Literature Review

Adolescents who underwent cognitive behavioral therapy (CBT) as part of postconcussion care reported significantly lower levels of postconcussive and depressive symptoms, according to the results of a randomized trial published online ahead of print September 12 in Pediatrics.

“Affective symptoms, including depression and anxiety, commonly co-occur with cognitive and somatic symptoms and may prolong recovery from postconcussive symptoms, wrote Carolyn A. McCarty, PhD, Research Associate Professor of Pediatrics and Adjunct Research Associate Professor of Psychology at Seattle Children’s Hospital Center for Child Health Behavior and Development in Seattle, and her colleagues.

“The complexities of managing persistent postconcussive symptoms in conjunction with comorbid psychological symptoms create a significant burden for injured children and adolescents, their families, and schools.”

To determine the impact of CBT on persistent symptoms in adolescents with concussions, the researchers randomized 49 patients, ages 11 to 17, to usual care or a collaborative care plan that included usual care plus CBT.

Concussions were diagnosed by sports medicine or rehabilitative medicine specialists. The patients assigned to CBT received usual care management, CBT, and possible psychopharmacologic consultation. Control patients received usual concussion care, generally defined as an initial visit with a sports medicine physician and assessments at one, three, and six months. Usual care also could include MRI, sleep medication, and subthreshold exercise, depending on the patient. No serious adverse events were reported. The average age of the patients was 15, approximately 65% were girls, and 76% were white.

After six months, approximately 13% of the teens in the CBT group reported high levels of postconcussive symptoms, compared with 42% of controls. In addition, 78% of patients receiving CBT reported a depressive symptom reduction of more than 50%, compared with 46% of controls.

Overall, 83% of the patients receiving CBT and 87% of their parents were “very satisfied” with their care, compared with 46% of patients and 29% of parents in the control group.

“Although patients in both groups showed symptom reduction in the first three months, only those who received collaborative care demonstrated sustained improvements through six months of follow-up,” Dr. McCarty and her colleagues wrote.

The results were limited by several factors, including the small size of the study, the researchers said. However, the findings “prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion” and also suggest that collaborative care can help improve persistent postconcussive symptoms in teens.The Seattle Sports Concussion Research Collaborative supported the study.

—Heidi Splete

Suggested Reading

McCarty CA, Zatzick D, Stein E, et al. Collaborative care for adolescents with persistent postconcussive symptoms: a randomized trial. Pediatrics. 2016 Sept 13 [Epub ahead of print].

Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg Pediatr. 2016 September 13 [Epub ahead of print].

Adolescents who underwent cognitive behavioral therapy (CBT) as part of postconcussion care reported significantly lower levels of postconcussive and depressive symptoms, according to the results of a randomized trial published online ahead of print September 12 in Pediatrics.

“Affective symptoms, including depression and anxiety, commonly co-occur with cognitive and somatic symptoms and may prolong recovery from postconcussive symptoms, wrote Carolyn A. McCarty, PhD, Research Associate Professor of Pediatrics and Adjunct Research Associate Professor of Psychology at Seattle Children’s Hospital Center for Child Health Behavior and Development in Seattle, and her colleagues.

“The complexities of managing persistent postconcussive symptoms in conjunction with comorbid psychological symptoms create a significant burden for injured children and adolescents, their families, and schools.”

To determine the impact of CBT on persistent symptoms in adolescents with concussions, the researchers randomized 49 patients, ages 11 to 17, to usual care or a collaborative care plan that included usual care plus CBT.

Concussions were diagnosed by sports medicine or rehabilitative medicine specialists. The patients assigned to CBT received usual care management, CBT, and possible psychopharmacologic consultation. Control patients received usual concussion care, generally defined as an initial visit with a sports medicine physician and assessments at one, three, and six months. Usual care also could include MRI, sleep medication, and subthreshold exercise, depending on the patient. No serious adverse events were reported. The average age of the patients was 15, approximately 65% were girls, and 76% were white.

After six months, approximately 13% of the teens in the CBT group reported high levels of postconcussive symptoms, compared with 42% of controls. In addition, 78% of patients receiving CBT reported a depressive symptom reduction of more than 50%, compared with 46% of controls.

Overall, 83% of the patients receiving CBT and 87% of their parents were “very satisfied” with their care, compared with 46% of patients and 29% of parents in the control group.

“Although patients in both groups showed symptom reduction in the first three months, only those who received collaborative care demonstrated sustained improvements through six months of follow-up,” Dr. McCarty and her colleagues wrote.

The results were limited by several factors, including the small size of the study, the researchers said. However, the findings “prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion” and also suggest that collaborative care can help improve persistent postconcussive symptoms in teens.The Seattle Sports Concussion Research Collaborative supported the study.

—Heidi Splete

Suggested Reading

McCarty CA, Zatzick D, Stein E, et al. Collaborative care for adolescents with persistent postconcussive symptoms: a randomized trial. Pediatrics. 2016 Sept 13 [Epub ahead of print].

Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg Pediatr. 2016 September 13 [Epub ahead of print].

Adolescents who underwent cognitive behavioral therapy (CBT) as part of postconcussion care reported significantly lower levels of postconcussive and depressive symptoms, according to the results of a randomized trial published online ahead of print September 12 in Pediatrics.

“Affective symptoms, including depression and anxiety, commonly co-occur with cognitive and somatic symptoms and may prolong recovery from postconcussive symptoms, wrote Carolyn A. McCarty, PhD, Research Associate Professor of Pediatrics and Adjunct Research Associate Professor of Psychology at Seattle Children’s Hospital Center for Child Health Behavior and Development in Seattle, and her colleagues.

“The complexities of managing persistent postconcussive symptoms in conjunction with comorbid psychological symptoms create a significant burden for injured children and adolescents, their families, and schools.”

To determine the impact of CBT on persistent symptoms in adolescents with concussions, the researchers randomized 49 patients, ages 11 to 17, to usual care or a collaborative care plan that included usual care plus CBT.

Concussions were diagnosed by sports medicine or rehabilitative medicine specialists. The patients assigned to CBT received usual care management, CBT, and possible psychopharmacologic consultation. Control patients received usual concussion care, generally defined as an initial visit with a sports medicine physician and assessments at one, three, and six months. Usual care also could include MRI, sleep medication, and subthreshold exercise, depending on the patient. No serious adverse events were reported. The average age of the patients was 15, approximately 65% were girls, and 76% were white.

After six months, approximately 13% of the teens in the CBT group reported high levels of postconcussive symptoms, compared with 42% of controls. In addition, 78% of patients receiving CBT reported a depressive symptom reduction of more than 50%, compared with 46% of controls.

Overall, 83% of the patients receiving CBT and 87% of their parents were “very satisfied” with their care, compared with 46% of patients and 29% of parents in the control group.

“Although patients in both groups showed symptom reduction in the first three months, only those who received collaborative care demonstrated sustained improvements through six months of follow-up,” Dr. McCarty and her colleagues wrote.

The results were limited by several factors, including the small size of the study, the researchers said. However, the findings “prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion” and also suggest that collaborative care can help improve persistent postconcussive symptoms in teens.The Seattle Sports Concussion Research Collaborative supported the study.

—Heidi Splete

Suggested Reading

McCarty CA, Zatzick D, Stein E, et al. Collaborative care for adolescents with persistent postconcussive symptoms: a randomized trial. Pediatrics. 2016 Sept 13 [Epub ahead of print].

Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg Pediatr. 2016 September 13 [Epub ahead of print].

The annual suicide mortality rate among those with epilepsy is 22% higher than that in the general population, according to a report in the August issue of Epilepsy and Behavior. Researchers estimated that the annual suicide mortality rate in those with epilepsy during the period from 2003 through 2011 was 16.89 per 100,000 persons.

Researchers at Columbia University’s Mailman School of Public Health in New York and the Centers for Disease Control and Prevention in Atlanta studied the prevalence of suicide among people with epilepsy, compared with that in the population overall. This is the first study to estimate suicide rates among people with epilepsy in a large US general population. The researchers also investigated epilepsy-specific suicide risk factors.

The study, coauthored by Dale Hesdorffer, PhD, Professor of Epidemiology at the Mailman School of Public Health, was based on data from the US National Violent Death Reporting System, a multistate, population-based surveillance system that collects information on violent deaths, including suicide. From 2003 through 2011, the researchers identified, among people age 10 and older, 972 suicide cases with epilepsy and 81,529 suicide cases without epilepsy in 17 states. The investigators estimated suicide rates, evaluated suicide risk among people with epilepsy, and investigated suicide risk factors specific to epilepsy by comparing people with and without epilepsy. In 16 of the 17 states providing continual data from 2005 through 2011, they also compared suicide trends in people with and without epilepsy.

Compared with the non-epilepsy population, those with epilepsy were more likely to have died from suicide in houses, apartments, or residential institutions (81% vs 76%) and were more than twice as likely to poison themselves (38% vs 17%). More people with epilepsy ages 40 to 49 died from suicide than persons without epilepsy in the same age group (29% vs 22%). The proportion of suicides among those with epilepsy increased steadily from 2005 through 2010.

“Of particular significance is what we learned about those 40 to 49 years old,” said Dr. Hesdorffer. “Efforts for suicide prevention should target people with epilepsy in this age category specifically. Additional preventive efforts should include reducing the availability or exposure to poisons, especially at home, and supporting other evidence-based programs to reduce mental illness comorbidity associated with suicide.”

Suggested Reading

Tian N, Cui W, Zack M, et al. Suicide among people with epilepsy: a population-based analysis of data from the U.S. National Violent Death Reporting System, 17 states, 2003-2011. Epilepsy Behav. 2016;61:210-217.

Mula M, McGonigal A, Micoulaud-Franchi JA, et al. Validation of rapid suicidality screening in epilepsy using the NDDIE. Epilepsia. 2016;57(6):949-955.

The annual suicide mortality rate among those with epilepsy is 22% higher than that in the general population, according to a report in the August issue of Epilepsy and Behavior. Researchers estimated that the annual suicide mortality rate in those with epilepsy during the period from 2003 through 2011 was 16.89 per 100,000 persons.

Researchers at Columbia University’s Mailman School of Public Health in New York and the Centers for Disease Control and Prevention in Atlanta studied the prevalence of suicide among people with epilepsy, compared with that in the population overall. This is the first study to estimate suicide rates among people with epilepsy in a large US general population. The researchers also investigated epilepsy-specific suicide risk factors.

The study, coauthored by Dale Hesdorffer, PhD, Professor of Epidemiology at the Mailman School of Public Health, was based on data from the US National Violent Death Reporting System, a multistate, population-based surveillance system that collects information on violent deaths, including suicide. From 2003 through 2011, the researchers identified, among people age 10 and older, 972 suicide cases with epilepsy and 81,529 suicide cases without epilepsy in 17 states. The investigators estimated suicide rates, evaluated suicide risk among people with epilepsy, and investigated suicide risk factors specific to epilepsy by comparing people with and without epilepsy. In 16 of the 17 states providing continual data from 2005 through 2011, they also compared suicide trends in people with and without epilepsy.

Compared with the non-epilepsy population, those with epilepsy were more likely to have died from suicide in houses, apartments, or residential institutions (81% vs 76%) and were more than twice as likely to poison themselves (38% vs 17%). More people with epilepsy ages 40 to 49 died from suicide than persons without epilepsy in the same age group (29% vs 22%). The proportion of suicides among those with epilepsy increased steadily from 2005 through 2010.

“Of particular significance is what we learned about those 40 to 49 years old,” said Dr. Hesdorffer. “Efforts for suicide prevention should target people with epilepsy in this age category specifically. Additional preventive efforts should include reducing the availability or exposure to poisons, especially at home, and supporting other evidence-based programs to reduce mental illness comorbidity associated with suicide.”

Suggested Reading

Tian N, Cui W, Zack M, et al. Suicide among people with epilepsy: a population-based analysis of data from the U.S. National Violent Death Reporting System, 17 states, 2003-2011. Epilepsy Behav. 2016;61:210-217.

Mula M, McGonigal A, Micoulaud-Franchi JA, et al. Validation of rapid suicidality screening in epilepsy using the NDDIE. Epilepsia. 2016;57(6):949-955.

The annual suicide mortality rate among those with epilepsy is 22% higher than that in the general population, according to a report in the August issue of Epilepsy and Behavior. Researchers estimated that the annual suicide mortality rate in those with epilepsy during the period from 2003 through 2011 was 16.89 per 100,000 persons.

Researchers at Columbia University’s Mailman School of Public Health in New York and the Centers for Disease Control and Prevention in Atlanta studied the prevalence of suicide among people with epilepsy, compared with that in the population overall. This is the first study to estimate suicide rates among people with epilepsy in a large US general population. The researchers also investigated epilepsy-specific suicide risk factors.

The study, coauthored by Dale Hesdorffer, PhD, Professor of Epidemiology at the Mailman School of Public Health, was based on data from the US National Violent Death Reporting System, a multistate, population-based surveillance system that collects information on violent deaths, including suicide. From 2003 through 2011, the researchers identified, among people age 10 and older, 972 suicide cases with epilepsy and 81,529 suicide cases without epilepsy in 17 states. The investigators estimated suicide rates, evaluated suicide risk among people with epilepsy, and investigated suicide risk factors specific to epilepsy by comparing people with and without epilepsy. In 16 of the 17 states providing continual data from 2005 through 2011, they also compared suicide trends in people with and without epilepsy.

Compared with the non-epilepsy population, those with epilepsy were more likely to have died from suicide in houses, apartments, or residential institutions (81% vs 76%) and were more than twice as likely to poison themselves (38% vs 17%). More people with epilepsy ages 40 to 49 died from suicide than persons without epilepsy in the same age group (29% vs 22%). The proportion of suicides among those with epilepsy increased steadily from 2005 through 2010.

“Of particular significance is what we learned about those 40 to 49 years old,” said Dr. Hesdorffer. “Efforts for suicide prevention should target people with epilepsy in this age category specifically. Additional preventive efforts should include reducing the availability or exposure to poisons, especially at home, and supporting other evidence-based programs to reduce mental illness comorbidity associated with suicide.”

Suggested Reading

Tian N, Cui W, Zack M, et al. Suicide among people with epilepsy: a population-based analysis of data from the U.S. National Violent Death Reporting System, 17 states, 2003-2011. Epilepsy Behav. 2016;61:210-217.

Mula M, McGonigal A, Micoulaud-Franchi JA, et al. Validation of rapid suicidality screening in epilepsy using the NDDIE. Epilepsia. 2016;57(6):949-955.

An analysis of 27 studies involving over 3000 patients with drug resistant temporal lobe epilepsy has shed light on the value of various type of neuroimaging. Seven studies suggest that clinical outcomes are more favorable when patients have MRI-identified hippocampal atrophy and mesial temporal sclerosis. On the other hand, 5 studies concluded that outcomes were less favorable when patients had unremarkable MIR findings. The value of PET imaging seems less clear. Study findings were inconsistent on the prognostic value of PET-identified focal hypometabolism, for instance.    

Jones AL, Cascino GD. Evidence on Use of Neuroimaging for Surgical Treatment of Temporal Lobe Epilepsy: A Systematic Review. JAMA Neurol. 2016;73(4):464-470.

An analysis of 27 studies involving over 3000 patients with drug resistant temporal lobe epilepsy has shed light on the value of various type of neuroimaging. Seven studies suggest that clinical outcomes are more favorable when patients have MRI-identified hippocampal atrophy and mesial temporal sclerosis. On the other hand, 5 studies concluded that outcomes were less favorable when patients had unremarkable MIR findings. The value of PET imaging seems less clear. Study findings were inconsistent on the prognostic value of PET-identified focal hypometabolism, for instance.    

Jones AL, Cascino GD. Evidence on Use of Neuroimaging for Surgical Treatment of Temporal Lobe Epilepsy: A Systematic Review. JAMA Neurol. 2016;73(4):464-470.

An analysis of 27 studies involving over 3000 patients with drug resistant temporal lobe epilepsy has shed light on the value of various type of neuroimaging. Seven studies suggest that clinical outcomes are more favorable when patients have MRI-identified hippocampal atrophy and mesial temporal sclerosis. On the other hand, 5 studies concluded that outcomes were less favorable when patients had unremarkable MIR findings. The value of PET imaging seems less clear. Study findings were inconsistent on the prognostic value of PET-identified focal hypometabolism, for instance.    

Jones AL, Cascino GD. Evidence on Use of Neuroimaging for Surgical Treatment of Temporal Lobe Epilepsy: A Systematic Review. JAMA Neurol. 2016;73(4):464-470.

In an effort to detect links between seizure clusters and as yet unknown clinical factors among patients with drug-resistant focal epilepsy, researchers performed a retrospective analysis of 764 patients. They found clustering in 23.6% of patients with temporal lobe epilepsy (TLE) and 16.9% of patients with extratemporal seizures. Unfortunately, they failed to detect any clinical factors associated with the clustering. However, they did notice that TLE patients fared better after surgery if they had a history of seizure clusters.

Asadi-Pooya AA, Nei M, Sharan A, Sperling MR. Seizure clusters in drug-resistant focal epilepsy. Epilepsia. 2016;57(9):e187-e190.

In an effort to detect links between seizure clusters and as yet unknown clinical factors among patients with drug-resistant focal epilepsy, researchers performed a retrospective analysis of 764 patients. They found clustering in 23.6% of patients with temporal lobe epilepsy (TLE) and 16.9% of patients with extratemporal seizures. Unfortunately, they failed to detect any clinical factors associated with the clustering. However, they did notice that TLE patients fared better after surgery if they had a history of seizure clusters.

Asadi-Pooya AA, Nei M, Sharan A, Sperling MR. Seizure clusters in drug-resistant focal epilepsy. Epilepsia. 2016;57(9):e187-e190.

In an effort to detect links between seizure clusters and as yet unknown clinical factors among patients with drug-resistant focal epilepsy, researchers performed a retrospective analysis of 764 patients. They found clustering in 23.6% of patients with temporal lobe epilepsy (TLE) and 16.9% of patients with extratemporal seizures. Unfortunately, they failed to detect any clinical factors associated with the clustering. However, they did notice that TLE patients fared better after surgery if they had a history of seizure clusters.

Asadi-Pooya AA, Nei M, Sharan A, Sperling MR. Seizure clusters in drug-resistant focal epilepsy. Epilepsia. 2016;57(9):e187-e190.

Functional magnetic resonance imaging (fMRI), volumetric MRI, and diffusion tensor imaging are providing new insights into the epileptic brain, according to a recent review of the research literature from Balter et al. fMRI, for instance, is improving clinicians’ understanding of how patients with epilepsy organize and reorganize the complexities of language before and after surgery. Volumetric MRI and diffusion tensor imaging are giving investigators insights into how patients with various epilepsy syndromes cope with language dysfunction by allowing the researchers to visualize structural and microsctructural changes associated with these syndromes. The literature review also discusses the value of new analytic techniques like graph theory to better understand abnormal brain connectivity in this patient population.Functional magnetic resonance imaging (fMRI), volumetric MRI, and diffusion tensor imaging are providing new insights into the epileptic brain, according to a recent review of the research literature from Balter et al. fMRI, for instance, is improving clinicians’ understanding of how patients with epilepsy organize and reorganize the complexities of language before and after surgery. Volumetric MRI and diffusion tensor imaging are giving investigators insights into how patients with various epilepsy syndromes cope with language dysfunction by allowing the researchers to visualize structural and microsctructural changes associated with these syndromes. The literature review also discusses the value of new analytic techniques like graph theory to better understand abnormal brain connectivity in this patient population.

Balter S, Lin G, Leyden KM, Paul BM, McDonald CR. Neuroimaging correlates of language network impairment and reorganization in temporal lobe epilepsy. Brain Lang. 2016:pii S0093-934X(15)30127-9.

Functional magnetic resonance imaging (fMRI), volumetric MRI, and diffusion tensor imaging are providing new insights into the epileptic brain, according to a recent review of the research literature from Balter et al. fMRI, for instance, is improving clinicians’ understanding of how patients with epilepsy organize and reorganize the complexities of language before and after surgery. Volumetric MRI and diffusion tensor imaging are giving investigators insights into how patients with various epilepsy syndromes cope with language dysfunction by allowing the researchers to visualize structural and microsctructural changes associated with these syndromes. The literature review also discusses the value of new analytic techniques like graph theory to better understand abnormal brain connectivity in this patient population.Functional magnetic resonance imaging (fMRI), volumetric MRI, and diffusion tensor imaging are providing new insights into the epileptic brain, according to a recent review of the research literature from Balter et al. fMRI, for instance, is improving clinicians’ understanding of how patients with epilepsy organize and reorganize the complexities of language before and after surgery. Volumetric MRI and diffusion tensor imaging are giving investigators insights into how patients with various epilepsy syndromes cope with language dysfunction by allowing the researchers to visualize structural and microsctructural changes associated with these syndromes. The literature review also discusses the value of new analytic techniques like graph theory to better understand abnormal brain connectivity in this patient population.

Balter S, Lin G, Leyden KM, Paul BM, McDonald CR. Neuroimaging correlates of language network impairment and reorganization in temporal lobe epilepsy. Brain Lang. 2016:pii S0093-934X(15)30127-9.

Functional magnetic resonance imaging (fMRI), volumetric MRI, and diffusion tensor imaging are providing new insights into the epileptic brain, according to a recent review of the research literature from Balter et al. fMRI, for instance, is improving clinicians’ understanding of how patients with epilepsy organize and reorganize the complexities of language before and after surgery. Volumetric MRI and diffusion tensor imaging are giving investigators insights into how patients with various epilepsy syndromes cope with language dysfunction by allowing the researchers to visualize structural and microsctructural changes associated with these syndromes. The literature review also discusses the value of new analytic techniques like graph theory to better understand abnormal brain connectivity in this patient population.Functional magnetic resonance imaging (fMRI), volumetric MRI, and diffusion tensor imaging are providing new insights into the epileptic brain, according to a recent review of the research literature from Balter et al. fMRI, for instance, is improving clinicians’ understanding of how patients with epilepsy organize and reorganize the complexities of language before and after surgery. Volumetric MRI and diffusion tensor imaging are giving investigators insights into how patients with various epilepsy syndromes cope with language dysfunction by allowing the researchers to visualize structural and microsctructural changes associated with these syndromes. The literature review also discusses the value of new analytic techniques like graph theory to better understand abnormal brain connectivity in this patient population.

Balter S, Lin G, Leyden KM, Paul BM, McDonald CR. Neuroimaging correlates of language network impairment and reorganization in temporal lobe epilepsy. Brain Lang. 2016:pii S0093-934X(15)30127-9.

Dr. Tunc's literature review and retrospective review of headache clinic data provide food for thought with regard to chronic daily headache (CDH) in younger children. The rate of CDH in the papers reviewed ranged from 8% to 30%. I think this range represents the differences in nature between the pediatric headache clinics included in the sample. In some areas, the local primary care providers refer all children with headache to headache clinics. In other areas, the primary care providers hold on to "easy" headache patients and refer only the "tough cases." For that reason, it is hard to generalize from Dr. Tunc's finding. Suffice it to say that tertiary pediatric headache clinics do see some younger children with CDH. The Cleveland Clinic experience showed a prevalence of 58%, so that clinic sees the harder cases.

Dr. Tunc did not find MRI to be useful in children with CDH. I just want to caution readers to order MRIs when patients have systemic signs (eg, growth failure or secondary amenorrhea), neurologic signs (eg, ataxia, slurred speech, one-sided weakness, or facial asymmetry), abrupt onset of headache (think of ruptured aneurysm), or a new change in headache pattern. We must be careful with conclusions drawn from retrospective studies because we can't control for any factors. Although no MRIs were positive, we don't know about patients who came to the neurosurgeon through other pathways besides the headache clinic.

Dr. Tunc mentioned that younger patients had a longer duration of illness before seeking tertiary care, and she speculated as to why. Further clarification is needed to develop a plausible explanation. How was the time measured? Was it measured from the first headache until the tertiary care visit, or from onset of CDH until the tertiary care visit? If the former is true, then I might reach a different conclusion. Perhaps it takes longer for younger children to chronify than older children. If, on the other hand, time was measured from the onset of CDH until presentation, then the authors' explanations may indeed be sound.

In summary, this is a great study that shows that small children presenting to a tertiary care center do get CDH at a higher rate than we thought. It would be terrific to poll other pediatric headache programs to compare and contrast with the findings of this study.

—Jack Gladstein, MD
Professor of Pediatrics and Neurology
Director of the Pediatric Headache Clinic
University of Maryland School of Medicine
Baltimore

Dr. Tunc's literature review and retrospective review of headache clinic data provide food for thought with regard to chronic daily headache (CDH) in younger children. The rate of CDH in the papers reviewed ranged from 8% to 30%. I think this range represents the differences in nature between the pediatric headache clinics included in the sample. In some areas, the local primary care providers refer all children with headache to headache clinics. In other areas, the primary care providers hold on to "easy" headache patients and refer only the "tough cases." For that reason, it is hard to generalize from Dr. Tunc's finding. Suffice it to say that tertiary pediatric headache clinics do see some younger children with CDH. The Cleveland Clinic experience showed a prevalence of 58%, so that clinic sees the harder cases.

Dr. Tunc did not find MRI to be useful in children with CDH. I just want to caution readers to order MRIs when patients have systemic signs (eg, growth failure or secondary amenorrhea), neurologic signs (eg, ataxia, slurred speech, one-sided weakness, or facial asymmetry), abrupt onset of headache (think of ruptured aneurysm), or a new change in headache pattern. We must be careful with conclusions drawn from retrospective studies because we can't control for any factors. Although no MRIs were positive, we don't know about patients who came to the neurosurgeon through other pathways besides the headache clinic.

Dr. Tunc mentioned that younger patients had a longer duration of illness before seeking tertiary care, and she speculated as to why. Further clarification is needed to develop a plausible explanation. How was the time measured? Was it measured from the first headache until the tertiary care visit, or from onset of CDH until the tertiary care visit? If the former is true, then I might reach a different conclusion. Perhaps it takes longer for younger children to chronify than older children. If, on the other hand, time was measured from the onset of CDH until presentation, then the authors' explanations may indeed be sound.

In summary, this is a great study that shows that small children presenting to a tertiary care center do get CDH at a higher rate than we thought. It would be terrific to poll other pediatric headache programs to compare and contrast with the findings of this study.

—Jack Gladstein, MD
Professor of Pediatrics and Neurology
Director of the Pediatric Headache Clinic
University of Maryland School of Medicine
Baltimore

Dr. Tunc's literature review and retrospective review of headache clinic data provide food for thought with regard to chronic daily headache (CDH) in younger children. The rate of CDH in the papers reviewed ranged from 8% to 30%. I think this range represents the differences in nature between the pediatric headache clinics included in the sample. In some areas, the local primary care providers refer all children with headache to headache clinics. In other areas, the primary care providers hold on to "easy" headache patients and refer only the "tough cases." For that reason, it is hard to generalize from Dr. Tunc's finding. Suffice it to say that tertiary pediatric headache clinics do see some younger children with CDH. The Cleveland Clinic experience showed a prevalence of 58%, so that clinic sees the harder cases.

Dr. Tunc did not find MRI to be useful in children with CDH. I just want to caution readers to order MRIs when patients have systemic signs (eg, growth failure or secondary amenorrhea), neurologic signs (eg, ataxia, slurred speech, one-sided weakness, or facial asymmetry), abrupt onset of headache (think of ruptured aneurysm), or a new change in headache pattern. We must be careful with conclusions drawn from retrospective studies because we can't control for any factors. Although no MRIs were positive, we don't know about patients who came to the neurosurgeon through other pathways besides the headache clinic.

Dr. Tunc mentioned that younger patients had a longer duration of illness before seeking tertiary care, and she speculated as to why. Further clarification is needed to develop a plausible explanation. How was the time measured? Was it measured from the first headache until the tertiary care visit, or from onset of CDH until the tertiary care visit? If the former is true, then I might reach a different conclusion. Perhaps it takes longer for younger children to chronify than older children. If, on the other hand, time was measured from the onset of CDH until presentation, then the authors' explanations may indeed be sound.

In summary, this is a great study that shows that small children presenting to a tertiary care center do get CDH at a higher rate than we thought. It would be terrific to poll other pediatric headache programs to compare and contrast with the findings of this study.

—Jack Gladstein, MD
Professor of Pediatrics and Neurology
Director of the Pediatric Headache Clinic
University of Maryland School of Medicine
Baltimore

A new consensus statement provides recommendations for transitioning adolescents and young adults with neurologic disorders to adult care. Created by the Child Neurology Foundation, the recommendations were published online ahead of print July 27 in Neurology.

"The goal of this research is to help make the transition easier for millions of parents and caregivers of children who are reaching the age where they will be dealing with complex teenage and adult life situations," said study author Lawrence W. Brown, MD, a pediatric neurologist at the Children's Hospital of Philadelphia.

The consensus statement is the work of the Neurology Transition Consensus Panel, an interdisciplinary team including child neurologists, child neurology nurses, adult neurologists, rehabilitation specialists, patients, and family members of neurology patients.

The research team reviewed studies published within the last 10 years focused mainly on transition of care for those with neurologic disorders. Older studies and book chapters that were relevant to transition in general were also included. The consensus statement addresses the great majority of adolescents and young adults whose care shifts from pediatric to adult providers. The paper does not directly address children with brain diseases who are not expected to live to adulthood or those children who are managed by adult neurologists. However, it strongly recommends that adult models of care be introduced even if providers are unchanged.

The consensus statement identifies the following eight best practices for making the transition from pediatric to adult care as smooth as possible:

· Expectation of future transition to the adult care system with the youth and family is discussed before age 13.

· Self-management skills should be assessed at age 12 and reevaluated on a yearly basis.

· Yearly transition planning sessions should also address the youth's medical condition, including current medications and potential side effects; signs and symptoms of concern; genetic counseling and reproductive implications of the condition; issues of puberty and sexuality; driving, alcohol, substance use, and other risks; and emotional or psychological concerns and wellness.

· If appropriate, a discussion with the caregivers regarding the youth's expected legal competency (ie, whether there is a need for legal guardianship and powers of attorney) should begin by age 14. If the youth's expected legal competency is unclear, assessment of that capacity should be made yearly.

· A comprehensive transition plan should be developed by age 14 in collaboration with the youth, caregivers, other health care providers, school personnel, vocational professionals, community services providers, and legal services regarding all aspects of health, financial, and legal care. This is usually the responsibility of the primary care provider.

· The child neurology team is responsible for the neurologic component of the comprehensive transition plan and should update it annually.

· Adult providers are identified in collaboration with the youth and caregivers prior to the anticipated time of transfer. A medical transfer packet is prepared for the adult provider and provided to the youth; it includes the transition plan and medical summary with pertinent history, diagnostic evaluations, previous drug trials, current medications, and protocol for emergency care.

· The child neurology team communicates directly with the new adult provider to ensure smooth completion of the transition process, which is finalized after the first appointment. It is recommended that the child neurologist be available to the youth and the adult provider for continuity and support.

"We believe that following these steps will make a real difference in the lives of our patients as they become independent and self-sufficient adults to the greatest extent possible," said Dr. Brown.

The consensus statement was endorsed by the American Academy of Neurology, the Child Neurology Society, and the American Academy of Pediatrics and was cosponsored by Eisai.

A new consensus statement provides recommendations for transitioning adolescents and young adults with neurologic disorders to adult care. Created by the Child Neurology Foundation, the recommendations were published online ahead of print July 27 in Neurology.

"The goal of this research is to help make the transition easier for millions of parents and caregivers of children who are reaching the age where they will be dealing with complex teenage and adult life situations," said study author Lawrence W. Brown, MD, a pediatric neurologist at the Children's Hospital of Philadelphia.

The consensus statement is the work of the Neurology Transition Consensus Panel, an interdisciplinary team including child neurologists, child neurology nurses, adult neurologists, rehabilitation specialists, patients, and family members of neurology patients.

The research team reviewed studies published within the last 10 years focused mainly on transition of care for those with neurologic disorders. Older studies and book chapters that were relevant to transition in general were also included. The consensus statement addresses the great majority of adolescents and young adults whose care shifts from pediatric to adult providers. The paper does not directly address children with brain diseases who are not expected to live to adulthood or those children who are managed by adult neurologists. However, it strongly recommends that adult models of care be introduced even if providers are unchanged.

The consensus statement identifies the following eight best practices for making the transition from pediatric to adult care as smooth as possible:

· Expectation of future transition to the adult care system with the youth and family is discussed before age 13.

· Self-management skills should be assessed at age 12 and reevaluated on a yearly basis.

· Yearly transition planning sessions should also address the youth's medical condition, including current medications and potential side effects; signs and symptoms of concern; genetic counseling and reproductive implications of the condition; issues of puberty and sexuality; driving, alcohol, substance use, and other risks; and emotional or psychological concerns and wellness.

· If appropriate, a discussion with the caregivers regarding the youth's expected legal competency (ie, whether there is a need for legal guardianship and powers of attorney) should begin by age 14. If the youth's expected legal competency is unclear, assessment of that capacity should be made yearly.

· A comprehensive transition plan should be developed by age 14 in collaboration with the youth, caregivers, other health care providers, school personnel, vocational professionals, community services providers, and legal services regarding all aspects of health, financial, and legal care. This is usually the responsibility of the primary care provider.

· The child neurology team is responsible for the neurologic component of the comprehensive transition plan and should update it annually.

· Adult providers are identified in collaboration with the youth and caregivers prior to the anticipated time of transfer. A medical transfer packet is prepared for the adult provider and provided to the youth; it includes the transition plan and medical summary with pertinent history, diagnostic evaluations, previous drug trials, current medications, and protocol for emergency care.

· The child neurology team communicates directly with the new adult provider to ensure smooth completion of the transition process, which is finalized after the first appointment. It is recommended that the child neurologist be available to the youth and the adult provider for continuity and support.

"We believe that following these steps will make a real difference in the lives of our patients as they become independent and self-sufficient adults to the greatest extent possible," said Dr. Brown.

The consensus statement was endorsed by the American Academy of Neurology, the Child Neurology Society, and the American Academy of Pediatrics and was cosponsored by Eisai.

A new consensus statement provides recommendations for transitioning adolescents and young adults with neurologic disorders to adult care. Created by the Child Neurology Foundation, the recommendations were published online ahead of print July 27 in Neurology.

"The goal of this research is to help make the transition easier for millions of parents and caregivers of children who are reaching the age where they will be dealing with complex teenage and adult life situations," said study author Lawrence W. Brown, MD, a pediatric neurologist at the Children's Hospital of Philadelphia.

The consensus statement is the work of the Neurology Transition Consensus Panel, an interdisciplinary team including child neurologists, child neurology nurses, adult neurologists, rehabilitation specialists, patients, and family members of neurology patients.

The research team reviewed studies published within the last 10 years focused mainly on transition of care for those with neurologic disorders. Older studies and book chapters that were relevant to transition in general were also included. The consensus statement addresses the great majority of adolescents and young adults whose care shifts from pediatric to adult providers. The paper does not directly address children with brain diseases who are not expected to live to adulthood or those children who are managed by adult neurologists. However, it strongly recommends that adult models of care be introduced even if providers are unchanged.

The consensus statement identifies the following eight best practices for making the transition from pediatric to adult care as smooth as possible:

· Expectation of future transition to the adult care system with the youth and family is discussed before age 13.

· Self-management skills should be assessed at age 12 and reevaluated on a yearly basis.

· Yearly transition planning sessions should also address the youth's medical condition, including current medications and potential side effects; signs and symptoms of concern; genetic counseling and reproductive implications of the condition; issues of puberty and sexuality; driving, alcohol, substance use, and other risks; and emotional or psychological concerns and wellness.

· If appropriate, a discussion with the caregivers regarding the youth's expected legal competency (ie, whether there is a need for legal guardianship and powers of attorney) should begin by age 14. If the youth's expected legal competency is unclear, assessment of that capacity should be made yearly.

· A comprehensive transition plan should be developed by age 14 in collaboration with the youth, caregivers, other health care providers, school personnel, vocational professionals, community services providers, and legal services regarding all aspects of health, financial, and legal care. This is usually the responsibility of the primary care provider.

· The child neurology team is responsible for the neurologic component of the comprehensive transition plan and should update it annually.

· Adult providers are identified in collaboration with the youth and caregivers prior to the anticipated time of transfer. A medical transfer packet is prepared for the adult provider and provided to the youth; it includes the transition plan and medical summary with pertinent history, diagnostic evaluations, previous drug trials, current medications, and protocol for emergency care.

· The child neurology team communicates directly with the new adult provider to ensure smooth completion of the transition process, which is finalized after the first appointment. It is recommended that the child neurologist be available to the youth and the adult provider for continuity and support.

"We believe that following these steps will make a real difference in the lives of our patients as they become independent and self-sufficient adults to the greatest extent possible," said Dr. Brown.

The consensus statement was endorsed by the American Academy of Neurology, the Child Neurology Society, and the American Academy of Pediatrics and was cosponsored by Eisai.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: Service handovers contribute to discontinuity of care in hospitalized patients. Research on hospitalist service handovers is limited, and no previous study has examined the service handover from the patient’s perspective.

Study design: Interview-based, qualitative analysis.

Setting: Urban academic medical center.

Synopsis: Researchers interviewed 40 hospitalized patients using a semi-structured nine-question interview regarding their attending hospitalist service change. The constant comparative method was used to identify recurrent themes in patient responses. The research team identified six themes representative of patient concerns during service change: physician-patient communication, transparency in communication, hospitalist-specialist communication, new opportunities due to transition, bedside manner, and indifference toward the transition.

Authors used the six themes to develop a model for the ideal service handover, utilizing open lines of communication, facilitated by multiple modalities and disciplines, and recognizing the patient’s role as the primary stakeholder in the transition of care.

Bottom line: Incorporating patients’ perspective presents an opportunity to improve communication and efficiency during hospitalist service transitions.

Citation: Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients’ experience with hospitalist service handovers [published online ahead of print May 11, 2016]. J Hosp Med. doi:10.1002/jhm.2608.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Background: For patients with atrial fibrillation and history of intracranial hemorrhage (ICH), the risk of further ICH and the benefit of antithrombotic agents for stroke risk reduction remain unclear.

Study design: Retrospective cohort study.

Setting: National Health Research Institutes, Taiwan.

Synopsis: Using the National Health Insurance Research Database in Taiwan, researchers identified 307,640 patients with atrial fibrillation and a CHA2DS2-VASc score >/= 2. Of this group, 12,917 patients with a history of ICH were identified and separated into three groups: no treatment, antiplatelet treatment, or warfarin. Among the no treatment group, the rate of ICH and ischemic cerebrovascular accident were 4.2 and 5.8 per 100 person-years, respectively. Among patients on antiplatelet therapy, the rates were 5.3% and 5.2%, respectively. Among patients on warfarin, the number needed to treat (NNT) for preventing one ischemic stroke was lower than the number needed to harm (NNH) for producing one ICH among patients with a CHA2DS2-VASc score >/= 6. In patients with lower CHA2DS2-VASc scores, the NNT was higher than NNH.

Bottom line: Treatment with warfarin may benefit patients with atrial fibrillation and prior ICH with CHA2DS2-VASc scores >/= 6, but risk likely outweighs benefit in patients with lower scores.

Citation: Chao TF, Liu CJ, Liao JN, et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation. 2016;133(16):1540-1547.

Elevated blood ammonia levels may help differentiate epileptic generalized convulsive seizures (GCS) from other events, suggests a recent report in Epilepsia. When Rawan Albadareen and associates measured blood ammonia levels in 78 patients with GCS, psychogenic nonepileptic seizures with convulsions (PNES-C), or focal seizures using video–electroencephalography (vEEG) monitoring, they discovered that ammonia levels at or above 80 μmol/L could classify generalized convulsive seizures in 80% of patients with a sensitivity of 53.9% and specificity of 100%. Their findings suggest that transient hyperammonemia may serve as an inexpensive test for the diagnosis of GCS.

Albadareen R, Gronseth G, Landazuri P, et al. Postictal ammonia as a biomarker for electrographic convulsive seizures: a prospective study. Epilepsia. 2016;57(8): 1221-1227.

Elevated blood ammonia levels may help differentiate epileptic generalized convulsive seizures (GCS) from other events, suggests a recent report in Epilepsia. When Rawan Albadareen and associates measured blood ammonia levels in 78 patients with GCS, psychogenic nonepileptic seizures with convulsions (PNES-C), or focal seizures using video–electroencephalography (vEEG) monitoring, they discovered that ammonia levels at or above 80 μmol/L could classify generalized convulsive seizures in 80% of patients with a sensitivity of 53.9% and specificity of 100%. Their findings suggest that transient hyperammonemia may serve as an inexpensive test for the diagnosis of GCS.

Albadareen R, Gronseth G, Landazuri P, et al. Postictal ammonia as a biomarker for electrographic convulsive seizures: a prospective study. Epilepsia. 2016;57(8): 1221-1227.

Elevated blood ammonia levels may help differentiate epileptic generalized convulsive seizures (GCS) from other events, suggests a recent report in Epilepsia. When Rawan Albadareen and associates measured blood ammonia levels in 78 patients with GCS, psychogenic nonepileptic seizures with convulsions (PNES-C), or focal seizures using video–electroencephalography (vEEG) monitoring, they discovered that ammonia levels at or above 80 μmol/L could classify generalized convulsive seizures in 80% of patients with a sensitivity of 53.9% and specificity of 100%. Their findings suggest that transient hyperammonemia may serve as an inexpensive test for the diagnosis of GCS.

Albadareen R, Gronseth G, Landazuri P, et al. Postictal ammonia as a biomarker for electrographic convulsive seizures: a prospective study. Epilepsia. 2016;57(8): 1221-1227.