Literature Review

“Our results further point to a possible sequence of events leading to MS, in which changes in vibration sensitivity may precede the appearance of demyelinating lesions in the brain,” said the researchers.

Evaluating First-Degree Relatives

Dr. Xia and colleagues conducted the Genes and Environment in MS (GEMS) project, the first prospective study of populations at risk for MS and the first detailed cross-sectional examination of higher-risk and lower-risk family members of patients with MS. The study involved 100 neurologically asymptomatic adults (ages 18 to 50) who were first-degree relatives of patients with MS and participated in the GEMS project from August 2012 to July 2015.

Forty-one of the participants were high-risk patients who scored in the top 10% of a Genetic and Environmental Risk Score (GERS), and 59 participants were low-risk and scored in the bottom 10% of the GERS. The GERS included genetic risk factors (ie, HLA alleles and several MS-associated non-HLA genetic variants) and environmental factors, such as smoking status, BMI, history of infectious mononucleosis and migraine, and vitamin D levels.

Since 40 of the 41 high-risk individuals were female, and 25 of the 59 low-risk individuals were female, the investigators limited the study to the 65 female participants to avoid “attributing any potential difference primarily to the role of sex,” the researchers said.

Testing Neurologic Function

To help identify early signs of MS, the investigators used brain MRI, optical coherence tomography, and other measures of neurologic function, including the Expanded Disability Status Scale, Timed 25-Foot Walk, Nine-Hole Peg Test, Paced Auditory Serial Addition Test, Symbol Digit Modalities Test, Timed Up and Go, and high-contrast and low-contrast visual acuity.

Overall, women at high risk showed more subclinical signs of MS than women at low risk, based on an omnibus test that globally assessed the burden of neurologic dysfunction by comparing the overall differences between the two groups. Impaired vibration perception yielded a stronger result; of 47 women (27 at high risk and 20 at low risk) tested in this manner, women at high risk showed significantly reduced vibration perception in the distal lower extremities.

One patient in the high-risk group converted to clinically definite MS during the study. Four of the women at high risk had T2-weighted hyperintense lesions that met the 2010 McDonald MRI criteria for dissemination in space, compared with one woman at low risk. Two women at high risk and one at low risk met the 2016 proposed consensus MRI criteria for MS diagnosis. In addition, radiologic isolated syndrome occurred in one woman from each group. Also, there was a single focus of leptomeningeal enhancement in three women at high risk and one woman at low risk.

Some limitations of this study include the small size, the lack of male participants, the cross-sectional design, and the fact that the vibration sensitivity thresholds were in the normal range for individuals at high risk and low risk. Researchers “plan to confirm the finding of change in vibration sensitivity with a follow-up study.” They added that the “study highlights the importantneed to develop and test more sensitive measures, particularly with biometric devices, to detect subtle subclinical changes early in the disease process.”

Identifying High-Risk Individuals

“The GEMS study represents the most ambitious effort yet to identify presymptomatic individuals who are at increased risk for MS, and it is a valuable first step toward targeted screening,” said Fredrik Piehl, MD, PhD, Professor of Neuroimmunology at Karolinska Institutet and Karolinska University Hospital in Stockholm, in an accompanying editorial. “Even if we cannot yet intervene therapeutically using currently available disease-modifying treatments in presymptomatic stages of MS, the ability to better define high-risk individuals is likely to make active surveillance programs more cost effective. It also provides important information to counsel individuals about lifestyle changes, such as quitting smoking. The GERS also can likely be further refined with more up-to-date data on the interaction between specific genetic and environmental factors,” he added. Dr. Piehl disclosed research support, travel grants, and other relationships with Biogen, Genzyme, Novartis, Merck, Roche, Serono, and Teva.

—Heidi Splete

Suggested Reading

Xia Z, Steele SU, Bakshi A, et al. Assessment of early evidence of multiple sclerosis in a prospective study of asymptomatic high-risk family members. JAMA Neurol. 2017 Jan 17 [Epub ahead of print].

Piehl F. Multiple sclerosis-a tuning fork still required. JAMA Neurol. 2017 Jan 17 [Epub ahead of print].

“Our results further point to a possible sequence of events leading to MS, in which changes in vibration sensitivity may precede the appearance of demyelinating lesions in the brain,” said the researchers.

Evaluating First-Degree Relatives

Dr. Xia and colleagues conducted the Genes and Environment in MS (GEMS) project, the first prospective study of populations at risk for MS and the first detailed cross-sectional examination of higher-risk and lower-risk family members of patients with MS. The study involved 100 neurologically asymptomatic adults (ages 18 to 50) who were first-degree relatives of patients with MS and participated in the GEMS project from August 2012 to July 2015.

Forty-one of the participants were high-risk patients who scored in the top 10% of a Genetic and Environmental Risk Score (GERS), and 59 participants were low-risk and scored in the bottom 10% of the GERS. The GERS included genetic risk factors (ie, HLA alleles and several MS-associated non-HLA genetic variants) and environmental factors, such as smoking status, BMI, history of infectious mononucleosis and migraine, and vitamin D levels.

Since 40 of the 41 high-risk individuals were female, and 25 of the 59 low-risk individuals were female, the investigators limited the study to the 65 female participants to avoid “attributing any potential difference primarily to the role of sex,” the researchers said.

Testing Neurologic Function

To help identify early signs of MS, the investigators used brain MRI, optical coherence tomography, and other measures of neurologic function, including the Expanded Disability Status Scale, Timed 25-Foot Walk, Nine-Hole Peg Test, Paced Auditory Serial Addition Test, Symbol Digit Modalities Test, Timed Up and Go, and high-contrast and low-contrast visual acuity.

Overall, women at high risk showed more subclinical signs of MS than women at low risk, based on an omnibus test that globally assessed the burden of neurologic dysfunction by comparing the overall differences between the two groups. Impaired vibration perception yielded a stronger result; of 47 women (27 at high risk and 20 at low risk) tested in this manner, women at high risk showed significantly reduced vibration perception in the distal lower extremities.

One patient in the high-risk group converted to clinically definite MS during the study. Four of the women at high risk had T2-weighted hyperintense lesions that met the 2010 McDonald MRI criteria for dissemination in space, compared with one woman at low risk. Two women at high risk and one at low risk met the 2016 proposed consensus MRI criteria for MS diagnosis. In addition, radiologic isolated syndrome occurred in one woman from each group. Also, there was a single focus of leptomeningeal enhancement in three women at high risk and one woman at low risk.

Some limitations of this study include the small size, the lack of male participants, the cross-sectional design, and the fact that the vibration sensitivity thresholds were in the normal range for individuals at high risk and low risk. Researchers “plan to confirm the finding of change in vibration sensitivity with a follow-up study.” They added that the “study highlights the importantneed to develop and test more sensitive measures, particularly with biometric devices, to detect subtle subclinical changes early in the disease process.”

Identifying High-Risk Individuals

“The GEMS study represents the most ambitious effort yet to identify presymptomatic individuals who are at increased risk for MS, and it is a valuable first step toward targeted screening,” said Fredrik Piehl, MD, PhD, Professor of Neuroimmunology at Karolinska Institutet and Karolinska University Hospital in Stockholm, in an accompanying editorial. “Even if we cannot yet intervene therapeutically using currently available disease-modifying treatments in presymptomatic stages of MS, the ability to better define high-risk individuals is likely to make active surveillance programs more cost effective. It also provides important information to counsel individuals about lifestyle changes, such as quitting smoking. The GERS also can likely be further refined with more up-to-date data on the interaction between specific genetic and environmental factors,” he added. Dr. Piehl disclosed research support, travel grants, and other relationships with Biogen, Genzyme, Novartis, Merck, Roche, Serono, and Teva.

—Heidi Splete

Suggested Reading

Xia Z, Steele SU, Bakshi A, et al. Assessment of early evidence of multiple sclerosis in a prospective study of asymptomatic high-risk family members. JAMA Neurol. 2017 Jan 17 [Epub ahead of print].

Piehl F. Multiple sclerosis-a tuning fork still required. JAMA Neurol. 2017 Jan 17 [Epub ahead of print].

“Our results further point to a possible sequence of events leading to MS, in which changes in vibration sensitivity may precede the appearance of demyelinating lesions in the brain,” said the researchers.

Evaluating First-Degree Relatives

Dr. Xia and colleagues conducted the Genes and Environment in MS (GEMS) project, the first prospective study of populations at risk for MS and the first detailed cross-sectional examination of higher-risk and lower-risk family members of patients with MS. The study involved 100 neurologically asymptomatic adults (ages 18 to 50) who were first-degree relatives of patients with MS and participated in the GEMS project from August 2012 to July 2015.

Forty-one of the participants were high-risk patients who scored in the top 10% of a Genetic and Environmental Risk Score (GERS), and 59 participants were low-risk and scored in the bottom 10% of the GERS. The GERS included genetic risk factors (ie, HLA alleles and several MS-associated non-HLA genetic variants) and environmental factors, such as smoking status, BMI, history of infectious mononucleosis and migraine, and vitamin D levels.

Since 40 of the 41 high-risk individuals were female, and 25 of the 59 low-risk individuals were female, the investigators limited the study to the 65 female participants to avoid “attributing any potential difference primarily to the role of sex,” the researchers said.

Testing Neurologic Function

To help identify early signs of MS, the investigators used brain MRI, optical coherence tomography, and other measures of neurologic function, including the Expanded Disability Status Scale, Timed 25-Foot Walk, Nine-Hole Peg Test, Paced Auditory Serial Addition Test, Symbol Digit Modalities Test, Timed Up and Go, and high-contrast and low-contrast visual acuity.

Overall, women at high risk showed more subclinical signs of MS than women at low risk, based on an omnibus test that globally assessed the burden of neurologic dysfunction by comparing the overall differences between the two groups. Impaired vibration perception yielded a stronger result; of 47 women (27 at high risk and 20 at low risk) tested in this manner, women at high risk showed significantly reduced vibration perception in the distal lower extremities.

One patient in the high-risk group converted to clinically definite MS during the study. Four of the women at high risk had T2-weighted hyperintense lesions that met the 2010 McDonald MRI criteria for dissemination in space, compared with one woman at low risk. Two women at high risk and one at low risk met the 2016 proposed consensus MRI criteria for MS diagnosis. In addition, radiologic isolated syndrome occurred in one woman from each group. Also, there was a single focus of leptomeningeal enhancement in three women at high risk and one woman at low risk.

Some limitations of this study include the small size, the lack of male participants, the cross-sectional design, and the fact that the vibration sensitivity thresholds were in the normal range for individuals at high risk and low risk. Researchers “plan to confirm the finding of change in vibration sensitivity with a follow-up study.” They added that the “study highlights the importantneed to develop and test more sensitive measures, particularly with biometric devices, to detect subtle subclinical changes early in the disease process.”

Identifying High-Risk Individuals

“The GEMS study represents the most ambitious effort yet to identify presymptomatic individuals who are at increased risk for MS, and it is a valuable first step toward targeted screening,” said Fredrik Piehl, MD, PhD, Professor of Neuroimmunology at Karolinska Institutet and Karolinska University Hospital in Stockholm, in an accompanying editorial. “Even if we cannot yet intervene therapeutically using currently available disease-modifying treatments in presymptomatic stages of MS, the ability to better define high-risk individuals is likely to make active surveillance programs more cost effective. It also provides important information to counsel individuals about lifestyle changes, such as quitting smoking. The GERS also can likely be further refined with more up-to-date data on the interaction between specific genetic and environmental factors,” he added. Dr. Piehl disclosed research support, travel grants, and other relationships with Biogen, Genzyme, Novartis, Merck, Roche, Serono, and Teva.

—Heidi Splete

Suggested Reading

Xia Z, Steele SU, Bakshi A, et al. Assessment of early evidence of multiple sclerosis in a prospective study of asymptomatic high-risk family members. JAMA Neurol. 2017 Jan 17 [Epub ahead of print].

Piehl F. Multiple sclerosis-a tuning fork still required. JAMA Neurol. 2017 Jan 17 [Epub ahead of print].

Epilepsy-related research studies that rely on medical claims data have significant limitations that can be improved by choosing better selection algorithms. When Moura et al performed a medical chart review of 1377 patients, they found that the best algorithms to identify people with epilepsy included diagnostic and prescription drug data, as well as current antiepileptic drug usage, the location of the site that patients received medical care, and the specialty of the physician providing that care.

Moura LM, Price M, Cole AJ, et al. Accuracy of claims-based algorithms for epilepsy research: Revealing the unseen performance of claims-based studies. Epilepsia. 2017; Feb 15. doi: 10.1111/epi.13691. [Epub ahead of print]

Epilepsy-related research studies that rely on medical claims data have significant limitations that can be improved by choosing better selection algorithms. When Moura et al performed a medical chart review of 1377 patients, they found that the best algorithms to identify people with epilepsy included diagnostic and prescription drug data, as well as current antiepileptic drug usage, the location of the site that patients received medical care, and the specialty of the physician providing that care.

Moura LM, Price M, Cole AJ, et al. Accuracy of claims-based algorithms for epilepsy research: Revealing the unseen performance of claims-based studies. Epilepsia. 2017; Feb 15. doi: 10.1111/epi.13691. [Epub ahead of print]

Epilepsy-related research studies that rely on medical claims data have significant limitations that can be improved by choosing better selection algorithms. When Moura et al performed a medical chart review of 1377 patients, they found that the best algorithms to identify people with epilepsy included diagnostic and prescription drug data, as well as current antiepileptic drug usage, the location of the site that patients received medical care, and the specialty of the physician providing that care.

Moura LM, Price M, Cole AJ, et al. Accuracy of claims-based algorithms for epilepsy research: Revealing the unseen performance of claims-based studies. Epilepsia. 2017; Feb 15. doi: 10.1111/epi.13691. [Epub ahead of print]

People with epilepsy vary widely in their self-management skills according to a survey of 172 patients with the disease. Using the Epilepsy Self-Management Scale, investigators found that respondents scored better on medication, seizure, and safety management when compared to lifestyle and information management (P<.01). The differences have implications for how patients are counseled and educated, according to Ramon Edmundo D. Bautista of the University of Florida Health Sciences Center.

Bautista RE. Understanding the self-management skills of persons with epilepsy. Epilepsy Behav. 2017;69:7-11.

People with epilepsy vary widely in their self-management skills according to a survey of 172 patients with the disease. Using the Epilepsy Self-Management Scale, investigators found that respondents scored better on medication, seizure, and safety management when compared to lifestyle and information management (P<.01). The differences have implications for how patients are counseled and educated, according to Ramon Edmundo D. Bautista of the University of Florida Health Sciences Center.

Bautista RE. Understanding the self-management skills of persons with epilepsy. Epilepsy Behav. 2017;69:7-11.

People with epilepsy vary widely in their self-management skills according to a survey of 172 patients with the disease. Using the Epilepsy Self-Management Scale, investigators found that respondents scored better on medication, seizure, and safety management when compared to lifestyle and information management (P<.01). The differences have implications for how patients are counseled and educated, according to Ramon Edmundo D. Bautista of the University of Florida Health Sciences Center.

Bautista RE. Understanding the self-management skills of persons with epilepsy. Epilepsy Behav. 2017;69:7-11.

Epilepsy-related deaths increased by 47% from 2005 to 2014, according to a new analysis of data from the Centers for Disease Control and Prevention (CDC). Greenlund et al report that age-adjusted epilepsy mortality rates per 100,000 jumped from 0.58 to 0.85 in this time span. The increase warrants more attention be paid to preventive measures and the need for heightened attention and monitoring of epilepsy-related deaths, according to the researchers. Among non-Hispanic Blacks, epilepsy-related deaths were higher than in non-Hispanic Whites in 2014 (1.42/100,000 compared to 0.86/100,000). The report also found that males were more likely to die (1.01/100,000 vs 0.74/100,000).  

Greenlund SF, Croft JB, Kibau R. Epilepsy by the Numbers. Epilepsy Behav. 2017; 69:28-30.

Epilepsy-related deaths increased by 47% from 2005 to 2014, according to a new analysis of data from the Centers for Disease Control and Prevention (CDC). Greenlund et al report that age-adjusted epilepsy mortality rates per 100,000 jumped from 0.58 to 0.85 in this time span. The increase warrants more attention be paid to preventive measures and the need for heightened attention and monitoring of epilepsy-related deaths, according to the researchers. Among non-Hispanic Blacks, epilepsy-related deaths were higher than in non-Hispanic Whites in 2014 (1.42/100,000 compared to 0.86/100,000). The report also found that males were more likely to die (1.01/100,000 vs 0.74/100,000).  

Greenlund SF, Croft JB, Kibau R. Epilepsy by the Numbers. Epilepsy Behav. 2017; 69:28-30.

Epilepsy-related deaths increased by 47% from 2005 to 2014, according to a new analysis of data from the Centers for Disease Control and Prevention (CDC). Greenlund et al report that age-adjusted epilepsy mortality rates per 100,000 jumped from 0.58 to 0.85 in this time span. The increase warrants more attention be paid to preventive measures and the need for heightened attention and monitoring of epilepsy-related deaths, according to the researchers. Among non-Hispanic Blacks, epilepsy-related deaths were higher than in non-Hispanic Whites in 2014 (1.42/100,000 compared to 0.86/100,000). The report also found that males were more likely to die (1.01/100,000 vs 0.74/100,000).  

Greenlund SF, Croft JB, Kibau R. Epilepsy by the Numbers. Epilepsy Behav. 2017; 69:28-30.

Clinicians would be wise to recommend stress reduction techniques to patients with epilepsy, despite the fact that randomized controlled trials have yet to demonstrate that stress management reduces the frequency of seizures. One survey has suggested that most patients who report stress-triggered seizures use some sort of stress reduction methods and most say they are effective. McKee et al also point out that studies have found that stress management does improve quality of life in this patient population. The investigators also recommended that stressed patients with epilepsy should be screened for depression, anxiety, and other treatable mood disorders since they are more common in these patients.

McKee HR, Privitera MD. Stress as a seizure precipitant: Identification, associated factors, and treatment options. Seizure. 2017; 44:21-26.

Clinicians would be wise to recommend stress reduction techniques to patients with epilepsy, despite the fact that randomized controlled trials have yet to demonstrate that stress management reduces the frequency of seizures. One survey has suggested that most patients who report stress-triggered seizures use some sort of stress reduction methods and most say they are effective. McKee et al also point out that studies have found that stress management does improve quality of life in this patient population. The investigators also recommended that stressed patients with epilepsy should be screened for depression, anxiety, and other treatable mood disorders since they are more common in these patients.

McKee HR, Privitera MD. Stress as a seizure precipitant: Identification, associated factors, and treatment options. Seizure. 2017; 44:21-26.

Clinicians would be wise to recommend stress reduction techniques to patients with epilepsy, despite the fact that randomized controlled trials have yet to demonstrate that stress management reduces the frequency of seizures. One survey has suggested that most patients who report stress-triggered seizures use some sort of stress reduction methods and most say they are effective. McKee et al also point out that studies have found that stress management does improve quality of life in this patient population. The investigators also recommended that stressed patients with epilepsy should be screened for depression, anxiety, and other treatable mood disorders since they are more common in these patients.

McKee HR, Privitera MD. Stress as a seizure precipitant: Identification, associated factors, and treatment options. Seizure. 2017; 44:21-26.

Patients with temporal lobe epilepsy (TLE) are more likely to experience restless leg syndrome (RLS) than the general public, according to a recent outpatient clinic analysis, which compared 98 TLE patients to 50 controls who did not have a history of epilepsy or any family members with the disorder. The investigators also found that the odds of developing RLS were 4.6 times greater in patients with right-sided TLE, when compared to left-sided TLE. They also suggested that worsening RLS may serve as an early warning of an impending seizure in some patients.

Geyer JD, Geyer EE, Fetterman Z, Carney PR. Epilepsy and restless legs syndrome. Epilepsy Behav. 2017;68:41-44.

Patients with temporal lobe epilepsy (TLE) are more likely to experience restless leg syndrome (RLS) than the general public, according to a recent outpatient clinic analysis, which compared 98 TLE patients to 50 controls who did not have a history of epilepsy or any family members with the disorder. The investigators also found that the odds of developing RLS were 4.6 times greater in patients with right-sided TLE, when compared to left-sided TLE. They also suggested that worsening RLS may serve as an early warning of an impending seizure in some patients.

Geyer JD, Geyer EE, Fetterman Z, Carney PR. Epilepsy and restless legs syndrome. Epilepsy Behav. 2017;68:41-44.

Patients with temporal lobe epilepsy (TLE) are more likely to experience restless leg syndrome (RLS) than the general public, according to a recent outpatient clinic analysis, which compared 98 TLE patients to 50 controls who did not have a history of epilepsy or any family members with the disorder. The investigators also found that the odds of developing RLS were 4.6 times greater in patients with right-sided TLE, when compared to left-sided TLE. They also suggested that worsening RLS may serve as an early warning of an impending seizure in some patients.

Geyer JD, Geyer EE, Fetterman Z, Carney PR. Epilepsy and restless legs syndrome. Epilepsy Behav. 2017;68:41-44.

A recent analysis of Medicare records has found that among 3706 new cases of epilepsy, 79.6% had received 1 antiepilepsy drug within 1 year of follow-up. However, only 50% of patients had received prompt therapy, which was defined as receiving the first medication within 30 days of diagnosis. The delay in initiating monotherapy was detected when researchers performed retrospective analyses of 2008–2010 Medicare administrative claims that were obtained from a 5% random sample of patients. The investigators have called for additional research to determine the reasons for the delays and have urged the development of new paradigms to improve patient care.

Martin RC, Faught E, Szaflarski JP, et al. What does the U.S. Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy? Epilepsia. 2017[Epub ahead of print]

A recent analysis of Medicare records has found that among 3706 new cases of epilepsy, 79.6% had received 1 antiepilepsy drug within 1 year of follow-up. However, only 50% of patients had received prompt therapy, which was defined as receiving the first medication within 30 days of diagnosis. The delay in initiating monotherapy was detected when researchers performed retrospective analyses of 2008–2010 Medicare administrative claims that were obtained from a 5% random sample of patients. The investigators have called for additional research to determine the reasons for the delays and have urged the development of new paradigms to improve patient care.

Martin RC, Faught E, Szaflarski JP, et al. What does the U.S. Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy? Epilepsia. 2017[Epub ahead of print]

A recent analysis of Medicare records has found that among 3706 new cases of epilepsy, 79.6% had received 1 antiepilepsy drug within 1 year of follow-up. However, only 50% of patients had received prompt therapy, which was defined as receiving the first medication within 30 days of diagnosis. The delay in initiating monotherapy was detected when researchers performed retrospective analyses of 2008–2010 Medicare administrative claims that were obtained from a 5% random sample of patients. The investigators have called for additional research to determine the reasons for the delays and have urged the development of new paradigms to improve patient care.

Martin RC, Faught E, Szaflarski JP, et al. What does the U.S. Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy? Epilepsia. 2017[Epub ahead of print]

Electronic medical records have the potential to improve quality of care among patients with epilepsy. With that goal in mind, Jaishree Narayanan et al have created a digital toolkit that allows providers to capture structured clinical data at the point of care. The software facilitates writing notes and inputting test scores in several domains, including Generalized Anxiety Disorder-7, Neurological Disorders Depression Inventory for Epilepsy, the Montreal Cognitive Assessment/Short Test of Mental Status, and the Medical Research Council Prognostic Index.

Narayanan J, Dobrin S, Choi  J, et al. Structured clinical documentation in the electronic medical record to improve quality and to support practice-based research in epilepsy. Epilepsia. 2017;58(1):68-76.

Electronic medical records have the potential to improve quality of care among patients with epilepsy. With that goal in mind, Jaishree Narayanan et al have created a digital toolkit that allows providers to capture structured clinical data at the point of care. The software facilitates writing notes and inputting test scores in several domains, including Generalized Anxiety Disorder-7, Neurological Disorders Depression Inventory for Epilepsy, the Montreal Cognitive Assessment/Short Test of Mental Status, and the Medical Research Council Prognostic Index.

Narayanan J, Dobrin S, Choi  J, et al. Structured clinical documentation in the electronic medical record to improve quality and to support practice-based research in epilepsy. Epilepsia. 2017;58(1):68-76.

Electronic medical records have the potential to improve quality of care among patients with epilepsy. With that goal in mind, Jaishree Narayanan et al have created a digital toolkit that allows providers to capture structured clinical data at the point of care. The software facilitates writing notes and inputting test scores in several domains, including Generalized Anxiety Disorder-7, Neurological Disorders Depression Inventory for Epilepsy, the Montreal Cognitive Assessment/Short Test of Mental Status, and the Medical Research Council Prognostic Index.

Narayanan J, Dobrin S, Choi  J, et al. Structured clinical documentation in the electronic medical record to improve quality and to support practice-based research in epilepsy. Epilepsia. 2017;58(1):68-76.