Neurology. Clinical practice最新文献

Background and objectives: Sleep is a critical component of health and recovery. Awakening sleeping patients for routine vital sign monitoring overnight is a common inpatient practice, but its benefits are uncertain. This study asked 3 questions: (1) How often are routine overnight vital signs abnormal? (2) How often are those abnormal vital signs clinically actionable? (3) Are there patients who may not need routine overnight vital sign monitoring?

Methods: We analyzed observational retrospective data extracted from electronic health records of patients admitted to inpatient neurology floors at our institution between 2017 and 2024. We defined routine vital signs as collected by nursing assistants at least 3 hours apart. The outcome measure was an urgent clinical action (stat orders, rapid responses, or transfers to a higher level of care) within 1 hour of vital sign events. We compared the rate of urgent clinical actions after abnormal vital signs with the base rate of those events after normal vital signs. Statistical analysis used generalized estimating equations to account for repeated measures.

Results: We analyzed 102,184 routine vital sign events from 5,569 neurology admissions. In total, 9% of vital sign events were abnormal. The likelihood of urgent clinical actions increased after abnormal vital sign events, compared with after normal vital sign events during the day (4.3% vs 2.4%, odds ratio (OR) 1.8 [1.6-2.1]); at night (2.4% vs 0.9%, OR 2.8 [2.2-3.7]); during the night in low-risk patients with normal daytime vitals (2.0% vs 0.7%, OR 3.0 [1.8-4.9]); and at night in high-risk patients with abnormal daytime vitals (2.6% vs 1.1%, OR 2.5 [1.7-3.6]). The number needed to treat (NNT), i.e., the number of vital sign events needed to initiate 1 extra urgent clinical action above the base rate, was 1,856 [943; 4,598] in low-risk patients. The NNT for low-risk stroke patients was 1,570 [679; 4,707] and for general neurology patients was 2,231 [797; 5,423].

Discussion: Urgent clinical actions attributable to abnormal routine vital signs were uncommon in neurology inpatients, especially overnight in patients with normal daytime vital signs. Determining the risks and benefits of routine overnight vital sign monitoring will help hospitals and health care providers move toward more patient-centered inpatient neurologic care.

Background and objectives: Evidence on the diagnostic journey and health care burden of patients with Creutzfeldt-Jakob disease (CJD) in the United States is limited. A real-world evidence study using a US health care claims database was undertaken to address this gap.

Methods: A retrospective observational cohort study was conducted using data from the Merative MarketScan Research Databases (01/2012-12/2020). Study population comprised adults aged 18 years or older with evidence of CJD (initial diagnosis = index date), no evidence of selected neurologic conditions after the last CJD diagnosis, and health care coverage during the 12-month pre-index period; adults meeting selection criteria are referred herein as "patients with CJD." Diagnostic journey was detailed based on evidence of symptoms and alternative neurologic conditions during the pre-index period as well as time to death (based on a proxy). Health care burden was summarized through levels of all-cause health care utilization and expenditures during the pre/post-index periods.

Results: A total of 215 patients with CJD qualified for inclusion in the study population. The mean duration from first symptom to initial CJD diagnosis was 5.0 months, and 80% of patients had ≥3 symptoms, most commonly altered mental status (82%), gait/coordination disturbance (60%), and malaise/fatigue (44%). Most patients (63%) also had ≥1 alternative diagnosis, including cerebrovascular disease (49%), peripheral vertigo (11%), and Alzheimer disease (7%); the mean duration from first alternative diagnosis to initial CJD diagnosis was 2.4 months. The mean (median) time to death (proxy) from first symptom was 7.9 (6.6) months and from initial CJD diagnosis was 2.9 (1.1) months. During the 12-month pre-index period, mean (95% CI) cumulative health care expenditures were $35,493 ($28,914-$42,722); by the end of the post-index period, cumulative expenditures averaged $93,601 ($78,878-$109,776) per patient.

Discussion: Study findings suggest that, in US clinical practice, patients with CJD present with one or more clinical symptoms affecting motor, cognitive, or other domains, and many alternative diagnoses are considered, which may prolong the diagnostic journey. Study findings also suggest that health care expenditures-especially proximate to the initial CJD diagnosis-are notably high. CJD should be considered in the differential diagnosis of adults with rapidly progressing dementia or motor disturbance.

Background and objectives: Adolescence is a crucial life period, which is extra challenging for young persons with epilepsy (YPE), coinciding with transfer from pediatric to adult care. Knowledge on medical and socioeconomic effects of this care transfer is scarce. The aim of this study was to determine medical and socioeconomic outcomes after transfer to adult care in YPE and to identify risk factors of poor outcome.

Methods: We conducted a population-based retrospective follow-up study of all individuals in Sweden with epilepsy during their 18th year of life over 5 consecutive years. The data were extracted from 5 comprehensive national registries for 2013-2021.

Results: A total of 2,491 adolescents with epilepsy were identified (prevalence 0.46%). Mortality was 0.7% with a standardized mortality rate of 13 compared with the total adolescent population. In patients with an epilepsy-related specialist care contact before the age of 18 years (n = 1719), 22% did not have a planned follow-up visit in specialist care in the 2 following years. The proportion of adolescents who consulted acute medical care for epilepsy increased from 3% to 7% after age 18. Loss to follow-up and acute medical care visits were positively correlated with socioeconomic factors such as lower income, foreign background, and geographic region.

Discussion: A gap in care exists for adolescents with epilepsy after transfer to adult medical care with an increase in epilepsy-related emergency care visits and a decrease in planned specialist care follow-up. A poor epilepsy care outcome is associated with lower economic status, foreign background, and more remote geographic region. The pattern of health care consumption suggests that socioeconomic and geographic factors augment known difficulties in transition to adult epilepsy care and highlights that interventions are needed to ensure optimal outcomes.

Background and objectives: In recent decades, many legal cases have resulted from physicians ineffectively communicating to a family that their loved one is brain dead (brain dead/death by neurologic criteria [BD/DNC]). Although the definition of BD/DNC has recently undergone revision, little research has been conducted to establish optimal approaches in communicating BD/DNC status to families. The aim of this study was to characterize what highly experienced physicians perceive to be the best communication practices and language choices during BD/DNC conversations.

Methods: In this qualitative study, we conducted semistructured, in-depth interviews with physician leaders in the field of BD/DNC between September 2023 and January 2024. All interviews were conducted through Zoom. Twenty expert physician participants were recruited from multiple institutions across the United States through convenience sampling. Participants were current or former attending physicians whose practices at academic institutions involved communication with families about BD/DNC in either the pediatric or adult setting. Participants completed a Qualtrics form containing questions about their demographic background and practice characteristics, including an estimate of the number of times they communicated BD/DNC to patient families. Semistructured interviews were conducted with each of the participants and included hypothetical scenarios and views about best practices.

Results: Using 20 qualitative interview transcripts, we identified multiple areas of agreement and disagreement among expert physicians regarding best practices in communicating BD/DNC status. While physicians concurred on specific language to use and avoid, they differed on whether to use the word "coma," on when to introduce the possibility of brain death, and on whether to analogize with cardiac death. There was strong agreement on the utility of visualization through imaging and family attendance at BD/DNC testing. Finally, physicians were in consensus that multiple family meetings with the same providers are crucial for successful BD/DNC communication.

Discussion: This study described main convergences and divergences in physician language during BD/DNC conversations and used qualitative data to present a "train journey" theory of ideal physician communication with families. By investigating and improving physician communication styles during BD/DNC conversations, the medical community may ameliorate the legal and medical fallout that results from clinical miscommunication.

Background and objectives: Hemorrhagic transformation is a prevalent and serious complication that frequently occurs after endovascular recanalization in acute large vessel occlusion stroke. The impact of asymptomatic intracranial hemorrhage (aICH) on outcomes after endovascular thrombectomy (EVT) remains to be elucidated.

Methods: This was a pooled analysis of individual patient data of 2 randomized trials in China, the RESCUE BT trial from October 2018 to October 2021 and the Direct Endovascular Treatment for Large Vessel Occlusion Stroke trial from May 2018 to May 2020. Patients with acute anterior circulation large vessel occlusion were categorized into 3 groups based on CT or MRI examination within 48 hours after thrombectomy: no intracranial hemorrhage (no-ICH), aICH, and symptomatic ICH (sICH). The primary outcome was functional independence (defined as modified Rankin Scale score of 0-2) at 90 days. Secondary outcomes were the change in NIH Stroke Scale score from baseline to 5-7 days and 3-month mortality.

Result: A total of 1,177 patients (median age, 68 years; 58.4% male) were included in this study, comprising 818 patients without ICH, 268 patients with aICH, and 91 patients with sICH. The proportion of functional independence was 57.3% in the no-ICH group, 34.7% in the aICH group, and 3.3% in the sICH group. Compared with the no-ICH group, there was a lower proportion of functional independence in the aICH group (adjusted odds ratio [aOR], 0.40; 95% CI 0.29-0.55; p < 0.001) and the sICH group (aOR, 0.02; 95% CI 0.01-0.07; p < 0.001). Both aICH and sICH were associated with less improvement of neurologic disability at 5-7 days from baseline and higher mortality at 90 days.

Discussion: Among patients with large vessel occlusion stroke who underwent EVT, the presence of aICH was associated with less early neurologic improvement and greater disability at 90 days. Asymptomatic ICH should be assessed in EVT trials, and strategies to reduce asymptomatic hemorrhage should be investigated.

Background and objectives: The relationship between socioeconomic factors and Parkinson disease (PD) is unclear. Previous literature suggests a potential disconnect between the effect of socioeconomic status (SES) on PD risk and severity. A recent study found that people with PD in the United States were more likely to come from well-resourced communities. Multiple possible explanations were proposed, including that lower SES could be protective against PD risk. Other studies have found worsened PD symptoms and outcomes associated with lower individual SES. If environmental factors associated with lower SES influence PD biology in a way that worsens symptoms, those processes should also increase PD risk. We set out to determine whether community disadvantage, rather than individual SES, is associated with motor or cognitive symptom severity in PD and atypical parkinsonisms.

Methods: Community disadvantage was defined using the Material Community Deprivation Index, a compound score of multiple poverty markers. In our Cincinnati Cohort Biomarkers Program, a cohort that includes PD and atypical parkinsonisms, we tested for associations between community disadvantage and motor symptom severity (Movement Disorders Society Unified PD Rating Scale part III; MDS-UPDRS III), motor disability (Hoehn and Yahr stage [HY]), and cognition (Montreal Cognitive Assessment [MoCA]). We considered age, sex, disease duration, levodopa equivalent daily dose, education years, and race as covariates in multiple regression analyses.

Results: A total of 565 people with PD or atypical parkinsonisms were included (458 idiopathic PD and 107 atypical parkinsonisms). Their mean age was 69 years, and 65% were men. The mean disease duration was 7 years, and the mean MDS-UPDRS III score was 30. The majority (75%) were HY stage 2, and the mean cognitive screening score was nondemented (MoCA 25/30). Worse community disadvantage was significantly associated with worse MDS-UPDRS III score (β 1.58, p = 0.01; adjusted for age, sex, and disease duration) and HY stage (OR 1.27, p = 0.04, adjusted for age, sex, disease duration, and education years). Community disadvantage was not significantly associated with MoCA score (p = 0.45).

Discussion: Community disadvantage was associated with worse motor symptom severity and motor disability in PD, suggesting that there are modifiable social and environmental factors that can affect parkinsonian symptom severity.

Background and objectives: Understanding the impact of social determinants of health (SDoH) on clinical outcomes in conditions such as intracerebral hemorrhage (ICH) is crucial for enhancing patient management and improving health policy. The aim of this study was to assess the impact of SDoH on the prognosis and clinical outcomes of patients with ICH.

Methods: This retrospective study used the MARINER165 national administrative database, encompassing medical and surgical claims from January 2010 to October 2022. It adhered to the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines. Patients with ICH were identified using International Classification of Diseases and Current Procedural Terminology codes. Propensity score matching generated 2 cohorts based on SDoH presence. Primary outcomes focused on functional status at 30 days and survival rates at 90 days and 1 year. Functional outcomes included the rates of tracheostomy and gastronomy tube placement, wheelchair dependency, mobility scores, and readmission within 30 days after ICH. Kaplan-Meier survival analysis was used to determine survival rates at 90 days and 1 year after index event. A significance level of p < 0.05 was applied.

Results: A total of 481,754 patients with ICH were included, with 240,877 individuals in each cohort after matching. Gender distribution was balanced (50.5% female), and common comorbidities included hypertension (89%), depression (47%), and diabetes mellitus (45%). The SDoH group demonstrated pronounced disparities in food security (87%), social integration (14.2%), and physical environment (8.3%). At 30 days, this group experienced worse functional outcomes with higher rates of tracheostomy (2% vs 0.9%, p < 0.001) and G-tube placement (3.2% vs 1.5%, p < 0.001), increased wheelchair dependency (3.2% vs 2.5%, p < 0.001), and lower mobility scores (3.5 vs 2.7, p < 0.001), alongside higher readmission rates (9.8% vs 6.2%, p < 0.001). Despite these challenges, the SDoH cohort demonstrated better survival rates at both 90 days (78.1% vs 72.6%, p < 0.001) and 1 year (62.1% vs 57.6%, p < 0.001).

Discussion: This study underscores significant disparities in functional outcomes and survival rates associated with SDoH among patients with ICH. It highlights the paradox where individuals with SDoH, despite facing greater health-related challenges and higher readmission rates, tend to survive longer. Integrating socioeconomic factors into patient management strategies is crucial for addressing these differences and improving overall health care outcomes.

Background and objectives: Antiamyloid immunotherapies are associated with increased risk of intracerebral hemorrhage, particularly in the setting of APOE-ε4 carriership, anticoagulation, thrombolytics, and other lesions at risk of hemorrhagic conversion. It is not known whether patients with cavernous malformations are at increased risk of complication because patients with these lesions were excluded from clinical trials.

Methods: We describe a case of a patient with Alzheimer disease (AD) with an incidental cavernous malformation treated with lecanemab.

Results: A 73-year-old APOE ε4 heterozygous woman with mild cognitive impairment and CSF biomarker evidence of AD underwent treatment with intravenous lecanemab. Baseline MRI revealed 3 lobar microhemorrhages and an asymptomatic left orbitofrontal cavernous malformation. This cavernous malformation exhibited gross radiologic stability at surveillance brain MRI before the 5th and 7th infusions, but on surveillance MRI after infusion 13 exhibited an asymptomatic increase in size with subacute blood products without additional new amyloid-related imaging abnormalities (ARIA), resulting in treatment discontinuation.

Discussion: Lecanemab therapy was associated with asymptomatic expansion of an incidental cavernous malformation in a patient with AD and without evidence of ARIA.

Background and objectives: Past studies have reported racial and ethnic differences in patients with myasthenia gravis (MG) but either are over a decade old or only examine small samples. To better understand these differences, using the EXPLORE-MG registry, we conducted a retrospective cohort study of racial and ethnic differences in the characteristics and long-term outcomes of patients with MG.

Methods: Patients with a diagnosis of MG confirmed by one or more of the assessments such as antibody seropositivity, positive single-fiber electromyography, or decremental repetitive nerve stimulation between January 2001 and October 2023 were included in the analysis. For logistic regression models, we performed a complete case analysis, therefore excluding patients with unknown age at onset or history of thymoma. Only patients with 2 years of follow-up data were included in the long-term outcome analysis.

Results: Of 594 study participants, the clinical features of 473 White, 48 African American (AA), 42 Hispanic, and 523 non-Hispanic patients were compared. Hispanic patients (mean age 41.5 ± 20.3 years vs 58.9 ± 19.9 years; p < 0.001) were significantly younger at onset compared with non-Hispanic patients, and AA patients were significantly younger at onset compared with White patients (mean age 38.6 ± 17.1 years vs 60.7 ± 19.4 years; p < 0.001). AA patients underwent thymectomy more frequently (63.6% vs 29.5%; p < 0.001) compared with White patients. After adjusting for covariates, AA patients were approximately 3 times more likely to experience hospitalization for MG crisis or exacerbation compared with White patients (odds ratio 2.77; 95% CI 1.19-6.50; p = 0.018).

Discussion: Despite variations in disease severity and clinical profiles, long-term outcomes of patients did not differ. Our findings identify the areas of MG care that vary across racial and ethnic groups, which should be further addressed by clinicians.