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Revised Guideline for Adult Bacterial Meningitis Improves Treatment, Outcome
Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?
Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.
Study design: Retrospective.
Setting: Inpatient; two to six months post-discharge.
Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.
Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.
CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.
The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.
Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.
Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.
Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?
Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.
Study design: Retrospective.
Setting: Inpatient; two to six months post-discharge.
Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.
Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.
CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.
The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.
Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.
Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.
Clinical question: Did revision of guidelines recommending computerized tomography (CT) scan before lumbar puncture (LP) reduce delayed treatment of acute bacterial meningitis (ABM)?
Background: Guidelines were introduced in Sweden in 2004 identifying patients at risk for LP-induced brain herniation. They were revised in 2009 to exclude moderate to severe mental status impairment and new seizures as contraindications to LP. This study evaluates the effects of the revision.
Study design: Retrospective.
Setting: Inpatient; two to six months post-discharge.
Synopsis: Data from the Swedish Quality Registry for Community-Acquired Acute Bacterial Meningitis from 2005 to 2009 (394 patients) was compared to data from 2010 to 2012 (318 patients). Mortality and neurological deficits were analyzed, as were effects of LP-CT sequence on time to treatment and outcome.
Treatment was started 1.18 hours earlier (95%CI, .46-1.90 hours, P<0.01) in 2010-2012. After adjusting for confounding factors, there was a nonsignificant reduction in mortality. Treatment delay was significantly associated with increased mortality of 12.6% per hour (95% CI, 3.4%-14.4%; P<0.01). There was significant reduction of neurological sequelae during 2010-2012.
CT performed before LP was associated with a treatment delay of 1.6 hours. In patients with impaired mental status in whom LP was done before CT, mortality was similar and the risk of neurological sequelae was lower.
The study is limited by its retrospective design, nonspecific criteria for diagnosing ABM, and frequent use of meropenem between 2010-2012.
Bottom line: The 2009 revision of Swedish guidelines resulted in earlier treatment of ABM, lower mortality, and fewer unfavorable results, suggesting further revision of international guidelines.
Citation: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162-1169.
Multifaceted Intervention to Decrease Frequency of Common Labs
Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?
Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.
Study design: QI project.
Setting: Large, community-based hospitalist group.
Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.
Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).
Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.
Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?
Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.
Study design: QI project.
Setting: Large, community-based hospitalist group.
Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.
Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).
Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.
Clinical question: Can a multifaceted intervention decrease the frequency of unnecessary labs?
Background: Implementation of a multifaceted QI intervention within a large, community-based hospitalist group to decrease ordering of common labs.
Study design: QI project.
Setting: Large, community-based hospitalist group.
Synopsis: QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered daily. Researchers performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the seven-month intervention period. The baseline (n=7,824) and intervention (n=5,759) cohorts were similar in their demographics.
Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared with baseline (95% confidence interval [CI], 0.34 to 0.11; P<0.01). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).
Bottom line: A community-based, hospitalist-led, QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
Citation: Corson AH, Fan VS, White T, et al. A multifaceted hospitalist quality improvement intervention: decreased frequency of common labs. J Hosp Med. 2015;10(6):390-395.
When Do Patient-Reported Outcome Measures Inform Readmission Risk?
Clinical question: Among patients discharged from the hospital, how do patient-reported outcome (PRO) measures change after discharge, and can they predict readmission or ED visit?
Background: Variables to predict 30-day rehospitalizations of discharged general medical patients have been looked into, but not many strategies have incorporated PRO measures in predictive models.
Study design: Longitudinal cohort study.
Setting: Patients discharged from an urban safety-net hospital that serves 128 municipalities in northeastern Illinois, including the city of Chicago.
Synopsis: One hundred ninety-six patients completed the initial survey; completion rates were 98%, 90%, and 88% for the 30-, 90-, and 180-day follow-up surveys, respectively. The Memorial Symptom Assessment Scale (MSAS) and the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health short form assessing general self-rated health (GSRH), global physical health (GPH), and global mental health (GMH) were administered. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas post-hospitalization assessments of MSAS and GPH predicted subsequent utilizations. Notable limitations of the study include small sample size with high proportion of uninsured and racial/ethnic minorities and inability to count utilization at hospital(s) other than the hospital studied.
Bottom line: PRO measures are likely to be useful predictors in clinical medicine. More research is needed to improve the generalizability of PRO measures. Perhaps determination of specific measures of high predictive value may be more useful.
Citation: Hinami K, Smith J, Deamant CD, DuBeshter K, Trick WE. When do patient-reported outcome measures inform readmission risk? J Hosp Med. 2015;10(5):294-300.
Clinical question: Among patients discharged from the hospital, how do patient-reported outcome (PRO) measures change after discharge, and can they predict readmission or ED visit?
Background: Variables to predict 30-day rehospitalizations of discharged general medical patients have been looked into, but not many strategies have incorporated PRO measures in predictive models.
Study design: Longitudinal cohort study.
Setting: Patients discharged from an urban safety-net hospital that serves 128 municipalities in northeastern Illinois, including the city of Chicago.
Synopsis: One hundred ninety-six patients completed the initial survey; completion rates were 98%, 90%, and 88% for the 30-, 90-, and 180-day follow-up surveys, respectively. The Memorial Symptom Assessment Scale (MSAS) and the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health short form assessing general self-rated health (GSRH), global physical health (GPH), and global mental health (GMH) were administered. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas post-hospitalization assessments of MSAS and GPH predicted subsequent utilizations. Notable limitations of the study include small sample size with high proportion of uninsured and racial/ethnic minorities and inability to count utilization at hospital(s) other than the hospital studied.
Bottom line: PRO measures are likely to be useful predictors in clinical medicine. More research is needed to improve the generalizability of PRO measures. Perhaps determination of specific measures of high predictive value may be more useful.
Citation: Hinami K, Smith J, Deamant CD, DuBeshter K, Trick WE. When do patient-reported outcome measures inform readmission risk? J Hosp Med. 2015;10(5):294-300.
Clinical question: Among patients discharged from the hospital, how do patient-reported outcome (PRO) measures change after discharge, and can they predict readmission or ED visit?
Background: Variables to predict 30-day rehospitalizations of discharged general medical patients have been looked into, but not many strategies have incorporated PRO measures in predictive models.
Study design: Longitudinal cohort study.
Setting: Patients discharged from an urban safety-net hospital that serves 128 municipalities in northeastern Illinois, including the city of Chicago.
Synopsis: One hundred ninety-six patients completed the initial survey; completion rates were 98%, 90%, and 88% for the 30-, 90-, and 180-day follow-up surveys, respectively. The Memorial Symptom Assessment Scale (MSAS) and the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health short form assessing general self-rated health (GSRH), global physical health (GPH), and global mental health (GMH) were administered. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas post-hospitalization assessments of MSAS and GPH predicted subsequent utilizations. Notable limitations of the study include small sample size with high proportion of uninsured and racial/ethnic minorities and inability to count utilization at hospital(s) other than the hospital studied.
Bottom line: PRO measures are likely to be useful predictors in clinical medicine. More research is needed to improve the generalizability of PRO measures. Perhaps determination of specific measures of high predictive value may be more useful.
Citation: Hinami K, Smith J, Deamant CD, DuBeshter K, Trick WE. When do patient-reported outcome measures inform readmission risk? J Hosp Med. 2015;10(5):294-300.
PRONE Score Can Track Medicolegal Complaints
Clinical question: Is there a standardized way to identify doctors at high risk of incurring repeated medicolegal events?
Background: Medicolegal agencies react to episodes of substandard care rather than intervening to prevent them due to lack of robust prediction tools at the individual practitioner level. Various studies have tried to predict complaints at the individual practitioner level accurately but had limited success.
Study design: Retrospective cohort study.
Setting: Commissions in all Australian states, except South Australia, with 70,200 practicing doctors.
Synopsis: Researchers used administrative data to analyze a national sample of 13,849 formal complaints, which were lodged by patients in Australia over a 12-year period against 8,424 doctors. Using multivariate logistic regression analysis, predictors for subsequent complaints within two years of an index complaint were estimated. These predictors were used in a simple predictive algorithm, the PRONE (Predicted Risk Of New Event), a score designed for application at the doctor level. PRONE is a 22-point scoring system that estimates a doctor’s future complaint risk based on specialty, sex, the number of previous complaints, and the time since the last complaint.
Because the scoring system has strong validity and reliability, regulators could harness such information to target quality improvement interventions and prevent substandard care and patient dissatisfaction.
Bottom line: The PRONE score appears to be a valid method for assessing individual doctors’ risks of attracting recurrent complaints.
Citation: Spittal MJ, Bismark MM, Studdert DM. The PRONE score: an algorithm for predicting doctors risks of formal patient complaints using routinely collected administrative data. BMJ Qual Saf. 2015;24(6):360-368.
Clinical question: Is there a standardized way to identify doctors at high risk of incurring repeated medicolegal events?
Background: Medicolegal agencies react to episodes of substandard care rather than intervening to prevent them due to lack of robust prediction tools at the individual practitioner level. Various studies have tried to predict complaints at the individual practitioner level accurately but had limited success.
Study design: Retrospective cohort study.
Setting: Commissions in all Australian states, except South Australia, with 70,200 practicing doctors.
Synopsis: Researchers used administrative data to analyze a national sample of 13,849 formal complaints, which were lodged by patients in Australia over a 12-year period against 8,424 doctors. Using multivariate logistic regression analysis, predictors for subsequent complaints within two years of an index complaint were estimated. These predictors were used in a simple predictive algorithm, the PRONE (Predicted Risk Of New Event), a score designed for application at the doctor level. PRONE is a 22-point scoring system that estimates a doctor’s future complaint risk based on specialty, sex, the number of previous complaints, and the time since the last complaint.
Because the scoring system has strong validity and reliability, regulators could harness such information to target quality improvement interventions and prevent substandard care and patient dissatisfaction.
Bottom line: The PRONE score appears to be a valid method for assessing individual doctors’ risks of attracting recurrent complaints.
Citation: Spittal MJ, Bismark MM, Studdert DM. The PRONE score: an algorithm for predicting doctors risks of formal patient complaints using routinely collected administrative data. BMJ Qual Saf. 2015;24(6):360-368.
Clinical question: Is there a standardized way to identify doctors at high risk of incurring repeated medicolegal events?
Background: Medicolegal agencies react to episodes of substandard care rather than intervening to prevent them due to lack of robust prediction tools at the individual practitioner level. Various studies have tried to predict complaints at the individual practitioner level accurately but had limited success.
Study design: Retrospective cohort study.
Setting: Commissions in all Australian states, except South Australia, with 70,200 practicing doctors.
Synopsis: Researchers used administrative data to analyze a national sample of 13,849 formal complaints, which were lodged by patients in Australia over a 12-year period against 8,424 doctors. Using multivariate logistic regression analysis, predictors for subsequent complaints within two years of an index complaint were estimated. These predictors were used in a simple predictive algorithm, the PRONE (Predicted Risk Of New Event), a score designed for application at the doctor level. PRONE is a 22-point scoring system that estimates a doctor’s future complaint risk based on specialty, sex, the number of previous complaints, and the time since the last complaint.
Because the scoring system has strong validity and reliability, regulators could harness such information to target quality improvement interventions and prevent substandard care and patient dissatisfaction.
Bottom line: The PRONE score appears to be a valid method for assessing individual doctors’ risks of attracting recurrent complaints.
Citation: Spittal MJ, Bismark MM, Studdert DM. The PRONE score: an algorithm for predicting doctors risks of formal patient complaints using routinely collected administrative data. BMJ Qual Saf. 2015;24(6):360-368.
Novel Rapid Response Team Can Decrease Non-ICU Cardiopulmonary Arrests, Mortality
Clinical question: Can novel configured rapid response teams (RRTs) improve non-ICU cardiopulmonary arrest (CPA) and overall hospital mortality rate?
Background: RRTs are primarily executed in hospital settings to avert non-ICU CPA through early detection and intervention. Prevailing evidence has not shown consistent clear benefit of RRTs in this regard.
Study design: A parallel-controlled, before-after design.
Setting: Two urban university hospitals with approximately 500 medical/surgical beds.
Synopsis: Researchers compared annual non-ICU CPA rates from two university hospitals with newly configured RRTs (implemented in November 2007) from July 2005 through June 2011 and found a decline in the incidence of non-ICU CPA to 1.1 from 2.7 per 1000 discharges (P<0.0001) while comparing pre- (2005/2006 to 2006/2007) to post- RRT implementation (2007-2011), respectively. Post-implementation, the overall hospital mortality dropped to 1.74% from 2.12% (P<0.001). With year-over-year, the RRT activation was found to be inversely related to Code Blue activations (r=-0.68, P<0.001), while the case mix index coefficients were still high.
The study lacks internal validation and may carry bias by including just one pre-implementation year (2006) data. It demonstrates that the rounding of unit manager (charge nurse) on “at risk” patients might avert decompensation; however, there was no determination of their decision-making process, with regard to RRT activation. No comparison was done with other RRT configurations.
Bottom line: Novel configured RRTs may improve non-ICU CPA and overall hospital mortality rate.
Citation: Davis DP, Aguilar SA, Graham PG, et al. A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352-357.
Clinical question: Can novel configured rapid response teams (RRTs) improve non-ICU cardiopulmonary arrest (CPA) and overall hospital mortality rate?
Background: RRTs are primarily executed in hospital settings to avert non-ICU CPA through early detection and intervention. Prevailing evidence has not shown consistent clear benefit of RRTs in this regard.
Study design: A parallel-controlled, before-after design.
Setting: Two urban university hospitals with approximately 500 medical/surgical beds.
Synopsis: Researchers compared annual non-ICU CPA rates from two university hospitals with newly configured RRTs (implemented in November 2007) from July 2005 through June 2011 and found a decline in the incidence of non-ICU CPA to 1.1 from 2.7 per 1000 discharges (P<0.0001) while comparing pre- (2005/2006 to 2006/2007) to post- RRT implementation (2007-2011), respectively. Post-implementation, the overall hospital mortality dropped to 1.74% from 2.12% (P<0.001). With year-over-year, the RRT activation was found to be inversely related to Code Blue activations (r=-0.68, P<0.001), while the case mix index coefficients were still high.
The study lacks internal validation and may carry bias by including just one pre-implementation year (2006) data. It demonstrates that the rounding of unit manager (charge nurse) on “at risk” patients might avert decompensation; however, there was no determination of their decision-making process, with regard to RRT activation. No comparison was done with other RRT configurations.
Bottom line: Novel configured RRTs may improve non-ICU CPA and overall hospital mortality rate.
Citation: Davis DP, Aguilar SA, Graham PG, et al. A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352-357.
Clinical question: Can novel configured rapid response teams (RRTs) improve non-ICU cardiopulmonary arrest (CPA) and overall hospital mortality rate?
Background: RRTs are primarily executed in hospital settings to avert non-ICU CPA through early detection and intervention. Prevailing evidence has not shown consistent clear benefit of RRTs in this regard.
Study design: A parallel-controlled, before-after design.
Setting: Two urban university hospitals with approximately 500 medical/surgical beds.
Synopsis: Researchers compared annual non-ICU CPA rates from two university hospitals with newly configured RRTs (implemented in November 2007) from July 2005 through June 2011 and found a decline in the incidence of non-ICU CPA to 1.1 from 2.7 per 1000 discharges (P<0.0001) while comparing pre- (2005/2006 to 2006/2007) to post- RRT implementation (2007-2011), respectively. Post-implementation, the overall hospital mortality dropped to 1.74% from 2.12% (P<0.001). With year-over-year, the RRT activation was found to be inversely related to Code Blue activations (r=-0.68, P<0.001), while the case mix index coefficients were still high.
The study lacks internal validation and may carry bias by including just one pre-implementation year (2006) data. It demonstrates that the rounding of unit manager (charge nurse) on “at risk” patients might avert decompensation; however, there was no determination of their decision-making process, with regard to RRT activation. No comparison was done with other RRT configurations.
Bottom line: Novel configured RRTs may improve non-ICU CPA and overall hospital mortality rate.
Citation: Davis DP, Aguilar SA, Graham PG, et al. A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality. J Hosp Med. 2015;10(6):352-357.
Health Resource Utilization after Video-EEG Confirmation of PNES among US Veterans
Researchers examined health care records of 65 US veterans before and after confirmed diagnosis of psychogenic nonepileptic seizures (PNES) using video-EEG (VEEG) monitoring. Researchers found that post diagnosis there were:
- a significant decrease in PNES-related outpatient visits
- a significant increase in non-PNES related outpatient visits
- increased attendance of psychiatric outpatient visits.
This new evidence shows that VEEG-confirmed PNES diagnosis in US veterans can reduce key measures of non-psychiatric/PNES-related resource utilization and show appropriate increase in psychiatric outpatient visits. However, further study is needed to investigate the increase in non-PNES-related outpatient visits in this patient population.
Nunez-Wallace KR, Murphey DK, Proto D, et al. Health resource utilization among US veterans with psychogenic nonepileptic seizures: a comparison before and after video-EEG monitoring. Epilepsy Res. 2015;114:114-121.
Researchers examined health care records of 65 US veterans before and after confirmed diagnosis of psychogenic nonepileptic seizures (PNES) using video-EEG (VEEG) monitoring. Researchers found that post diagnosis there were:
- a significant decrease in PNES-related outpatient visits
- a significant increase in non-PNES related outpatient visits
- increased attendance of psychiatric outpatient visits.
This new evidence shows that VEEG-confirmed PNES diagnosis in US veterans can reduce key measures of non-psychiatric/PNES-related resource utilization and show appropriate increase in psychiatric outpatient visits. However, further study is needed to investigate the increase in non-PNES-related outpatient visits in this patient population.
Nunez-Wallace KR, Murphey DK, Proto D, et al. Health resource utilization among US veterans with psychogenic nonepileptic seizures: a comparison before and after video-EEG monitoring. Epilepsy Res. 2015;114:114-121.
Researchers examined health care records of 65 US veterans before and after confirmed diagnosis of psychogenic nonepileptic seizures (PNES) using video-EEG (VEEG) monitoring. Researchers found that post diagnosis there were:
- a significant decrease in PNES-related outpatient visits
- a significant increase in non-PNES related outpatient visits
- increased attendance of psychiatric outpatient visits.
This new evidence shows that VEEG-confirmed PNES diagnosis in US veterans can reduce key measures of non-psychiatric/PNES-related resource utilization and show appropriate increase in psychiatric outpatient visits. However, further study is needed to investigate the increase in non-PNES-related outpatient visits in this patient population.
Nunez-Wallace KR, Murphey DK, Proto D, et al. Health resource utilization among US veterans with psychogenic nonepileptic seizures: a comparison before and after video-EEG monitoring. Epilepsy Res. 2015;114:114-121.
What are the Predictors of Cognitive Side Effects among AED Use?
A retrospective study examined medical records of 2860 adult patients with epilepsy over a 12-year period. Researchers found that in patients with new medication:
- 11.2% of those on polytherapy had intolerable cognitive side effects (CSEs)
- 7.6% of those on monotherapy had intolerable CSEs
Polytherapy and intellectual disability were found to be predictors of cognitive side effects. Intolerable CSEs were most commonly seen with topiramate in both polytherapy and monotherapy.
Javed A, Cohen B, Detyniecki K, et al. Rates and predictors of patient-reported cognitive side effects of antiepileptic drugs: an extended follow-up. Seizure. 2015;29:34-40.
A retrospective study examined medical records of 2860 adult patients with epilepsy over a 12-year period. Researchers found that in patients with new medication:
- 11.2% of those on polytherapy had intolerable cognitive side effects (CSEs)
- 7.6% of those on monotherapy had intolerable CSEs
Polytherapy and intellectual disability were found to be predictors of cognitive side effects. Intolerable CSEs were most commonly seen with topiramate in both polytherapy and monotherapy.
Javed A, Cohen B, Detyniecki K, et al. Rates and predictors of patient-reported cognitive side effects of antiepileptic drugs: an extended follow-up. Seizure. 2015;29:34-40.
A retrospective study examined medical records of 2860 adult patients with epilepsy over a 12-year period. Researchers found that in patients with new medication:
- 11.2% of those on polytherapy had intolerable cognitive side effects (CSEs)
- 7.6% of those on monotherapy had intolerable CSEs
Polytherapy and intellectual disability were found to be predictors of cognitive side effects. Intolerable CSEs were most commonly seen with topiramate in both polytherapy and monotherapy.
Javed A, Cohen B, Detyniecki K, et al. Rates and predictors of patient-reported cognitive side effects of antiepileptic drugs: an extended follow-up. Seizure. 2015;29:34-40.
Continuous Electroencephalography (cEEG) Provides Independent Outcome Information
In a study of 120 adult patients with status epilepticus (SE), researchers found that cEEG background information (posterior dominant rhythm and sleep patterns) to be more predictive of clinical outcome than seizures or rhythmic and periodic patterns. Of the EEG features studied, only two were significantly correlated with outcome: absence of a posterior dominant rhythm for mortality and changes in stage II sleep patterns for complete recovery.
Alvarez V, Drislane FW, Westover MB, Dworetzky BA, Lee JW. Characteristics and role in outcome prediction of continuous EEG after status epilepticus: a prospective observational cohort study. Epilepsia. 2015;56(6):933-941.
In a study of 120 adult patients with status epilepticus (SE), researchers found that cEEG background information (posterior dominant rhythm and sleep patterns) to be more predictive of clinical outcome than seizures or rhythmic and periodic patterns. Of the EEG features studied, only two were significantly correlated with outcome: absence of a posterior dominant rhythm for mortality and changes in stage II sleep patterns for complete recovery.
Alvarez V, Drislane FW, Westover MB, Dworetzky BA, Lee JW. Characteristics and role in outcome prediction of continuous EEG after status epilepticus: a prospective observational cohort study. Epilepsia. 2015;56(6):933-941.
In a study of 120 adult patients with status epilepticus (SE), researchers found that cEEG background information (posterior dominant rhythm and sleep patterns) to be more predictive of clinical outcome than seizures or rhythmic and periodic patterns. Of the EEG features studied, only two were significantly correlated with outcome: absence of a posterior dominant rhythm for mortality and changes in stage II sleep patterns for complete recovery.
Alvarez V, Drislane FW, Westover MB, Dworetzky BA, Lee JW. Characteristics and role in outcome prediction of continuous EEG after status epilepticus: a prospective observational cohort study. Epilepsia. 2015;56(6):933-941.
New Recommendations for Neuropsychological Assessment in Epilepsy
The International League Against Epilepsy (ILAE) Neuropsychology Task force developed recommendations to address the neuropsychological assessment in routine epilepsy care. The recommendations endorse:
- Routine screening of cognition, mood, and behavior in new-onset epilepsy patients
- Routine feedback to patients, families, and clinicians about assessment results and implications.
The ILAE recommendations also identify situations where detailed, formal neuropsychological assessment is warranted.
Wilson SJ, Baxendale S, Barr W, et al. Indications and expectations for neuropsychological assessment in routine epilepsy care: Report of the ILAE Neuropsychology Task Force, Diagnostic Methods Commission, 2013-2017. Epilepsia. 2015;56(5):674-681.
The International League Against Epilepsy (ILAE) Neuropsychology Task force developed recommendations to address the neuropsychological assessment in routine epilepsy care. The recommendations endorse:
- Routine screening of cognition, mood, and behavior in new-onset epilepsy patients
- Routine feedback to patients, families, and clinicians about assessment results and implications.
The ILAE recommendations also identify situations where detailed, formal neuropsychological assessment is warranted.
Wilson SJ, Baxendale S, Barr W, et al. Indications and expectations for neuropsychological assessment in routine epilepsy care: Report of the ILAE Neuropsychology Task Force, Diagnostic Methods Commission, 2013-2017. Epilepsia. 2015;56(5):674-681.
The International League Against Epilepsy (ILAE) Neuropsychology Task force developed recommendations to address the neuropsychological assessment in routine epilepsy care. The recommendations endorse:
- Routine screening of cognition, mood, and behavior in new-onset epilepsy patients
- Routine feedback to patients, families, and clinicians about assessment results and implications.
The ILAE recommendations also identify situations where detailed, formal neuropsychological assessment is warranted.
Wilson SJ, Baxendale S, Barr W, et al. Indications and expectations for neuropsychological assessment in routine epilepsy care: Report of the ILAE Neuropsychology Task Force, Diagnostic Methods Commission, 2013-2017. Epilepsia. 2015;56(5):674-681.
Imaging Signs May Not Alter the Effects of IV t-PA
Brain imaging signs may not indicate an increased risk of symptomatic intracranial hemorrhage after treatment with IV t-PA, according to a study in the May Lancet Neurology. Certain early ischemic and pre-existing signs are associated with reduced independence at six months and increased symptomatic intracranial hemorrhage, however. Neurologists should consider these signs when assessing patients with acute ischemic stroke, said the investigators.
An Analysis of IST-3 Data
The results come from a prespecified analysis of data from the third International Stroke Trial (IST-3), which enrolled 3,035 patients with acute ischemic stroke. Eligible participants were 18 or older, and their treating clinicians observed no clear indication for or contraindication to IV t-PA for them. Before randomization, all patients underwent CT or MRI, which was repeated at 24 to 48 hours after stroke. Participants were randomized to 0.9 mg/kg of IV t-PA plus standard care or to standard care alone within six hours of stroke. A group of neuroradiologists and stroke neurologists who were blinded to study information assessed the scans for early signs of ischemia (ie, tissue hypoattenuation, infarct extent, swelling, and hyperattenuated artery) and pre-existing signs (ie, old infarct, leukoaraiosis, and atrophy).
The primary outcome of IST-3 was independence at six months, which the researchers defined as an Oxford Handicap Scale (OHS) score of 0 to 2. For this secondary analysis, the researchers performed logistic regression to identify associations between imaging signs and age, NIH Stroke Scale (NIHSS) score, time to randomization, and outcomes at seven days (ie, symptomatic intracranial hemorrhage) and six months (ie, OHS score of 0–2 and OHS score of 0–1).
Old Infarct Predicted Symptomatic Hemorrhage
Brain scans were available for 1,507 patients randomized to IV t-PA and for 1,510 controls. In all, 1,224 (41%) patients had early ischemic signs and 1,524 (51%) had pre-existing signs but no early ischemic signs. The most common early ischemic sign was tissue hypoattenuation (40% of patients), and the least common was hyperattenuated artery (24% of patients).
All early ischemic signs except severe hypoattenuation individually predicted worse outcomes. Of all pre-existing signs, only old infarct predicted symptomatic hemorrhage. Time to randomization did not change the associations between imaging signs and outcomes.
Increasing NIHSS score, IV t-PA, antiplatelet treatment, and pre-existing old infarcts predicted a significantly higher risk of symptomatic intracranial hemorrhage. With standard stepwise model selection methods, retaining age, NIHSS score, time to randomization, and treatment group, old infarcts and hyperattenuated arteries were potentially significant predictors of symptomatic intracranial hemorrhage.
Increasing age and NIHSS score were the strongest predictors of adverse functional outcomes. Hyperattenuated arteries, large lesion, and leukoaraiosis each individually reduced the chance of a good outcome by 25% to 30%.
The investigators found no interaction between any individual imaging finding or any combination of imaging findings and IV t-PA for functional outcome or symptomatic intracranial hemorrhage. “Despite the absence of definite interactions between imaging signs and alteplase, the absolute increase in symptomatic intracranial hemorrhage after alteplase with combined imaging signs was substantial,” said the researchers. After adjustments for age, NIHSS score, and time to randomization, the combination of old infarcts and hyperattenuated arteries predicted approximately threefold increased odds of symptomatic intracranial hemorrhage, compared with patients with neither sign. The authors saw similar absolute effects on symptomatic intracranial hemorrhage for patients randomized within three hours of stroke.
“Combinations of imaging signs in patients after stroke might provide additional information to decision making when clinical uncertainty exists about the likely benefit of alteplase—eg, in a patient presenting close to the latest time window or for whom the likelihood of benefit was marginal,” said the authors. “Our findings confirm that neither early tissue hypoattenuation nor large infarct extent on [Alberta Stroke Program Early CT score] should exclude patients from alteplase, hopefully improving confidence in use of CT scanning in acute stroke. ”
—Erik Greb
Suggested Reading
IST-3 collaborative group. Association between brain imaging signs, early and late outcomes, and response to intravenous alteplase after acute ischaemic stroke in the third International Stroke Trial (IST-3): secondary analysis of a randomised controlled trial. Lancet Neurol. 2015;14(5):485-496.
Brain imaging signs may not indicate an increased risk of symptomatic intracranial hemorrhage after treatment with IV t-PA, according to a study in the May Lancet Neurology. Certain early ischemic and pre-existing signs are associated with reduced independence at six months and increased symptomatic intracranial hemorrhage, however. Neurologists should consider these signs when assessing patients with acute ischemic stroke, said the investigators.
An Analysis of IST-3 Data
The results come from a prespecified analysis of data from the third International Stroke Trial (IST-3), which enrolled 3,035 patients with acute ischemic stroke. Eligible participants were 18 or older, and their treating clinicians observed no clear indication for or contraindication to IV t-PA for them. Before randomization, all patients underwent CT or MRI, which was repeated at 24 to 48 hours after stroke. Participants were randomized to 0.9 mg/kg of IV t-PA plus standard care or to standard care alone within six hours of stroke. A group of neuroradiologists and stroke neurologists who were blinded to study information assessed the scans for early signs of ischemia (ie, tissue hypoattenuation, infarct extent, swelling, and hyperattenuated artery) and pre-existing signs (ie, old infarct, leukoaraiosis, and atrophy).
The primary outcome of IST-3 was independence at six months, which the researchers defined as an Oxford Handicap Scale (OHS) score of 0 to 2. For this secondary analysis, the researchers performed logistic regression to identify associations between imaging signs and age, NIH Stroke Scale (NIHSS) score, time to randomization, and outcomes at seven days (ie, symptomatic intracranial hemorrhage) and six months (ie, OHS score of 0–2 and OHS score of 0–1).
Old Infarct Predicted Symptomatic Hemorrhage
Brain scans were available for 1,507 patients randomized to IV t-PA and for 1,510 controls. In all, 1,224 (41%) patients had early ischemic signs and 1,524 (51%) had pre-existing signs but no early ischemic signs. The most common early ischemic sign was tissue hypoattenuation (40% of patients), and the least common was hyperattenuated artery (24% of patients).
All early ischemic signs except severe hypoattenuation individually predicted worse outcomes. Of all pre-existing signs, only old infarct predicted symptomatic hemorrhage. Time to randomization did not change the associations between imaging signs and outcomes.
Increasing NIHSS score, IV t-PA, antiplatelet treatment, and pre-existing old infarcts predicted a significantly higher risk of symptomatic intracranial hemorrhage. With standard stepwise model selection methods, retaining age, NIHSS score, time to randomization, and treatment group, old infarcts and hyperattenuated arteries were potentially significant predictors of symptomatic intracranial hemorrhage.
Increasing age and NIHSS score were the strongest predictors of adverse functional outcomes. Hyperattenuated arteries, large lesion, and leukoaraiosis each individually reduced the chance of a good outcome by 25% to 30%.
The investigators found no interaction between any individual imaging finding or any combination of imaging findings and IV t-PA for functional outcome or symptomatic intracranial hemorrhage. “Despite the absence of definite interactions between imaging signs and alteplase, the absolute increase in symptomatic intracranial hemorrhage after alteplase with combined imaging signs was substantial,” said the researchers. After adjustments for age, NIHSS score, and time to randomization, the combination of old infarcts and hyperattenuated arteries predicted approximately threefold increased odds of symptomatic intracranial hemorrhage, compared with patients with neither sign. The authors saw similar absolute effects on symptomatic intracranial hemorrhage for patients randomized within three hours of stroke.
“Combinations of imaging signs in patients after stroke might provide additional information to decision making when clinical uncertainty exists about the likely benefit of alteplase—eg, in a patient presenting close to the latest time window or for whom the likelihood of benefit was marginal,” said the authors. “Our findings confirm that neither early tissue hypoattenuation nor large infarct extent on [Alberta Stroke Program Early CT score] should exclude patients from alteplase, hopefully improving confidence in use of CT scanning in acute stroke. ”
—Erik Greb
Brain imaging signs may not indicate an increased risk of symptomatic intracranial hemorrhage after treatment with IV t-PA, according to a study in the May Lancet Neurology. Certain early ischemic and pre-existing signs are associated with reduced independence at six months and increased symptomatic intracranial hemorrhage, however. Neurologists should consider these signs when assessing patients with acute ischemic stroke, said the investigators.
An Analysis of IST-3 Data
The results come from a prespecified analysis of data from the third International Stroke Trial (IST-3), which enrolled 3,035 patients with acute ischemic stroke. Eligible participants were 18 or older, and their treating clinicians observed no clear indication for or contraindication to IV t-PA for them. Before randomization, all patients underwent CT or MRI, which was repeated at 24 to 48 hours after stroke. Participants were randomized to 0.9 mg/kg of IV t-PA plus standard care or to standard care alone within six hours of stroke. A group of neuroradiologists and stroke neurologists who were blinded to study information assessed the scans for early signs of ischemia (ie, tissue hypoattenuation, infarct extent, swelling, and hyperattenuated artery) and pre-existing signs (ie, old infarct, leukoaraiosis, and atrophy).
The primary outcome of IST-3 was independence at six months, which the researchers defined as an Oxford Handicap Scale (OHS) score of 0 to 2. For this secondary analysis, the researchers performed logistic regression to identify associations between imaging signs and age, NIH Stroke Scale (NIHSS) score, time to randomization, and outcomes at seven days (ie, symptomatic intracranial hemorrhage) and six months (ie, OHS score of 0–2 and OHS score of 0–1).
Old Infarct Predicted Symptomatic Hemorrhage
Brain scans were available for 1,507 patients randomized to IV t-PA and for 1,510 controls. In all, 1,224 (41%) patients had early ischemic signs and 1,524 (51%) had pre-existing signs but no early ischemic signs. The most common early ischemic sign was tissue hypoattenuation (40% of patients), and the least common was hyperattenuated artery (24% of patients).
All early ischemic signs except severe hypoattenuation individually predicted worse outcomes. Of all pre-existing signs, only old infarct predicted symptomatic hemorrhage. Time to randomization did not change the associations between imaging signs and outcomes.
Increasing NIHSS score, IV t-PA, antiplatelet treatment, and pre-existing old infarcts predicted a significantly higher risk of symptomatic intracranial hemorrhage. With standard stepwise model selection methods, retaining age, NIHSS score, time to randomization, and treatment group, old infarcts and hyperattenuated arteries were potentially significant predictors of symptomatic intracranial hemorrhage.
Increasing age and NIHSS score were the strongest predictors of adverse functional outcomes. Hyperattenuated arteries, large lesion, and leukoaraiosis each individually reduced the chance of a good outcome by 25% to 30%.
The investigators found no interaction between any individual imaging finding or any combination of imaging findings and IV t-PA for functional outcome or symptomatic intracranial hemorrhage. “Despite the absence of definite interactions between imaging signs and alteplase, the absolute increase in symptomatic intracranial hemorrhage after alteplase with combined imaging signs was substantial,” said the researchers. After adjustments for age, NIHSS score, and time to randomization, the combination of old infarcts and hyperattenuated arteries predicted approximately threefold increased odds of symptomatic intracranial hemorrhage, compared with patients with neither sign. The authors saw similar absolute effects on symptomatic intracranial hemorrhage for patients randomized within three hours of stroke.
“Combinations of imaging signs in patients after stroke might provide additional information to decision making when clinical uncertainty exists about the likely benefit of alteplase—eg, in a patient presenting close to the latest time window or for whom the likelihood of benefit was marginal,” said the authors. “Our findings confirm that neither early tissue hypoattenuation nor large infarct extent on [Alberta Stroke Program Early CT score] should exclude patients from alteplase, hopefully improving confidence in use of CT scanning in acute stroke. ”
—Erik Greb
Suggested Reading
IST-3 collaborative group. Association between brain imaging signs, early and late outcomes, and response to intravenous alteplase after acute ischaemic stroke in the third International Stroke Trial (IST-3): secondary analysis of a randomised controlled trial. Lancet Neurol. 2015;14(5):485-496.
Suggested Reading
IST-3 collaborative group. Association between brain imaging signs, early and late outcomes, and response to intravenous alteplase after acute ischaemic stroke in the third International Stroke Trial (IST-3): secondary analysis of a randomised controlled trial. Lancet Neurol. 2015;14(5):485-496.