Neurology. Clinical practice最新文献

The recent FDA approval of amyloid-lowering drugs is changing the landscape of Alzheimer disease (AD) clinical practice. Previously, apolipoprotein E (APOE) genetic testing was not recommended in the care of people with AD because of limited clinical utility. With the advent of amyloid-lowering drugs, APOE genotype will play an important role in guiding treatment recommendations. Recent clinical trials have reported strong associations between APOE genotype and the safety and possibly the efficacy of amyloid-lowering drugs. Therefore, a clinical workflow that includes biomarker and genetic testing should be implemented to provide patients with the opportunity to make informed decisions and instruct safety monitoring for clinicians. Pretest consent, education, and counseling will be an essential aspect of this process for patients and their family members to understand the implications of these tests and their results. Given that the approved amyloid-lowering drugs are indicated for patients with mild cognitive impairment or mild dementia with biomarker evidence of AD, biomarker testing should be performed before genetic testing and genetic testing should only be performed in patients interested in treatment with amyloid-lowering drugs. It is also important to consider other implications of genetic testing, including burden on and need for additional training for clinicians, the role of additional providers, and the potential challenges for patients and families.

Background and objectives: To investigate neurologists' practice variability in antiseizure medication (ASM) initiation after a first unprovoked seizure based on reported EEG interpretations.

Methods: We developed a 15-question multiple-choice survey incorporating a standardized clinical case scenario of a patient with a first unprovoked seizure for whom different EEG reports were provided. The survey was distributed among board-certified neurologists practicing in the United States. Associations between categorical variables were evaluated using the Fisher Exact test. Multivariate analysis was performed using logistic regression.

Results: A total of 106 neurologists responded to the survey. Most responders (75%-95%) would start ASM for definite epileptiform features on EEG, with similar rates between subgroups differing in years of practice, presence of subspecialty EEG training, and self-reported confidence in EEG interpretation. There was greater variability in practice for nonspecific EEG abnormalities, with sharply contoured activity, sharp transients, and focal delta slowing associated with the highest variability and uncertainty. Neurologists with >5 years of practice experience (21% vs 44%, OR 0.35 [95% CI 0.13-0.89], p = 0.021), subspecialty EEG training (15% vs 50%, OR = 0.17 [95% CI 0.06-0.48], p < 0.001), and greater confidence in EEG interpretation (21% vs 52%, OR 0.24 [95% CI 0.09-0.62], p = 0.001) were less likely to start ASM for ≥2 nonspecific EEG abnormalities and reported greater uncertainty. In multivariate analysis, seniority (p = 0.039) and subspecialty EEG training (p = 0.032) were associated with decreased ASM initiation for nonspecific EEG features.

Discussion: There was substantial variability in ASM initiation practices between board-certified neurologists after a first unprovoked seizure with nonspecific EEG abnormalities. These findings clarify specific areas where EEG reporting may be optimized and reinforces the importance of implementing evidence-based practice guidelines.

Background and objectives: The American Academy of Neurology has developed quality measures related to various neurologic disorders. A gap exists in the implementation of these measures in the different health care systems. To date, there has been no electronic health care record nor implementation of quality measures in Antigua. Therefore, we aimed to increase the percent of patients who have epilepsy quality measures documented using standardized common data elements in the outpatient neurology clinic at Sir Lester Bird Medical Center from 0% to 80% per week by June 1, 2022 and sustain for 6 months.

Methods: We used the Institute for Health care Improvement Model for Improvement methodology. A data use agreement was implemented. Data were displayed using statistical process control charts and the American Society for Quality criteria to determine statistical significance and centerline shifts.

Results: Current and future state process maps were developed to determine areas of opportunity for interventions. Interventions were developed following a "Plan-Do-Study-Act cycle." One intervention was the creation of a RedCap survey and database to be used by health care providers during clinical patient encounters. Because of multiple interventions, we achieved a 100% utilization of the survey for clinical care.

Discussion: Quality improvement (QI) methodology can be used for implementation of quality measures in various settings to improve patient care outcomes without use of significant resources. Implementation of quality measures can increase efficiency in clinical delivery. Similar QI methodology could be implemented in other resource-limited countries of the Caribbean and globally.

Background and objectives: In clinical practice, we have observed that patients with Parkinson disease (PD) often have blepharoclonus, but its prevalence is not well described in the literature. Understanding the relative frequencies of blepharoclonus in PD and atypical parkinsonian syndromes may shed light on the diagnostic utility of this clinical sign. We aimed to assess (1) the frequency of blepharoclonus in patients with PD in a single-center cohort; (2) the association of blepharoclonus with disease stage, tremor severity, and non-motor symptoms; and (3) the frequency of blepharoclonus in synucleinopathy vs non-synucleinopathy-associated parkinsonism.

Methods: We prospectively enrolled 85 patients, 75 with PD and 10 with atypical parkinsonism. Blepharoclonus was considered present if eyelid fluttering was sustained for >5 seconds after gentle eye closure. For each patient, demographics were collected, and we completed selected questions from the MDS-UPDRS (Unified Parkinson's Disease Rating Scale) part 2, REM Sleep Behavior Disorder Questionnaire, and MDS-UPDRS part 3 tremor assessments and recorded the presence/absence of dyskinesia.

Results: 63 of 75 patients with PD (84%) had blepharoclonus. Among the 10 patients with atypical parkinsonism, 5 had synucleinopathy syndromes. Blepharoclonus was present in 3 of 5 patients with synucleinopathy and 0 of 5 patients with non-synucleinopathy-associated parkinsonian syndromes.

Discussion: Blepharoclonus is prevalent in our PD cohort, suggesting possible utility as a clinical marker for PD. The absence of blepharoclonus in a patient with parkinsonism may suggest a non-synucleinopathy (e.g., tauopathy). Analysis of a larger cohort of both PD and atypical parkinsonism would be needed to establish whether blepharoclonus distinguishes PD from atypical parkinsonism, or synucleinopathy from non-synucleinopathy.

Background and objectives: Falls in a person with Parkinson disease (PwP) are frequent, consequential, and only partially prevented by current therapeutic options. Notably, most falls in PwPs occur in the home or its immediate surroundings; however, our current strategies for fall prevention are clinic-centered. The primary objective of this nonrandomized pilot trial was to investigate the feasibility and preliminary efficacy of the novel implementation of home-based PD telerehabilitation (tele-physical/occupational therapy) focusing on fall risk reduction and home-safety modification.

Methods: Persons with mild-to-moderate PD who were identified as being at risk of falls by their movement disorders neurologist were recruited from a tertiary movement disorders clinic. After an initial in-person evaluation by the study physical and occupational therapists, 15 patients with PD (Hoehn and Yahr Stage 2 (n = 8) and Stage 3 (n = 7)) participated in 4 biweekly PT/OT televisits with care partner supervision over the course of 10 weeks. The Goal Attainment Scale (GAS) was implemented to assess progress toward individualized PT/OT goals established at baseline. Outcomes were assessed at the end of the intervention at 10 weeks and at a six-month follow-up.

Results: Participants completed all 120 protocol-defined televisits without dropouts and adverse events. At 10 weeks, mean composite PT and OT-GAS scores showed significant improvement from baseline (PT: p < 0.001, OT: p < 0.008), which continued at 6 months (PT: p < 0.0005, OT: p < 0.0005). Home-modification recommendations made through novel virtual home-safety tours were cumulatively met by participants at 87% at 10 weeks and 91% at 6 months.

Discussion: Home-based telerehabilitation is a promising new strategy toward fall prevention in PD. The GAS has the potential to serve as an effective and patient-driven primary outcome variable for rehabilitation interventions for heterogeneous PwPs to assess progress toward personalized goals.

Trial registration information: ClinicalTrial.gov identifier: NCT04600011.

Background and objectives: Visual auras in migraine have been extensively studied, but less is known about unusual experiences in other sensory domains, including whether they should be diagnostically considered as part of aura symptoms. This study aimed to examine the prevalence of multisensory aura experiences in migraine and their phenomenologic and clinical correlates.

Methods: Respondents were 729 participants with probable migraine, who completed an online study examining unusual sensory experiences. These comprised aura experiences in the auditory, visual, olfactory, somatic-tactile, and gustatory domains. Basic demographic and clinical information and migraine symptomatology were also collected. To facilitate groupwise comparisons, participants with probable migraine were divided into those with and without (visual) aura experiences.

Results: Endorsement of visual aura experiences was the highest (42.1%), whether in a single modality (44.2%) or multiple (55.8%) modalities, followed by somatic-tactile (32.0%), gustatory (21.9%), olfactory (18.6%), and auditory (11.0%) domains. Phenomenologic similarities, for instance, in frequency, personification, and controllability, existed across sensory domains. Somatic-tactile and gustatory auras conversely exhibited greater duration and negative emotional valence. Participants with probable migraine with visual aura tended to report significantly more severe migraine symptoms relative to those with nonvisual or no aura.

Discussion: Our findings provide preliminary indication that unusual olfactory, somatic-tactile, and gustatory experiences in migraine are common and could be clinically significant as aura symptoms. Increased clinician and patient awareness and effective management of these symptoms are essential for a holistic therapeutic approach to migraine.

Background: Anti-CD20 therapies have proven to be highly effective and safe therapies for multiple sclerosis (MS) and have had rapid uptake in the MS community. However, no clear consensus has arisen regarding an approach to screening or surveillance lab monitoring.

Recent findings: Based on current evidence, for screening labs before anti-CD20 initiation, we propose checking liver function test (LFT), complete blood count with differential (CBC), absolute B-cell count, quantitative immunoglobulins, hepatitis B virus serologies, varicella zoster virus IgG, John Cunningham virus (JCV) status, and age-appropriate vaccination history. For surveillance monitoring in an otherwise asymptomatic individual, we propose biannual LFTs and CBC, quantitative immunoglobulins annually after year 3, absolute B-cell count at month 6 and in the setting of relapse, and JCV only if clinical or radiographic features of progressive multifocal leukoencephalopathy arise. For ublituximab, pregnancy testing is additionally recommended before each infusion.

Implications for practice: We propose evidence-based screening and safety surveillance labs which take into account likelihood of changing management in an otherwise stable or asymptomatic individual.

Purpose of review: Access to pediatric neurology care is limited, and outpatient waits can exceed 6 months. The referral process is often complex and burdensome. Our objective was to trial a program for scheduling access to pediatric neurology, to be controlled and accessed directly by outside providers.

Recent findings: We developed a web-based automated system, "Rapid Access Scheduler" (RASr), for direct scheduling by outside providers. RASr is built around a calendar view that allows the provider to see and reserve an available slot at the time of care. Once a slot is reserved, the scheduling team contacts the family to finalize scheduling.

Summary: The RASr system is a novel approach for facilitating pediatric neurology patient access through direct scheduling by outside providers using a web-based portal. Advantages of this include control and responsibility by outside providers, easy visibility of availability, and opportunity to inform patients and families at their point-of-care.