model simulates utilization of neurology services for each individual in a representative sample of the population in each state and for the United States as a whole. Demand projections reflect increased prevalence of neurologic conditions associated with population growth and aging, and expanded coverage under health care reform. The estimated active supply of 16,366 neurologists in 2012 is projected to increase to 18,060 by 2025. Long wait times for patients to see a neurologist, difficulty hiring new neurologists, and large numbers of neurologists who do not accept new Medicaid patients are consistent with a current national shortfall of neurologists. Demand for neurologists is projected to increase from ∼18,180 in 2012 (11% shortfall) to 21,440 by 2025 (19% shortfall). This includes an increased demand of 520 full-time equivalent neurologists starting in 2014 from expanded medical insurance coverage associated with the Patient Protection and Affordable Care Act. In the absence of efforts to increase the number of neurology professionals and retain the existing workforce, current national and geographic shortfalls of neurologists are likely to worsen, exacerbating long wait times and reducing access to care for Medicaid beneficiaries. Current geographic differences in adequacy of supply likely will persist into the future.

Getting to value in neurological care: A roadmap for academic neurology

Academic neurology is undergoing transformational changes. The public investment in biomedical research and clinical care is enormous and there is a growing perception that the return on this huge investment is insufficient. Hospitals, departments, and individual neurologists should expect more scrutiny as information about their quality of care and financial relationships with industry are increasingly reported to the public. There are unprecedented changes occurring in the financing and delivery of health care and research that will have profound impact on the mission and operation of academic departments of neurology. With the passage of the Patient Protection and Affordable Care Act (PPACA) there will be increasing emphasis on research that demonstrates value and includes the patient's perspective. Here we review neurological investigations of our clinical and research enterprises that focus on quality of care and comparative effectiveness, including cost-effectiveness. By highlighting progress made and the challenges that lie ahead, we hope to create a clinical, educational, and research roadmap for academic departments of neurology to thrive in today's increasingly regulated environment.

The Neurologist and Patient Safety

The objective of this article is to acquaint neurologists with the current status of evidence and opinion on patient safety in neurology. Research data on errors and preventable adverse events (harm from medical management) in neurology are sparse, with little light being cast thus far on the vulnerabilities of individual neurologists and neurologic office practices. However, areas of particular concern and lines of appropriate action are now becoming apparent. This review draws on the few studies of neurologic malpractice claims, inpatient incident reports and chart reviews, and articles and abstracts in the journal literature. These are placed in the context of the general epidemiology of medical errors, adverse events, and approaches to remediation. Accurate and timely diagnosis in all its aspects represents the single largest category of error. Most neurologists have their first interaction with a patient and family at the time of a critical illness, underlining the importance of improved communication, not only with them but with other caregivers. Systems of information transfer, such as those enabling timely imaging reports, are critical. Better consultative follow-up may be pivotal. Education in patient safety competencies and closer supervision of trainees can be expected to improve protection. Venues, such as emergency departments, in which relevant knowledge and skills may be insufficient to maximize patient safety, deserve particular attention.

Musings from Mayo

When I began my career in the Department of Neurology at Mayo in 1955, I was the 13th neurologist in the department. Although individual neurologists had special interests, every neurologist...

Validating a decision support system for anti-epileptic drug treatment: Part II: Adjusting anti-epileptic drug treatment

A model of expertise for monitoring antiepileptic drug treatment was implemented in a decision support system. We validated the advice of the system regarding treatment decisions at first follow-up with 265 paper cases based on patient records. The reference for comparison is based on the opinions of neurologists. We found considerable variation among the decisions of five neurologists. It could be shown that the system agreed with (groups of) neurologists at least as often as individual neurologists did. The correctness of the system was consistenly higher than that of each of the neurologists, when the majority decision of the remaining neurologists constituted the standard.

Validating a decision support system for anti-epileptic drug treatment: Part I: initiating anti-epileptic drug treatment

In this contribution the validation of a prototype decision support system that implements a model of expertise for initiating anti-epileptic drug treatment is described. Since domain experts were of the opinion that prescribing was a rather straightforward process we used only one expert neurologist for knowledge elicitation. To determine the correctness of the system we intended to compare the contents of the system’s prescriptions with the majority decision of three neurologists. Because of a large variation in prescribing a majority decision could not be obtained in many cases. Even a Delphi procedure did not yield a majority decision in a large number of cases. Therefore a consensus meeting was organised to discuss cases where discrepancies remained. In the process the participating neurologists formulated prescription guidelines. These guidelines were used as a reference to determine the correctness of the prescriptions of both the system and of the neurologists. The acceptability of all prescriptions for each case was rated by the two neurologists who did not write a prescription for that case. From both comparisons it could be concluded that the system was at least as good in prescribing as individual neurologists.

Agreement and correctness in adjusting antiepileptic drug treatment: a need for rational drug treatment?

To study interobserver variation in treatment decisions in a first follow-up contact after initiation of antiepileptic drug (AED) treatment. The results should aid us in the assessment of whether decision support can be of value in this situation. Data from patient records were used to construct 270 different test cases containing information about the course of the disease after initiation of drug treatment. The cases were presented to five neurologists from different general hospitals who previously agreed about the diagnosis and the initial treatment for these cases. They were asked to write a prescription for each test case. All five neurologists agreed on a treatment decision in 21.9% of the 265 cases available for analysis. Each neurologist made a decision different from the decisions taken by all other neurologists in 14.0-19.6% of the cases. Kappa values for agreement among individual neurologists as well as for agreement between an individual and the group of his peers were low. In 82.6% of the cases, a majority of the neurologists agreed on a treatment decision. Comparing the decisions of individual neurologists with the majority decision reference (219 cases) showed a significant difference in correctness (range, 67.1-82.6%) among the neurologists. The fact that a majority decision could be reached in a considerable number of cases, as well as the variability in adjustment of an initiated drug treatment, leads us to the conclusion that decision support can contribute to a rational adjustment of drug treatment.

Recent Advances in Neurology and Neuropsychiatry,

There is little doubt that this book is the best of its kind in the English language. English neurologists, in contrast to the Americans, have never felt compelled to denigrate clinical neurology in favor of mediocre research. The result has been that the English are often our superiors as clinicians, and the relative small amount of research that they do stands in sharp contrast to the monuments of the commonplace which bury the few good papers we produce. The English clinician and writer also persists in writing clearly, while Americans tend to belabor the language and are fearful of an individualistic style when writing about scientific subjects. The book reflects all the above English virtues. There is a happy mixture of the clinically relevant and the best of recent work in the field. There are ten chapters written by individual neurologists which cover topics such as disorders of memory, carcinomatous

Why Pupils Fail in Reading.

In this informative book, Dr. Robinson points out that the problem of the seriously retarded reader has in the past commanded the attention and study of individual ophthalmologists, neurologists, psychologists and educators, whose approaches to the problem and subsequent interpretations have been largely limited to their special interests and experience. The resultant confusion shows the need for a coordinated study by specialists in each of these fields. Such a coordinated study forms the unique contribution of this report. The book is divided into three major sections. The first offers a comprehensive analysis of previous studies, which reveals that assigned causes of reading disability can be grouped under the following headings : visual difficulties ; intellectual and maturational status ; neurologic and dominance factors ; auditory, speech and language factors ; physical difficulties ; emotional reactions, and social and environmental conditions. The second section describes a coordinated investigation into the causal factors of reading disability in each