Immediate Postoperative Imaging Following Elective Lumbar Fusion Provides Little Clinical Utility

STUDY DESIGN

Retrospective review at a single institution of all adult patients who underwent elective lumbar fusion surgery for degenerative spinal disease from 2013 to 2018. Reoperation rates and change in clinical management due to routine imaging findings were the primary outcomes.

OBJECTIVE

To investigate what effects immediate routine postoperative imaging has on the clinical management of patients following lumbar fusion surgery.

SUMMARY OF BACKGROUND DATA

The clinical utility of routine postoperative imaging following lumbar fusion surgery remains uncertain. Existing studies on the clinical utility of postoperative imaging in lumbar fusion patients have largely focused on imaging obtained post-discharge. We present a retrospective analysis that to our knowledge is the first study reporting on the clinical utility of routine imaging in lumbar fusion patients during the immediate postoperative period.

METHODS

The medical records of patients who had undergone elective lumbar instrumented fusion for degenerative disease from 2013 to 2018 by neurosurgeons across one regional healthcare system were retrospectively analyzed. Inpatient records and imaging orders for patients were reviewed. Routine immediate postoperative imaging was defined by any lumbar spine imaging prior to discharge in the absence of specific indications.

RESULTS

Analysis identified 115 patients who underwent elective lumbar instrumented fusion for degenerative disease. One-hundred-twelve patients received routine postoperative imaging. Routine imaging was abnormal in four patients (4%). There was one instance (<1%) where routine immediate postoperative imaging led to change in clinical management. Abnormal routine imaging was not associated with either reoperation or development of neurological symptoms postoperatively (P = 0.10), however, new or worsening neurologic deficits did predict reoperation (P < 0.01).

CONCLUSION

New neurologic deficit was the only significant predictor of reoperation. Routine imaging, whether normal or abnormal, was not found to be associated with reoperation. The practice of routine imaging prior to discharge following elective lumbar fusion surgery appears to provide little utility to clinical management.Level of Evidence: 3.

Epilepsy in Older People in Sub-Saharan Africa: A Systematic Review

BACKGROUND

Over one-fourth of new onset epilepsy occurs after age 60. However, the burden of epilepsy and other seizure disorders among this special population in Africa is largely unknown, despite a growingnumber of elderly persons on the continent. This study aimed to assess the prevalence and risk factors for epilepsy among persons aged 60 years or older in Africa.

METHODS

We conducted a systematic review by searching MEDLINE (via) and EMBASE databases from inception to 30th October 2020. Primary researches reporting prevalence or incidence of seizures or epilepsy in older persons (≥60 years) were included. Review articles were excluded.

RESULTS

We retrieved 107 citations from which 4 studies, recruiting 10, 334 participants were eligible. The studies were conducted between 1999 and 2018 and published between 2005 and 2019. Two of the studies were conducted in the West African countries of Niger and Senegal; meanwhile, the remaining 2 were conducted in East African country of Tanzania. Regarding study design, three were either hospital-based or community-based cross-sectional studies. Meanwhile, 1 was a retrospective hospital-based study. Of the 10,334 participants, 81 (0.78%) had a seizure disorder. The prevalence of seizure ranged from 0.02% to 3.2%.

CONCLUSION

There are limited data on the prevalence of epilepsy in older persons in older adults in most countries in sub-Saharan Africa. Epilepsy among the older adults remains a challenge in Africa and more information is needed to understand the burden to improve care.

Markers of Quality Care for Newly Diagnosed People With Epilepsy on Medicaid

BACKGROUND

For newly diagnosed people with epilepsy (PWE), proper treatment is important to improve outcomes, yet limited data exist on markers of quality care.

OBJECTIVE

Examine markers of quality care for newly diagnosed PWE.

METHODS

Using Medicaid claims data (2010-2014) for 15 states we identified adults 18-64 years of age diagnosed with incident epilepsy in 2012 or 2013. We built 5 sequential logistic regression models to evaluate: (1) seeing a neurologist; (2) diagnostic evaluation; (3) antiepileptic medication adherence; (4) serum drug levels checked; and (5) being in the top quartile of number of negative health events (NHEs). We adjusted for demographics, comorbidities, county-level factors, and the outcomes from all prior models.

RESULTS

Of 25,663 PWE, 37.3% saw a neurologist, with decreased odds for those of older age, those residing in counties with low-density of neurologists, and certain race/ethnicities; about 57% of PWE received at least 1 diagnostic test; and nearly 62% of PWE were adherent to their medication. The most common comorbidities were hypertension (37.1%) and psychoses (26.9%). PWE with comorbidities had higher odds of seeing a neurologist and to have NHEs. Substance use disorders were negatively associated with medication adherence and positively associated with high NHEs.

CONCLUSIONS

There are notable differences in demographics among people with incident epilepsy who do or do not see a neurologist. Differences in NHEs persist, even after controlling for neurologist care and diagnostic evaluation. Continued attention to these disparities and comorbidities is needed in the evaluation of newly diagnosed PWE.

Reducing stroke burden through a targeted self-management intervention for reducing stroke risk factors in high-risk Ugandans: A protocol for a randomized controlled trial

INTRODUCTION

Stroke burden is rapidly increasing globally. Modifiable risk factors offer an opportunity to intervene, and targeting hypertension is a key actionable target for stroke risk reduction in sub-Saharan Africa. This 3-site planned randomized controlled trial builds on promising preliminary data.

METHODS

A total of 246 Ugandan adults will be recruited randomized to experimental intervention vs. enhanced treatment control. Intervention participants will receive six weekly group-format stroke risk reduction self-management training sessions, and the controls will receive information on cardiovascular risk. The primary study outcome is systolic B.P. measured at baseline, 13-week, 24 weeks (6 months). Secondary outcomes include other biological and behavioral stroke risk factors.

DISCUSSION

The curriculum-guided self-management TargetEd MAnageMent Intervention (TEAM) program is anticipated to reduce the stroke burden in Uganda.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04685408, registered on 28 December 2020.

A Review of the Evidence Base for Nutrition and Nutritional Supplements in Older Adults with Bipolar Disorder: A report from the OABD task force

OBJECTIVES

To better understand the role of nutrition in older adults (aged 50 years or older) with bipolar disorders (OABD), we conducted a systematic review of the literature and appraise existing evidence.

METHODS

Following PRISMA guidelines, we searched databases including Medline/PubMed, PsychINFO, EMBASE, CINAHL, Scopus, Web of Science, Cochrane Register, FDA website, and clinical trial registries through 2019 for eligible reports. The search string combined MeSH terms for bipolar disorder, nutrition and older adults. This was supplemented by snowball searching of references in relevant studies and authors were contacted to request their work where necessary. All included studies were rated with the National Institutes of Health Study Quality Assessment Tools based on study designs.

RESULTS

Of 2280 papers screened, ten studies including eight observational and two interventional studies. The topic foci of the papers examined several nutrients, (including vitamin B12, vitamin D, coenzyme Q10, homocysteine, and folate), nutritional deficiencies and biochemical correlates. The prevalence rates of deficiencies varied with specific nutrients (3.7% to 71.6% for Vitamin B12 and 34.6% for Vitamin D), and between inpatient versus outpatient populations. While nutritional interventions appeared to be associated with improvement in both affective and cognitive outcomes, the sample sizes of OABD varied and were generally small.

CONCLUSION

While there is evidence for the benefits of nutritional interventions on affective, cognitive and overall outcome in OABD, the quality of the evidence is limited. Our findings underscore the need for high quality studies to inform evidence-based guidelines for nutritional assessment and supplemention in OABD.

Engaging stakeholders in the refinement of an evidence-based remotely delivered epilepsy self-management program for rural populations

A growing body of research supports self-management approaches that can improve outcomes in people living with epilepsy (PLWE). An evidence-based remotely delivered self-management program (SMART) that was successfully delivered in an urban/suburban setting has the potential to be particularly helpful to PLWE who live in rural communities, where heavy stigma burden and limited access to healthcare is common. In this Phase 1 exploratory study, focus groups of key rural stakeholders (PLWE, family members, care providers) were used to: (1) gather information on factors that may impede or facilitate participation in SMART and (2) elicit overall perceptions of the program, as well as suggestions and feedback for refining it for implementation in Phase 2 of the randomized controlled study (RCT). Qualitative data analysis revealed that focus group participants identified geographic and social isolation, and the more limited access to epilepsy care, as the major barriers to epilepsy self-management for rural populations. However, they felt strongly that SMART could fill an epilepsy care gap in rural communities, and provided suggestions for recruitment and retention strategies of subjects, as well as improvement/modifications to the program curriculum for the Phase 2 RCT.

Alcohol use in Tanzanians with chronic psychotic disorders and poor medication adherence

Background

The burden of chronic psychotic disorders (CPDs) in sub-Saharan Africa (SSA) is significant. Poorly medically adherent patients are more likely to have worse outcomes and require more resources. However, factors impacting effective treatment of CPD in this population are unclear.

Aim

Examine the relationship between alcohol use and disease management and compare alcohol risk stratification between the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in poorly medication adherent Tanzanians with CPD.

Setting

Muhimbili National Hospital and ambulatory clinics in Dar es Salaam, Tanzania.

Methods

100 Tanzanians with CPDs and suboptimal medication adherence were dichotomized into low and moderate-to-high risk alcohol use based on AUDIT scores and compared regarding medication attitudes, adherence and psychiatric symptoms. Patients completed the ASSIST for comparison to AUDIT risk stratification.

Results

Moderate-to-high risk alcohol users had worse medication attitudes (p < 0.01), medication adherence (previous week, p = 0.01; previous month, p < 0.001), and psychiatric symptoms (p = 0.03). They were younger, predominately male and more likely to have a family history of alcohol abuse. A logistic regression analysis found age, gender and family history of abuse as significant predictors of hazardous alcohol use (p = 0.02, 0.02, < 0.01, respectively). Risk stratification between AUDIT and ASSIST aligned in 85% of participants.

Conclusion

Alcohol use is an important consideration in treating poorly adherent Tanzanians with CPD. The ASSIST was comparable to the AUDIT in stratifying risky alcohol use with the additional benefit of screening for other substances.

A systematic literature review of recommendations for referral to specialty care for patients with epilepsy

OBJECTIVE

In epilepsy, patients who receive appropriate care receive treatment that differs substantially from those that do not. Given the need for a more detailed assessment of the role of specialty referral in the care of patients with epilepsy, this systematic literature review identified epilepsy care guidelines and recommendations that specifically address when and why people with epilepsy should be referred to specialty care.

METHODS

This study identified recent (in the last 10 years) publications that made best-practice recommendations for referring people with epilepsy to a neurologist or epileptologist. We searched six databases in December 2018: MEDLINE (PubMed), Cochrane Library, ProQuest, Web of Science, CINAHL (Ebsco), Scopus (Elsevier). Search terms included "Epilepsy" OR "Seizures," "Guideline" OR "Practice Parameter," and "Referral."

RESULTS

The 15 full-text articles identified included formal guidelines, summaries of these guidelines, or professional commentary that builds upon existing guidelines. Most of these publications came from the U.K and its National Institute for Health and Care Excellence. Overall, the included recommendations for referral varied considerably both for new-onset and refractory epilepsy. Although these recommendations were not consistent, it is reasonable to refer patients following the failure of 2 anti-seizure medication (ASM) trials.

SIGNIFICANCE

Guidelines and informal recommendations are not consistent regarding best practices for specialty care referral for patients with epilepsy. These guidelines and recommendations should consider the context of care in real-world settings and suggest pragmatic approaches that optimize seizure control and functioning.

Changes in Self-Reported Depressive Symptoms Among Adults in the United States From 2005 to 2016

BACKGROUND: This study examined interview data from the National Health and Nutrition Examination Survey from 2005 to 2016. AIM: To determine national trends in self-reported depressive symptoms. METHOD: Depressive symptoms were assessed using self-reported data on the nine-item Patient Health Questionnaire (PHQ-9), with a total score ≥10 and an individual item score of 2 or 3, indicating greater severity. RESULTS: A total of 31,191 individuals contributed PHQ-9 data from 2005 to 2016. The absolute proportion of individuals with total PHQ-9 score ≥10 increased from 6.2% to 8.1%. After adjustment for participant demographic characteristics and comorbid conditions, the odds ratio for high PHQ-9 score at the end versus the beginning of the study interval was 1.27 (95% confidence interval [CI: 1.07, 1.50]). Anhedonia, guilt/worthlessness, appetite, and hypoactivity/hyperactivity had the largest increases in individual item risk after adjusting for demographic and comorbid characteristics. CONCLUSIONS: There were sizeable increases in the prevalence of self-reported depressive symptoms in the United States over an 11-year period. Further work is needed to understand the reasons for and implications of this increase. However, the results suggest greater efforts should be made by health care providers to screen for depressive symptoms that may warrant further assessment, treatment, or referral to mental health services as needed.

The Targeted Management (TEAM) Intervention for Reducing Stroke Risk in African American Men: Rationale and Study Design of a Prospective Randomized Controlled Trial

BACKGROUND

African American (AA) male survivors of strokes or transient ischemic attacks (TIA) have the highest risk of recurrent stroke when compared to other racial-ethnic men. However, there is a paucity of evidence-based strategies, including organizational, educational, or behavioral interventions, that targets secondary stroke risk reduction in AA men.

METHODS

Targeted Management for Reducing Stroke Risk (TEAM) is an ongoing, 6-month prospective, randomized controlled trial that will determine whether a curriculum-guided self-management approach, using peer dyads (men who had a stroke or TIA and their care partners) will improve post-stroke care in AA men.

RESULTS

The study sample will consist of 160 AA men who have experienced a stroke or TIA within 5 years, randomized to TEAM or Wait-list control group. The primary outcome changes in systolic blood pressure (BP) and high-density lipoprotein (HDL), while secondary outcomes include diastolic BP, total cholesterol, low-density lipoprotein, triglycerides, and glycemic control for diabetics. We hypothesize that AA men in TEAM will have significantly lower systolic BP and higher HDL when compared to AA men in the Wait-list control group at 6-month.

CONCLUSION

Persistent disparities for stroke burden in AA men highlight the need for novel interventions to promote secondary stroke-risk reduction. Building on promising pilot data, TEAM uses a group format, with a nurse and patient co-led intervention focused on AA men and family needs, practice in problem-solving, and attention to emotional and role management. In addition, the TEAM approach may help reduce stroke risk factors and health disparities in AA men.

CLINICALTRIALSGOV IDENTIFIER

NCT04402125.

Recent developments in geriatric psychopharmacology

INTRODUCTION

There is a tremendous growing need to address the burden of geriatric psychiatric disorders. Recent developments relevant to geriatric psychiatry have focused on Alzheimer's disease (AD), severe/refractory depression, and cancer/end of life care.

AREAS COVERED

This is a non-systematic, narrative review (databases and websites for search: PubMed, Google Scholar, Medscape, ClinicalTrials.gov; focusing on the last 6 years), and covers developments in disease-modifying therapies for AD, diagnostic radiotracers for AD, medications for neuropsychiatric symptoms of dementia, ketamine/esketamine, psychedelics, and cannabinoids.

EXPERT OPINION

The focus of on-going trials of anti-amyloid agents has been on individuals with very early stage AD; several agents are under phase 3 investigation, and aducanumab is under FDA review. Amyloid and tau PET scans have been approved by the FDA to assist in the diagnoses of AD. Promising pharmaceuticals for neuropsychiatric symptoms of dementia include pimavanserin, brexpiprazole, escitalopram, dextromethorphan/quinidine, and lithium. Esketamine, although approved for treatment-resistant depression in general adults, failed to demonstrate efficacy in elderly patients in a phase 3 trial. There is preliminary evidence for benefit of psychedelic-assisted psychotherapy in end-of-life and cancer-related depression/anxiety. Evidence for the use of cannabinoids is currently lacking.

The Managing Epilepsy Well (MEW) network database: Lessons learned in refining and implementing an integrated data tool in service of a national U.S. Research Collaborative

Epilepsy self-management (ESM) is the summative set of behaviors that people with epilepsy use to cope with seizures and optimize health. This report describes the implementation and evolution of the Managing Epilepsy Well Network Database (MEW DB), an integrated data resource intended to advance knowledge on ESM. The MEW DB utilizes a three-tiered (Tier 1-3) system of data organization, with tiers of data generally increasing in ascending complexity or collection burden. A MEW DB Steering Committee (SC) establishes consensus on planned analyses using a standardized new analysis request template. The data management structure facilitates harmonization and integration of additional data, or to update the database as new data become available. The current MEW DB comprises 1,563 people with epilepsy. Mean age was 39.9 years, 64.9% women (N = 1006), 12.8% African American (N = 170), 22.2% Hispanic (N = 306). On average, individuals have lived with epilepsy since their early 20s and are prescribed between 1 and 2 antiepileptic drugs. The MEW DB spans multiple socio-ecological levels to provide a robust multi-tiered framework for studying ESM. A total of 41 common data elements have been identified through iterative consensus. This integrated database takes advantage of an extensive collective background of archival evidence in ESM and brings together engaged investigators to build a dataset that represents diverse types of individuals with epilepsy, targets health domains important to ESM, and facilitates analyses that would not be possible with sites operating independently. Overall, the MEW DB serves the greater mission of this research collaborative and has potential to advance ESM research.

Cranial Surgical Site Infection Interventions and Prevention Bundles: A Systematic Review of the Literature

BACKGROUND

Cranial surgical site infections (cSSIs) are associated with significant morbidity. Measures to reduce cSSI are necessary to reduce patient morbidity as well as hospital costs and resource utilization.

OBJECTIVE

To identify and characterize interventions or bundled interventions aimed at reduction of the incidence of cranial surgical site infections.

METHODS

A systematic review of the literature was conducted according to the PRISMA guidelines. The search strategy included randomized trials, quasi-experimental studies, cohort studies, and case series published between 2000 and 2020 that evaluated interventions implemented to reduce cSSI. Bias assessments and data extraction were performed on included studies.

RESULTS

The initial search generated 1249 studies. Application of inclusion and exclusion criteria and review of references yielded 15 single-intervention and 6 bundled-intervention studies. The single interventions included handwashing protocols, use of vancomycin powder, hair washing and clipping practices, and incision closure techniques. Bundled interventions addressed a variety of preoperative, intraoperative, and postoperative changes. Despite a lack of strong evidence to support the adoption of statistically significant interventions, the use of vancomycin powder may be effective in reducing cSSI. In addition, bundled interventions that involved cultural changes, such as increased teaching/education, personal accountability, direct observation, and feedback, showed some success in decreasing SSI rates.

CONCLUSIONS

The strength of the conclusions is limited by small sample sizes, study heterogeneity, relatively low cSSI incidence, and high case variability. Some evidence supports the use of intraoperative vancomycin powder in adult noncranioplasty cases and the application of accountability, teaching, and surveillance of faculty, particularly those early in training.

Higher dose weekly fluoxetine in hemodialysis patients: A case series report

OBJECTIVE

The antidepressant medication fluoxetine at 90 mg dosed weekly is as effective and safe as standard formulation fluoxetine 20 mg dosed daily in patients with major depressive disorder. Weekly fluoxetine has not been well studied in hemodialysis patients, and doses beyond 90 mg/week have not been described in this population. This case series, derived from a larger study on depression in hemodialysis patients, describes the use of weekly fluoxetine at dosages beyond 90 mg/week.

METHOD

Hemodialysis patients with depressive symptom severity scored ≥10 on the 9-item Patient Health Questionnaire and major depressive disorder confirmed with Mini International Neuropsychiatric Interview were initially prescribed daily fluoxetine for two weeks and then transitioned to weekly fluoxetine. Dosage titration was made at the discretion of the prescribing clinician. Fluoxetine was continued for a total of 12 weeks.

RESULTS

Four women, aged 24 to 65 years, on hemodialysis for 1 to 18 years, were started on weekly fluoxetine that was increased over several weeks up to 180 mg. Side effects included restlessness, dry mouth, sedation, and lightheadedness. Two patients ultimately had their weekly fluoxetine decreased back to 90 mg. However, all four continued weekly fluoxetine as part of poststudy aftercare and no longer met diagnostic criteria for major depressive disorder, current episode.

CONCLUSIONS

Weekly fluoxetine at doses of 180 mg may be a reasonable treatment consideration for hemodialysis patients who have partial or insufficient antidepressant response. Side effects may limit tolerance of the 180 mg dose in some individuals. Future research should investigate longer term health outcomes of weekly fluoxetine in this population.

Systematic Literature Review of Psychiatric Comorbidities in Adults with Epilepsy

Background and Purpose

Mental illness is disproportionately common in people with epilepsy (PWE). This systematic literature review identified original research articles that reported the prevalence of psychiatric comorbidities based upon clinical assessments in a sample of PWE and assessed the clinical features of the populations found in studies included in our review of mental health comorbidity.

Methods

The included articles were written in English and published from 2008 to 2018, and focused on adults aged ≥18 years who had psychiatric diagnoses determined in clinical assessments, such as those found in medical records, clinician psychiatric evaluations, structured diagnostic interviews, and mental health screening questionnaires specific for a psychiatric disorder. The primary outcome was the prevalence of psychiatric comorbidities as a percentage of the total sample of PWE. Additional data included the overall sample size, mean age, epilepsy type, study design, and method of diagnosis. A modified Newcastle Ottawa Scale was used to assess the quality of the studies. All 23 articles that were consistent with the inclusion criteria were related to observational studies.

Results

Mood disorders and anxiety disorders were the most common psychiatric comorbidities, with prevalence rates of 35.0% and 25.6%, respectively. Major depressive disorder was the most common mood disorder, with a prevalence of 24.2%. Post-traumatic stress disorder (PTSD) had the highest reported prevalence among anxiety disorders, at 14.2%, followed by general anxiety disorder at 11.1%. Other comorbidities included psychosis (5.7%), obsessivecompulsive disorder (3.8%), schizophrenia (1.7%), bipolar disorder (6.2%), and substance abuse (7.9%). The pooled prevalence of suicidality, as reported for two studies, was 9.3%. Temporal lobe epilepsy (TLE) was associated with higher levels of psychiatric comorbidity. Two (8.7%) of the 23 studies compared psychiatric comorbidities in TLE with that of extratemporal lobe epilepsy (ETLE), and one of these two studies found that depression was more common in TLE (53.8%) than in ETLE (25%). Regarding seizure types, partial seizures were associated with a higher prevalence of depression vs generalized seizures.

Conclusions

This systematic literature review of recent original research found a relatively high prevalence of mental health comorbidities in PWE. Mood and anxiety disorders are the most common comorbidities, while psychotic spectrum conditions such as schizophrenia and bipolar disorder are much rarer. The prevalence of comorbidity may vary with the epilepsy type and treatment responsiveness. These findings suggest that screening tools for depression and anxiety should be included as part of the training for epilepsy care, while resources for other relatively common conditions such as PTSD and substance abuse disorders should be readily available to neurology specialists who treat PWE.

Correlates of poor medication adherence in chronic psychotic disorders

Background

Chronic psychotic disorders (CPDs) occur worldwide and cause significant burden. Poor medication adherence is pervasive, but has not been well studied in sub-Saharan Africa.

Aims

This cross-sectional survey of 100 poorly adherent Tanzanian patients with CPD characterised clinical features associated with poor adherence.

Method

Descriptive statistics characterised demographic and clinical variables, including barriers to adherence, adherence behaviours and attitudes, and psychiatric symptoms. Measures included the Tablets Routine Questionnaire, Drug Attitudes Inventory, the Brief Psychiatric Rating Scale, the Clinical Global Impressions scale, the Alcohol Use Disorders Identification Test and Alcohol, Smoking and Substance Involvement Screening Test. The relationship between adherence and other clinical variables was evaluated.

Results

Mean age was 35.7 years (s.d. 8.8), 61% were male and 80% had schizophrenia, with a mean age at onset of 22.4 (s.d. 7.6) years. Mean proportion of missed CPD medication was 64%. One in ten had alcohol dependence. Most individuals had multiple adherence barriers. Most clinical variables were not significantly associated with the Tablets Routine Questionnaire; however, in-patients with CPD were more likely to have worse adherence (P ≤ 0.01), as were individuals with worse medication attitudes (Drug Attitudes Inventory, P < 0.01), higher CPD symptom severity levels (Brief Psychiatric Rating Scale, P < 0.001) and higher-risk use of alcohol (Alcohol Use Disorders Identification Test, P < 0.001).

Conclusions

Poorly adherent patients had multiple barriers to adherence, including poor attitudes toward medication and treatment, high illness acuity and substance use comorbidity. Treatments need to address adherence barriers, and consider family supports and challenges from an intergenerational perspective.

Use of Telemedicine to Improve Interfacility Communication and Aid in Triage of Patients with Intracerebral Hemorrhage: A Pilot Study

INTRODUCTION

Over the past several years there has been a dramatic increase in the implementation of telemedicine technology to aid in the delivery of care across community, inpatient, and emergency settings. This technology has proved valuable for acute life-threatening clinical scenarios. We aimed to pilot a novel neurosurgical telemedicine program within an academic tertiary care center to assist in consultation of patients with high-grade intracranial hemorrhage (ICH) (ICH score 4, 5).

METHODS

A quality improvement conceptual framework was developed. Subsequently, a process map and improvement interventions were created. Patients in community hospitals with high-grade ICH or pre-existing Do Not Resuscitate/Do Not Intubate orders with an admitting diagnosis of ICH triggered a TeleNeurosurgery consultation. Patients who met the inclusion criteria, with consent of their decision makers, were enrolled in the study. Post-encounter physician surveys were used to evaluate overall satisfaction with the implementation.

RESULTS

This 18-month pilot study proved feasible, with an enrollment of 63.6% (n = 14 of 22) of patients who met criteria. All patients who were enrolled in the study and participated in TeleNeurosurgery consultation remained at the presenting facility for end-of-life care and palliative medicine consultation. Both community emergency physicians and subspecialists who performed the consultations reported satisfaction with the TeleNeurosurgery consultation process and a perceived benefit both to patients, families, and emergency medicine physicians.

CONCLUSIONS

The program proved feasible and several areas in need of improvement within the health system were identified. Emergency physicians reported comfort with the process, program effectiveness, and improved access to care by implementation of this program.

Delays and disparities in diagnosis for adults with epilepsy: Findings from U.S. Medicaid data

OBJECTIVE

To identify disparities in care pathways and time from first seizure to epilepsy diagnosis, we examined 2010-2014 Medicaid claims (including pharmacy) data from 16 States for individuals with incident epilepsy.

METHODS

We identified adults (18-64) with an incident epilepsy diagnosis from 1/2012 through 6/2014. These individuals were enrolled in Medicaid for the entire study period and had no history of anti-epileptic drug (AED) use before their first seizure claim. We identified care pathways and calculated the duration from initial seizure to epilepsy diagnosis. We tested associations between these pathways and race/ethnicity, as well as time differences between care pathways using a Chi-squared and Kruskal-Wallis tests.

RESULTS

The 14,337 adults followed five different care pathways. Their overall median duration from first seizure code to epilepsy diagnosis code was 19.0 months (interquartile range: 4.6, 30.4), and 56.0% filled an AED prescription. Some minorities were more likely to follow pathways with increased durations and delay to diagnosis, and the duration to diagnosis varied significantly across the care pathways.

SIGNIFICANCE

The many different care pathways seen in people with epilepsy show substantial and significant time delays between first seizure diagnosis and epilepsy diagnosis, including significant racial/ethnic disparities that warrant attention.

Increased Risk of Dementia Among Veterans With Bipolar Disorder or Schizophrenia Receiving Care in the VA Health System

OBJECTIVE

The Veterans Health Administration (VHA) provides a continuum of care over the life course. Among U.S. adults, bipolar disorder and schizophrenia are associated with increased risk of dementia. To inform service planning, this study assessed the incidence of dementia among veteran VHA patients with bipolar disorder or schizophrenia, with adjustment for comorbid medical conditions.

METHODS

Using data from the VHA Corporate Data Warehouse, the authors identified all veterans who received VHA care in 2004 and 2005 without a dementia diagnosis and who were alive and between ages 18 and 100 as of January 1, 2006. Individuals were categorized as having bipolar disorder, schizophrenia, or neither condition on the basis of diagnoses in 2004-2005. Among ongoing VHA users, incidence of dementia was assessed for up to 10 years (2006-2015).

RESULTS

The cohort included 3,648,852 individuals. After analyses controlled for baseline comorbid general medical conditions and substance use disorders, the incidence rate ratios (IRRs) for dementia were 2.92 for those with schizophrenia and 2.26 for those with bipolar disorder, compared with VHA patients with neither condition.

CONCLUSIONS

Among veterans receiving VHA care, diagnoses of bipolar disorder and schizophrenia were each associated with increased risk of receiving a new diagnosis of dementia, even when analyses controlled for baseline medical comorbidities. IRRs were elevated for patients with either condition, compared with those with neither condition, and highest for those with schizophrenia. VHA clinicians should evaluate patients for dementia when signs or symptoms of cognitive impairment are present.

The relationship between fluid biomarkers and clinical outcomes in sports-related concussions: a systematic review

OBJECTIVES

The literature on fluid biomarkers for concussion has primarily focused on comparing athletes with and without a diagnosis of concussion and on examining the relationship between fluid biomarkers and exposure to head trauma. This systematic literature review aims to examine the strength of evidence for fluid biomarkers to be associated with clinically relevant outcomes in sports-related concussion.

METHODS

A systematic literature review was conducted using EmBASE, PubMed, and CINAHL. English-language articles that included athletes participating in organized sports and reported the relationship between at least one fluid biomarker and at least one clinical outcome measure, or provided data that could be used to analyze this relationship, were included.

RESULTS

Studies of the relationship between fluid biomarkers and clinical outcomes of concussion have yielded small or variable effects. There were significant inconsistencies in methodology including duration of time post-injury of biomarker collection, use of control groups, the number of time points post-injury that biomarkers were collected, and what clinical outcomes were utilized.

CONCLUSION

There is currently insufficient evidence to support a relationship between any of the included fluid biomarkers and clinical outcome measures of concussion. Future research including clinical outcome measures and using standardized study design and methodology is necessary.

Age-Related Differences in Medication Adherence, Symptoms, and Stigma in Poorly Adherent Adults With Bipolar Disorder

OBJECTIVE

We present a secondary analysis of data reporting differences in medication adherence, psychiatric symptom severity, and internalized stigma levels in older (age ≥ 55 years) versus younger (age < 55 years) adults with bipolar disorder (BD) and poor medication adherence.

METHODS

Data used for this analysis came from 184 participants in a National Institute of Mental Health-funded randomized controlled trial, comparing a customized adherence enhancement (CAE) intervention intended to promote BD medication adherence with a BD-specific educational program (EDU). At screen, study participants were ≥20% nonadherent with BD medications as measured by the Tablets Routine Questionnaire (TRQ). Psychiatric symptoms, functional status, and internalized stigma were measured using validated scales.

RESULTS

Older adults had significantly lower anxiety disorder comorbidity (P < .01 for 1 or more anxiety disorders), depressive symptom severity scores (P = .011), and self-stigma scores (P = .001) compared to their younger counterparts. In the analyses evaluating change over time in TRQ between older and younger participants by treatment arm (ie, CAE and EDU), there was a significant finding of interaction between time, age-group, and treatment arm (P = .007).

CONCLUSIONS

Older adults may be less anxious and depressed, with less self-stigma, compared to younger people with BD and poor adherence. With respect to medication adherence, older individuals in EDU appear to do less well than younger individuals over time.

Comparative epidemiology of gliosarcoma and glioblastoma and the impact of Race on overall survival: A systematic literature review

OBJECTIVE

Gliosarcoma (GSM) is a rare subtype of glioblastoma (GBM) that accounts for approximately four percent of high-grade gliomas. There is scarce epidemiological data on patients with GSM as a distinct subgroup of GBM.

METHODS

A systematic literature review was performed of peer-reviewed databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to evaluate the impact of race and ethnicity on survival in patients with GSM compared to patients with GBM.

RESULTS

Following initial abstract screening, a total of 138 articles pertaining to GSM and 275 pertaining to GBM met criteria for full-text review, with 5 and 27 articles included in the final analysis for GSM and GBM, respectively. The majority of patients in both cohorts were non-Hispanic Whites, representing 85.6 % of total GSM patients and 87.7 % of GBM patients analyzed. Two GSM studies stratified survival by race, with one reporting the longest median survival for the Hispanic population of 10.6 months and the shortest median survival for the Asian population of 9 months. Among the GBM studies analyzed, the majority of studies reported shorter survival and higher risk of mortality among White Non-Hispanics compared to non-White patients; and of the 15 studies which reported data for the Asian population, 12 studies reported this race category to have the longest survival compared to all other races studied. Younger age, female sex, MGMT promoter methylation status, and adjuvant chemoradiation therapy were associated with improved survival in both GSM and GBM cohorts, although these were not further stratified by race.

CONCLUSION

GSM portends a similarly poor prognosis to other GBM subtypes; however, few studies exist which have examined factors associated with differences in survival between these histologic variants. This review of the literature suggests there is a possible association between race and survival for patients with GBM, however data supporting this conclusion for patients with GSM is lacking. These findings suggest that GSM is a distinct disease from other GBM subtypes, with epidemiologic differences that should be further explored.