Neurology. Clinical practice最新文献

Background and objectives: Recent studies of national stroke door-in-door-out (DIDO) times found that most transfers for acute interventions are not completed within the recommended time frame. There is a critical need for effective emergent transfer protocols to improve outcomes. The Brain Emergency Management Initiative (BEMI) is a stroke transfer protocol connecting patients with acute stroke at spoke sites to a hub center for embolectomy. BEMI has been shown to significantly reduce transfer time metrics through rapid transit activation, CT head/CTA bundling, digital image sharing, standardized documentation, and remote patient admission. In this study, we evaluated the sustainability of BEMI's impact on reduction of these transfer metrics.

Methods: We assessed data for patients transferred for embolectomy in our stroke system. Patients were compared across 3 groups: before the protocol ("pre-BEMI"), the initial year of protocol implementation ("BEMI"), and the contemporaneous 5 years of protocol usage ("BEMI-S") to assess for sustainability. Time metrics assessed include DIDO time, time from treatment decision to groin puncture (TDGP), and a safety outcome of symptomatic ICH (sICH) rate.

Results: Four hundred twenty-nine transfers were evaluated, with a final sample size of 271 patients (pre-BEMI n = 31, BEMI n = 32, BEMI-S n = 208). A significantly shorter median DIDO time was found in the BEMI groups (pre-BEMI median = 143 minutes vs BEMI = 118 minutes, p = 0.015; vs BEMI-S = 97 minutes, p = 2.1e-07). DIDO time also improved significantly from BEMI to BEMI-S groups (118 vs 97 minutes; p = 0.0005). TDGP was significantly reduced in the BEMI and BEMI-S groups compared with the pre-BEMI group (pre-BEMI median = 155 minutes vs BEMI = 130 minutes, p = 0.01; vs BEMI-S = 125 minutes, p = 4.15e-13) but was similar between the BEMI and BEMI-S groups (130 vs 125 minutes, p = 0.89). Symptomatic ICH rates were similar before and immediately after BEMI implementation but significantly reduced in the BEMI-S group (pre-BEMI 12.9%, vs BEMI 15.6%, p = 1, vs BEMI-S 2.4%, p = 0.037; BEMI vs BEMI-S p = 0.014).

Discussion: The BEMI protocol significantly improved transfer (DIDO) time by 46 minutes and treatment time (TDGP) by 25 minutes in our stroke network, showing continuous sustainability. sICH rates significantly lowered by over 10% with continued use of the BEMI protocol. Our protocol builds on similar rapid transfer stroke protocols through incorporating unique features such as air transit, video telestroke specialist evaluation, and rapid on-loading protocols with uniform documentation.

Background and objectives: The SHOUT-STROKE study aimed to evaluate the effects of a shared decision-making (SDM) intervention on decision-making, health, and process outcomes during discharge planning of hospitalized patients with stroke. The intervention included a patient decision aid (PtDA) with integrated outcome information, training for health care professionals, and an implementation strategy.

Methods: A prospective multiple interrupted time-series study was conducted across 7 Dutch hospitals between November 2019 and March 2022. The study comprised 3 phases: a pre-implementation phase evaluating standard care, a transition phase integrating the PtDA and training into existing stroke care pathways, and a post-implementation phase evaluating the new workflow. Effects per hospital were estimated using segmented autoregression and combined in a meta-analysis to assess the overall effect.

Results: Of 635 eligible patients, 462 (73%) completed the primary outcome measure, the SDM-Q-9, a 9-item questionnaire assessing patient-reported levels of SDM (score range 0-100). The overall effect on SDM-Q-9 scores was -4.5 points (95% CI -11.3 to 2.2). No significant overall differences were observed in secondary decision-making outcomes (e.g., decisional conflict) or health outcomes (e.g., quality of life). Knowledge scores improved significantly in 2 hospitals, with an effect of 0.85 points (95% CI 0.08 to 1.6) in Hospital 4 and 0.94 points (95% CI 0.20 to 1.7) in Hospital 6. Of the 234 patients in the post-implementation phase, 137 (59%) received the PtDA, of whom 40% used it. Most patients reported that the PtDA with integrated outcome information was useful for decision-making and indicated that they would recommend the PtDA to other patients.

Discussion: The SDM intervention was appreciated by patients but did not significantly improve SDM levels or other decision-making or health outcomes. The significant improvement in patient knowledge scores in 2 hospitals is notable but insufficient to fully empower patients to actively participate in SDM. Future efforts should focus on optimizing the implementation process to achieve more impactful outcomes.

Clinical trials registration: The SHOUT-STROKE study was registered in the Dutch Clinical Trial Register and automatically listed in the International Clinical Trial Registry Platform: Registration IDs: NL8375 | NL-OMON21735. Link to the registration: trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON21735.

Purpose of review: The purpose of this review was to consolidate the clinical, radiographic, and laboratory findings of patients with immune effector cell-associated neurotoxicity syndrome (ICANS) to give physicians a comprehensive overview of its diagnosis and management.

Recent findings: ICANS is a rare but potentially lethal complication of chimeric antigen receptor (CAR) T-cell therapy in patients with hematologic malignancies including leukemia, lymphoma, and multiple myeloma. They often have nonspecific neurologic symptoms, such as language difficulties, encephalopathy, and tremors. Workup may involve brain imaging, EEG, or lumbar puncture, but often, these are normal or nonspecific. Laboratory studies, particularly C-reactive protein and ferritin, can help physicians determine which patients are at risk of developing ICANS and how severe the symptoms may become. While most cases of ICANS resolve spontaneously with supportive measures, studies have shown that steroids play an integral role in treating patients who develop neurotoxicity secondary to CAR T-cell therapy.

Summary: By recognizing the signs and symptoms of ICANS, physicians can begin interventions early in the disease course and potentially mitigate any long-term effects. Although most patients recover without residual deficits, rapid progression to death has been reported in a minority of cases. Workup for other etiologies should be performed as clinically indicated, and abnormal findings should be treated according to standard-of-care practices.

Background and objectives: As evidence supporting the robustness of blood-based biomarker (BBM) testing for Alzheimer disease (AD) continues to emerge, understanding the perceptions, drivers, and barriers to the adoption of these tests among primary care physicians (PCPs) in the United States is crucial for improving patient outcomes and advancing clinical management of AD. In this study, we perform a survey of PCPs in the United States to better understand current practices for detecting and diagnosing mild cognitive impairment (MCI) or mild dementia due to AD and to identify drivers and barriers to adopting BBM testing in primary care clinics in the United States.

Methods: This was a cross-sectional study involving a self-administered quantitative online survey. An advisory board was convened before and after the survey to advise on the survey design and discuss survey results. The survey was conducted online in the United States between December 2023 and January 2024, excluding Vermont and Maine because of state laws restricting PCP participation in market research. A total of 603 PCPs from the United States completed the survey for their self-reported perception and adoption of BBM tests for early diagnosis of AD, including awareness and/or experience with testing for patients with suspected cognitive/memory issues, and their belief, motivation, and obstacles for ordering BBM tests.

Results: Lack of effective diagnostic tools in the primary care setting and recognition of MCI/early AD symptoms were among the top barriers to early diagnosis of MCI/mild dementia due to AD. Although PCPs manage or treat patients with MCI/mild dementia independently, awareness and adoption of AD BBM tests are substantially lower (<15%) compared with standard cognitive assessments and non-AD-specific blood tests (>65%). Despite practice and perception barriers, two-thirds of PCPs reported that they would order a BBM test for patients with cognitive concerns to improve the diagnosis and management of AD. However, concerns were raised regarding testing accuracy, financial burden, and reimbursement.

Discussion: Primary care physicians are willing to adopt blood-based biomarker tests for diagnosing MCI and mild dementia due to AD, provided that they receive enhanced education, clear guidelines, and reimbursement support.

Background and objectives: An interim analysis of the modafinil/armodafinil Pregnancy Exposure Registry (PER) revealed a potential increased risk of major congenital malformations (MCMs) associated with maternal exposure to these products. To further investigate this safety signal, a 14-year safety update was conducted using the final PER data. The aim of this study was to evaluate pregnancy and fetal outcomes associated with modafinil/armodafinil exposure.

Methods: This was a prospective, observational longitudinal cohort study conducted from 2010 to 2024. Women exposed to modafinil/armodafinil during pregnancy or within 6 weeks before becoming pregnant were included. Women enrolled before the knowledge of pregnancy outcome or birth defect detection were classified as prospective, whereas those enrolled after such knowledge were classified as retrospective. MCMs were adjudicated and classified based on the Metropolitan Atlanta Congenital Defects Program (MACDP). Descriptive statistics were used to analyze pregnancy outcomes including births, spontaneous abortions, elective terminations, fetal death, neurodevelopmental abnormalities, low/very low birth weight (LBW/very LBW), small for gestational age (SGA), and intrauterine growth restriction. Follow-up growth measurements were evaluated. MCM prevalence was compared with the MACDP population-based rate.

Results: A total of 191 pregnancies (83.2% prospective and 16.8% retrospective) were enrolled. The mean maternal age was 31 years (SD = 4.5), and 182 (95.3%) had exposure during the first trimester. Outcomes were known for 179 pregnancies (93.7%). Among 156 prospective fetuses with known outcomes (83.0%), 137 (87.8%) resulted in live births, 17 (10.9%) in spontaneous abortions, and 2 (1.3%) in elective terminations. Among prospective live births, the prevalence of MCM was 13.1% (18/137, 95% CI, 8.0-20.0) overall and 13.7% after first trimester exposure, compared with the MACDP population-based rate of 3%. Other reported outcomes included 23 (16.8%) minor congenital malformations, 14 (10.2%) preterm births, 3 (2.2%) cases of IUGR, and 11 (8.0%) cases of LBW/VLBW; all were within the expected range of background rates. SGA was not reported. Growth parameters were within normal limits.

Discussion: This 14-year prospective study of pregnant women exposed to modafinil/armodafinil reveals a higher prevalence of MCMs among live births compared with the general population. The study limitations and conflicting results across the literature highlight the need for future research to further investigate the potential teratogenic risks of modafinil/armodafinil.

Background and objectives: Physician burnout is a major challenge for health systems, with some evidence suggesting that women physicians experience higher levels of burnout and lower professional fulfillment compared with men. However, findings on gender disparities in well-being outcomes have been inconsistent. The aim of this study was to quantitatively and qualitatively explore gender-based differences in the determinants of occupational well-being among academic faculty neurologists.

Methods: We conducted a convergent mixed-methods study using both survey and semistructured interview data. The quantitative component included data from the 2021 Professional Well-being Academic Consortium survey, which measures burnout, professional fulfillment, and hypothesized well-being determinants. The survey was completed by 539 neurologists from multiple academic medical centers. We used generalized regression models to assess gender differences in occupational well-being outcomes (i.e., burnout and professional fulfillment) including interaction terms to explore whether the relationship between each determinant and well-being outcomes differed by gender. The qualitative component involved interviews with 33 neurologists to explore gender-specific drivers of well-being and burnout, using thematic analysis to identify key patterns.

Results: While no significant differences in mean burnout or professional fulfillment scores were observed between men and women, there were gender-based differences in the determinants of occupational well-being outcomes. For men, negative impact of work on personal relationships, sleep-related impairment, and personal-organizational values alignment were more strongly associated with professional fulfillment, suggesting that these factors play a larger role in men's well-being. Perceived gratitude, although a protective factor for both genders, had a weaker buffering effect against burnout for women. Qualitatively, women reported facing unique drivers of burnout, including greater responsibilities at home, barriers to integrating responsibilities at work with those at home, and gender-based discrimination.

Discussion: Gender-based disparities in occupational well-being outcomes are, to some degree, driven by different determinants for men and women. While well-being was more affected by measurable factors in men, in women, well-being was shaped by broader sociocultural dynamics, making their challenges more difficult to capture with conventional workplace metrics. Interventions targeting relational aspects of work and improving work-life integration-especially for women in the early stages of their careers-may support neurologist well-being.

Objectives: Up to 40% of wean attempts from continuous intravenous anesthetic drugs (CIVADs) are associated with status epilepticus (SE) recurrence. Few features are known to be associated with successful wean from CIVADs. The 2HELPS2B score, designed to stratify the risk of electrographic seizures in critically ill patients, could be used for this purpose.

Methods: This was a single-center retrospective case-control study of nonanoxic adult patients treated with CIVADs for refractory SE. Clinical and EEG variables were collected. The original and modified 2HELPS2B scores were compared.

Results: We included 102 patients. Thirty-six attempts (35%) failed. Failure was associated with a higher STESS (3 [3-5] vs 3 [2-3], p = 0.03), super-refractoriness (81% vs 16%; p < 0.001), longer CIVAD therapy before weaning (37 vs 21 hours, p = 0.028), more CIVADs at the time of weaning [1 (1-2) vs 1 (1-1), p = 0.005), breakthrough seizures any time before the attempt (62% vs 35%, p = 0.025), and electrographic seizures during the hour before the attempt (11% vs 0%, p = 0.014). The modified 2HELPS2B score was more accurate than the original score (AUROC 0.79 [0.74-0.83] vs 0.72 [0.67-0.77]; p = 0.024), and a modified score ≥3 had 95% specificity for failure.

Discussion: In patients treated with CIVADs for refractory status epilepticus, a modified 2HELPS2B score could be used to guide weaning from CIVADs.

Background and objectives: Recent studies have highlighted the occurrence of reduced striatal signal intensity on dopamine transporter (DAT) scans in patients with idiopathic normal pressure hydrocephalus (iNPH). The aim of our study was to investigate whether the extent of symptom improvement after a CSF tap test (TT) differs between iNPH patients with reduced striatal DAT uptake and those with normal uptake.

Methods: We conducted gait analysis on 44 patients with iNPH who underwent DAT scans at Seoul National University Bundang Hospital (SNUBH) and Kyungpook National University Chilgok Hospital (KNUCH) both before and after a CSF TT. A positive response to the TT was defined as an improvement in walking speed of 10% or greater compared with baseline. We compared TT response rates between iNPH patients with and without striatal dopaminergic deficit using logistic regression models, with the medical institution (SNUBH, KNUCH) as a stratification variable.

Results: Among 36 patients without striatal dopaminergic deficit, 22 patients (61.11%) exhibited a response after the TT, whereas among 8 patients with striatal dopaminergic deficit, 5 patients (62.5%) exhibited a response after the TT. The response rate after TT was not significantly different between the iNPH patients with and without striatal dopaminergic deficit (odds ratio 0.46; p value = 0.4048).

Discussion: Our findings suggest that gait improvement after a CSF TT in patients with iNPH remains consistent regardless of the presence or absence of reduced striatal DAT uptake. Further research involving a larger cohort is necessary to validate these observations.