Neurology. Clinical practice最新文献

Background and objectives: Despite increasing interest in post-intensive care unit (ICU) clinical care and management, there have been limited descriptions focused on the post-neurologic (neuro)-ICU population. Here, we describe the design of a post-neuro-ICU Neurorecovery Clinic (NRC) and present data collected regarding the clinic's population, referrals, visits, and clinician satisfaction.

Methods: This is a single-institution experience with a NRC designed to provide an infrastructure for post-ICU care to patients recovering from acute neurologic disorders or systemic conditions with neurologic sequelae. The clinic offers 2 visit types with different frequencies: a weekly visit and a monthly multidisciplinary visit. This study assessed clinical utilization and clinician perspectives regarding the clinic. Data on clinic referrals, no-show frequency, visit types, and diagnoses for both weekly and monthly visits were collected. A survey was conducted to assess clinician satisfaction and perspectives. Qualitative thematic analysis was performed to identify major themes among survey free responses.

Results: In a 2-year period, 225 patients were referred from the Massachusetts General Hospital neuro-ICU to the NRC. Of those, 105 (47%) were seen in clinic for at least one visit. The most common reasons for loss to follow-up were no shows (38%) and noncontracted insurance (21%). Twenty percent of visits were in-person (the rest were by telehealth). Forty-eight percent were new patients compared with return visits. The most common diagnoses were other (36%), ischemic stroke (26%), and traumatic brain injury (17%). An additional monthly multidisciplinary clinic has seen 14 patients with one no show. Clinicians found their experience in the NRC valuable. Identified benefits included interdisciplinary collaboration, being a more well-rounded and better clinician, improving effectiveness in managing post-ICU problems, and influencing ICU prognosis. Clinicians' greatest challenge was navigating resource limitations for patients.

Discussion: A postneuro-ICU NRC is a feasible model of care delivery for patients after severe acute neurologic disorders. Patients with a broad variety of diagnoses were seen in a 2-year period. Providers valued their clinic time and experiences. Future studies should evaluate whether this model of care improves patients' postneuro-ICU outcomes.

Background and objectives: There are few specialists that serve adults with neurodevelopmental disabilities (NDD), and most adults with NDD receive care from providers without specialty training in NDD. Care for this population is highly variable, and patient and caregiver priorities in this age group are not well known. We aimed to explore individual and caregiver values around adult neurodevelopmental care.

Methods: In this qualitative study, a qualitative analyst conducted 22 semistructured virtual interviews from September 2021 to February 2022 with randomly selected adults with NDD and/or their caregivers. Each individual with NDD had at least one appointment in the adult NDD clinic, which started in October 2020. Interviews were recorded and professionally transcribed. An inductive codebook was developed and reconciled through an iterative process; transcripts were coded in Atlas.ti with 20% double-coding. Major themes were developed through team discussion.

Results: Most interviewees were caregivers of patients with NDD (12); 9 interviews were with patient/caregiver dyads; 1 interview was with a patient alone. Three main themes emerged from the interviews. (1) Value in providers who are curious, engaged, and knowledgeable about NDD-related conditions, which individuals and caregivers referred to as "Unicorn Providers." (2) Value in a connected and coordinated web of care. (3) Value in comfortable and adaptable clinic spaces. They value clinical environments that foster patient success during visits.

Discussion: The need for adult neurodevelopmental care is growing as more individuals with NDD are living into adulthood. Better understanding of patient and caregiver values can help shape this emerging field to meet the needs of this unique, often overlooked and underserved, population.

Objective: To describe a pragmatic process for translating quality improvement (QI) projects into published manuscripts.

Scope: Types of QI work that are generalizable and have broad relevance (to journals and readers), design principles that are important for publishable QI work, how QI manuscript organization might differ from biomedical manuscripts, how to use and not to use Standards for Quality Improvement Reporting Excellence and other guidelines, pitfalls, and how to avoid/repair them.

[This corrects the article DOI: 10.1212/CPJ.0000000000200324.].

Background and objectives: People with functional seizures (FSs) experience high health care utilization and costs revolving around the emergency department (ED). Overall, appropriate treatment of FS is underused, and better care pathways are associated with lower ED reattendance. Our objective was to assess changes in total ED and inpatient visits and costs before and after referral to a specialized, comprehensive FS treatment clinic.

Methods: We collected data from 100 consecutive patients referred to the University of Colorado (CU) FS Clinic between July 2019 and December 2021. Hospital account data were obtained directly from the electronic health record. Total ED and inpatient visits, charges, and payments 1 year before and 1 year after referral were collected and analyzed using the Wilcoxon signed-rank test.

Results: Ninety-four patients were included for analysis. 79% were female, 52% were on Medicaid, and the mean age was 41 (SD 13) years. Total visits after referral (ED and inpatient) were significantly reduced compared with total visits before referral (mean = 1.44 (SD 3.52) vs 1.83 (SD 3.52), p = 0.045). The same test was performed for total charges after and before referral ($15,551 (SD $38,712) vs $30,257 (SD $81,589), p = 0.03) and for total payments after and before referral ($2,469 (SD $6,682) vs $5,199 (SD $15,084), p = 0.02).

Discussion: Referral to a specialized FS clinic is associated with reduced health care utilization and costs. This proof-of-concept study reveals that hospitals should implement policies to support efficient care pathways to comprehensive FS treatment programs with potential for cost savings.

Background and objectives: Traumatic brain injury (TBI) is a common cause of epilepsy, and the risk increases with injury severity. Whether a first posttraumatic seizure (PTS) represents epilepsy is a common clinical problem, but often unknown. Prognostication is important for providing correct patient information and consideration of antiseizure medication. Our objective was to understand how trauma severity and latency from the injury affect the risk of epilepsy after a first PTS.

Methods: The register-based cohort study including all individuals hospitalized following a TBI in Sweden 2000-2010, in addition to 3 age-matched and sex-matched controls per case. We analyzed the 10-year probability of epilepsy following a first seizure using the Kaplan-Meier estimator.

Results: The risk of an epilepsy diagnosis was 41.1% (95% CI 38.6-43.7) following a PTS, higher than the risk of 33.4% (95% CI 30.3-36.5) in those without prior TBI. The risk increased with injury severity, with the highest risk following focal cerebral injuries, 62.3% (95% CI 53.7-70.9). Mild injuries and skull fractures showed a similar risk to the group without previous TBI. In addition, the risk was higher if the seizure occurred <2 years following the trauma.

Discussion: Severity of the injury and latency are major modulators of epilepsy risk following a first PTS. The risk was high in the most severe types of TBI, but a substantial proportion did not develop epilepsy, highlighting the need for further research on prognostication and biomarkers, as well as caution in diagnosing epilepsy based on a first PTS.

Background and objectives: Corticobasal syndrome (CBS) is a complex of symptoms and signs comprising limb rigidity, bradykinesia, dystonia, myoclonus, apraxia, cortical sensory loss, and a variety of cognitive and language impairments. CBS is commonly seen in tauopathies. Striking asymmetry in clinical and imaging findings in CBS raises questions about potential triggers initiating neurodegeneration. The objective of this study was to investigate potential central or peripheral triggers preceding CBS symptoms.

Methods: In this retrospective observational study, we reviewed medical records of patients with CBS at our Parkinson's Disease Center and Movement Disorders Clinic, focusing on evidence of possible central or peripheral "trigger" occurring within a year before the onset of CBS. We also reviewed records of patients with Parkinson disease (PD) for comparison.

Results: Of the 72 patients with CBS, 15 (20.8%) reported potential focal triggers before the onset of CBS-related neurologic symptoms. By contrast, only 1 of 72 patients with PD (1.4%) had a documented trigger before the onset of PD-related symptoms (p < 0.001). Of potential triggers, 13 were peripheral (related to hand or shoulder surgeries or trauma) and 2 were central (stroke and head trauma). Patients with CBS with triggers were younger, had earlier symptom onset, comprised a higher proportion of men, and had a higher likelihood of limb onset of symptoms than those without.

Discussion: Our finding of relatively high frequency of focal triggers in CBS compared with PD suggests potential central or peripheral triggers initiating neurodegeneration, possibly explaining asymmetric clinical and imaging features in CBS. Further research is necessary to validate and explore this observation's implications for CBS pathogenesis.

Background and objectives: In 2017, the FDA approved deutetrabenazine (AUSTEDO) for the treatment of tardive dyskinesia (TD) and chorea associated with Huntington disease (HD). Concurrently, valbenazine (INGREZZA) was approved specifically for TD. The adoption of new medications is influenced by various factors, including patient's medical needs, the prescriber's adoption of new practice, and external environmental factors (e.g., cost). Our analysis aims to examine the dissemination of 2 vesicular monoamine transporter 2 (VMAT-2) inhibitors, deutetrabenazine and valbenazine, in the market.

Methods: In this cross-sectional study, we conducted a descriptive statistical analysis of the 2017-2020 prescription records for deutetrabenazine and valbenazine using the Centers for Medicare & Medicaid Services Medicare Provider Utilization and Payment Data: Part D Prescriber public use file. In addition, we linked this data set to the Open Payment database to analyze industry payments.

Results: We identified a total of 3,706 deutetrabenazine prescribers and 4,895 valbenazine prescribers. Prescription volume (standardized 30-day prescription) increased annually across different specialties for both VMAT-2 inhibitors from 2017 to 2020. Neurologists were the highest contributors to deutetrabenazine prescriptions (N = 50,017; 35.2%), and psychiatrists were the highest contributors to valbenazine prescriptions (N = 77,799; 42.3%). A total of 1,217 deutetrabenazine physician prescribers (47.5%) and 1,509 valbenazine physician prescribers (49.7%) received industry payments from TEVA Pharmaceuticals and Neurocrine Biosciences, respectively. Receipt of industry payments was associated with higher prescription volume for both deutetrabenazine (p < 0.001) and valbenazine (p < 0.001). Approximately three-quarters of the industry payments were used in nonconsulting services, with a median payment value per physician of $18,101 for deutetrabenazine and $25,920 for valbenazine.

Discussion: The findings illustrate a yearly increase in Medicare prescription volume for deutetrabenazine and valbenazine after FDA approval, with neurologists and psychiatrists as primary prescribers of deutetrabenazine and valbenazine, respectively. There was a statistical difference in the prescription volume between those who received industry payments and those who did not, suggesting that receipt of payments may be associated with prescription volume. Nonconsulting services constituted the largest sum of industry payments for both medications. Further research exploring the causative factors of new medication uptake is needed to better understand how medications disseminate across the market.

Background and objectives: Prior research has shown several health disparities affecting sexual minority people. Research on the neurologic health of sexual minority people has been limited. Our objective was to characterize the prevalence of neurologic disease and utilization of a neurologist among a population of sexual minority people.

Methods: We conducted a cross-sectional analysis of sexual minority people, using people in same-sex relationships as a proxy for sexual minority status, from the Medical Expenditure Panel Survey (MEPS) from 2016 to 2020. The MEPS is a government-run survey that uses complex sampling to obtain a nationally representative sample. Our primary outcome was a diagnosis of any neurologic disease. We also completed stratified analyses by sex, race, and ethnicity. Our secondary outcome was visit to a neurologist within the past year. Logistic regression was used to compare the odds of both outcomes in those in same-sex relationships and those in different-sex relationships.

Results: Among 153,313 MEPS participants, there were 61,645 (40.2%) participants in relationships who were included in our sample. Of those, 822 (1.33%) participants were in same-sex relationships. Participants were, on average, aged 51 years (median 50 years, IQR 38-63); nearly 50% reported female sex and mostly non-Hispanic White (67.81%). Among those in same-sex relationships, 22.7% reported a neurologic diagnosis compared with 18.1% of those in different-sex relationships (OR 1.33; 95% CI 1.04-1.71). This difference was maintained with adjustment for age, sex, education, and insurance (OR 1.48; 95% CI 1.15-1.91). There was no significant difference in visit to a neurologist (adjusted OR 1.38; 95% CI 0.91-2.10).

Discussion: In this nationally representative sample, neurologic disease was more prevalent among those in same-sex relationships compared with those in different-sex relationships. Limited sample size and absent measurements of minority stress limited the etiologic search for factors driving this disparity. There was no significant difference in visit to a neurologist, and both groups reported their overall health as being similar. There is a need for more routine measurement of sexual orientation in neurologic research. This will allow us to detail differences in neurologic disease risk factors, prevalence, and outcomes. The end goal is the identification of opportunities for intervention and advancement of neurologic health equity.

Background and objectives: The purpose of the study was to determine the feasibility and patient satisfaction of telegenetic counseling, or counseling done by video, for Huntington disease (HD). Background: Genetic counseling is necessary for presymptomatic or symptomatic HD genetic testing, but the lack of access to counseling because of geography or expense is a critical gap for many patients. The hypothesis of this study was that there would be no difference in patient satisfaction between telegenetic counseling (tele-GC) or in-person counseling (in-person GC) for HD testing.

Methods: This was a prospective, randomized, unblinded study of either tele-GC or in-person GC for HD gene testing. Participants had standardized genetic counseling in the clinic or through a Health Insurance Portability and Accountability Act (HIPAA) appropriate telemedicine platform first and then crossed over. A study coordinator interviewed the participant using a telehealth survey after each encounter.

Results: A total of 19 in-person GC and 15 tele-GC participants were included: 68% women, 41 ± 15 years, 80% White, 10% Hispanic, and +CAG repeat length = 45 ± 4.4 (n = 15) (p > 0.1). All participants were satisfied with their initial counseling experience when asked to rate on a scale of 1-10 (median 10/10, p = 0.94). The majority of symptomatic HD participants (5/7) preferred in-person GC. The main advantage of tele-GC was reduction in travel time for both in-person GC first (n = 16) and tele-GC first (n = 11) participants. Technical challenges were encountered in many of the participants. Visually seeing the genetic counselor improved understanding for in-person GC (n = 10) and tele-GC (n = 8) participants. Participants felt they were able to pick up on emotional cues (n = 33) and felt comfortable asking questions (n = 34) using the tele-GC format.

Discussion: Telegenetic counseling is a feasible option for HD gene testing, if patients are able to overcome technical issues. Having a video visit with both audio and video components, rather than an audio-only phone call, should be considered when using telegenetic counseling for HD. Finally, in-person counseling may be preferred to increase understanding of the genetic counseling materials in patients, especially in motor manifest HD.