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Welte TM, Ernst S, Stritzelberger J, Gollwitzer S, Lang JD, Reindl C, Sprügel MI, Olmes D, Schwab S, Blinzler C, Hamer HM. Trends in the neurological emergency room, focusing on persons with seizures. Eur J Neurol 2023; 30:3008-3015. [PMID: 37422921 DOI: 10.1111/ene.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/15/2023] [Accepted: 07/04/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND AND PURPOSE Previous studies in neurological emergency rooms (nERs) have reported many non-acute, self-presenting patients, patients with delayed presentation of stroke, and frequent visits of persons with seizures (PWS). The aim of this study was to evaluate trends during the last decade, with special focus on PWS. METHODS We retrospectively analyzed patients who presented to our specialized nER during the course of 5 months in 2017 and 2019, and included information on admission/referral, hospitalization, discharge diagnosis, and diagnostic tests/treatment in the nER. RESULTS A total of 2791 patients (46.6% male, mean age 57 ± 21 years) were included. The most common diagnoses were cerebrovascular events (26.3%), headache (14.1%), and seizures (10.5%). Most patients presented with symptoms lasting >48 h (41.3%). The PWS group included the largest proportion of patients presenting within 4.5 h of symptom onset (171/293, 58.4%), whereas only 37.1% of stroke patients presented within this time frame (273/735). Self-presentation was the most common admission pathway (31.1%), followed by emergency service referral (30.4%, including the majority of PWS: 197/293, 67.2%). Despite known diagnosis of epilepsy in 49.2%, PWS more often underwent accessory diagnostic testing including cerebral imaging, compared to the overall cohort (accessory diagnostics 93.9% vs. 85.4%; cerebral imaging 70.1% vs. 64.1%). Electroencephalography in the nER was only performed in 20/111 patients (18.0%) with a first seizure. Nearly half of the patients (46.7%) were discharged home after nER work-up, including most self-presenters (632/869, 72.7%) and headache patients (377/393, 88.3%), as well as 37.2% (109/293) of PWS. CONCLUSION After 10 years, nER overuse remains a problem. Stroke patients still do not present early enough, whereas PWS, even those with known epilepsy, often seek acute and extensive assessment, indicating gaps in pre-hospital management and possible over-assessment.
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Affiliation(s)
- Tamara M Welte
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Sebastian Ernst
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Jenny Stritzelberger
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Stephanie Gollwitzer
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Johannes D Lang
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Caroline Reindl
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Maximilian I Sprügel
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - David Olmes
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Stefan Schwab
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Christian Blinzler
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
| | - Hajo M Hamer
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg, Full member of ERN EpiCARE, Erlangen, Germany
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Mass-Ramírez S, Vergara-Burgos H, Sierra-Ochoa C, Lozada-Martinez ID, Moscote-Salazar LR, Janjua T, Rahman MM, Rahman S, Picón-Jaimes YA. Utility of medical simulation in neurovascular critical care education. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Grant R, Dowswell T, Tomlinson E, Brennan PM, Walter FM, Ben-Shlomo Y, Hunt DW, Bulbeck H, Kernohan A, Robinson T, Lawrie TA. Interventions to reduce the time to diagnosis of brain tumours. Cochrane Database Syst Rev 2020; 9:CD013564. [PMID: 32901926 PMCID: PMC8082957 DOI: 10.1002/14651858.cd013564.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available. OBJECTIVES To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions. SEARCH METHODS For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014. SELECTION CRITERIA We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author. MAIN RESULTS We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic. AUTHORS' CONCLUSIONS In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.
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Affiliation(s)
- Robin Grant
- Edinburgh Centre for Neuro-Oncology (ECNO), Western General Hospital, Edinburgh, UK
| | - Therese Dowswell
- C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Eve Tomlinson
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancers, 1st Floor Education Centre, Royal United Hospital, Bath, UK
| | - Paul M Brennan
- Translational Neurosurgery Department, Western General Hospital, Edinburgh, UK
| | - Fiona M Walter
- Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - David William Hunt
- Foundation School/Dept of Clinical and Experimental Medicine, Royal Surrey County Hospital/University of Surrey, Guildford, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Umesh A, Gowda GS, Kumar CN, Srinivas D, Dawn BR, Botta R, Yadav R, Math SB. Unknown Patients and Neurology Casualty Services in an Indian Metropolitan City: A Decades Experience. Ann Indian Acad Neurol 2017; 20:109-115. [PMID: 28615894 PMCID: PMC5470161 DOI: 10.4103/0972-2327.205764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES A large number of unknown patients without any personal, family, or other identification details represent a unique problem in the neurological emergency services of developing countries like India in a context of legal, humanitarian, and treatment issues. These patients pose a diagnostic and management challenge to treating physicians and staff. There are sparse data on these patients. The objective of this study was to know the clinical, socio-demographic, and investigational profile of "unknown" patients. MATERIALS AND METHODS We did retrospective chart review of all "Unknown" patients from January 2002 to December 2011, who was admitted under Neurology Emergency Service at a Tertiary Care Neuropsychiatry Center in South Indian Metropolitan City. Clinical and sociodemographic characteristics and clinical outcome of the sample were analyzed. RESULTS A total of 151 unknown patients were admitted during the 10 years. Out of these, 134 (88.7%) were males with the mean age of 43.8 ± 14.8 years and 95 (63%) were aged >40 years. Among them, 147 (97.4%) were from the urban vicinity, 126 (83.6%) were brought by police and 75 (49.7%) were registered as medico-legal cases. Out of these, only 3 (2%) patients had normal sensorium, whereas 101 (66.9%) presented with loss of consciousness. Forty-one (27.2%) unknown patients had a seizure disorder, 37 (24.5%) had metabolic encephalopathy, 26 (17.2%) had a stroke, 9 (6%) had neuro-infection, and 17 (11.3%) had a head injury. Deranged liver functions were seen in 65 (43%), renal derangement in 37 (24.5%), dyselectrolytemia in 42 (27.8%), and abnormal brain imaging finding in 95 (62.9%) patients. Furthermore, there were 14 (9.3%) deaths. CONCLUSIONS Our findings demonstrate seizures, metabolic causes, and neuro-infections were the primary reasons for admission of unknown patients to neuro-emergency service. This novel Indian study data show the common causes of admission of unknown patients in neurology. This pattern can be useful to guide the approach of healthcare providers in India.
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Affiliation(s)
- Achary Umesh
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | | | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Bharath Rose Dawn
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Ragasudha Botta
- Department of Clinical Neuroscience, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
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Coban E, Mutluay B, Sen A, Keskek A, Atakl D, Soysal A. Characteristics, diagnosis and outcome of patients referred to a specialized neurology emergency clinic: prospective observational study. Ann Saudi Med 2016; 36:51-6. [PMID: 26922688 PMCID: PMC6074276 DOI: 10.5144/0256-4947.2016.51] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Organization and management of neurological emergencies differs among hospitals. Some have specialized neurological emergency rooms (ER). OBJECTIVES The purpose of this study was to determine the characteristics, diagnosis and outcome of patients referred to a specialized emergency neurology clinic. DESIGN Prospective, observational study of consecutive patients presenting between March 2014 and July 2014. SETTING Neurologicaler of a training and research neuropsychiatric hospital. PATIENTS AND METHODS Patients older than 16 years of age with a neurological complaint were assessed by neurological exam, laboratory and imaging tests including brain computed tomography (CT), brain magnetic resonance imaging (MRI), cerebrospinal fluid analysis, electroencephalography or electromyography. MAIN OUTCOME MEASURES Types of diagnosis. RESULTS Of 4500 patients, 2602 (57.8%) were female, and the mean age was 49.2 (23.6) years. The most common symptom was headache, which presented in 30.8% of all patients. The three most common diagnoses after emergency work-up were headache (27.8%), stroke (20.6%) and peripheral vertigo (13%). In the ER, CT was performed on 65.5% of patients and MRI on 66.9%. After emergency work-up, 72.2% patients were discharged home. CONCLUSIONS Neurological diseases are common, with headache and cerebrovascular diseases being the most frequent diagnosis in this specialized ER. CT and MRI are most often used to diagnose or exclude neurological diseases. Many patients do not require immediate hospitalization. The two most frequent diagnoses for hospitalization were stroke and demyelinating disease. LIMITATIONS Absence of follow up data on patients discharged home.
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Affiliation(s)
- Eda Coban
- Mrs. Eda Coban, Bakirkoy Education and Training Hospital of Neurology,, Neurosurgery and Psychiatry,, Istanbul, Turkey, M: 0505 483 43 77,
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Valença MM, da Silva AA, Bordini CA. Headache Research and Medical Practice in Brazil: An Historical Overview. Headache 2015; 55 Suppl 1:4-31. [DOI: 10.1111/head.12512] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2014] [Indexed: 12/28/2022]
Affiliation(s)
- Marcelo Moraes Valença
- Neurology and Neurosurgery Unit; Department of Neuropsychiatry; Federal University of Pernambuco; Recife Brazil
- Neurology and Neurosurgery Unit, Hospital Esperança; Brazil
| | - Amanda Araújo da Silva
- Neurology and Neurosurgery Unit; Department of Neuropsychiatry; Federal University of Pernambuco; Recife Brazil
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