The reversible dementias: do they reverse?

Thirty-two studies (2889 subjects) that investigated the prevalence of the causes of dementia were critically reviewed. Particular attention was paid to potential and actual reversibility. Although dementia manifests itself primarily in old age (particularly age 75 and older), the mean age of patients for the studies that reported age data (56%) was 72.3 years. Twenty-five studies originated from secondary or tertiary centers, and four were community-based. Dementias consisted of Alzheimer disease, 56.8%; multi-infarct, 13.3%; depression, 4.5%; alcoholic, 4.2%; and drugs, 1.5%. No single other cause contributed more than 1.6% of the cases. Potentially reversible causes made up 13.2% of all cases. However, the more important question of whether patients with potentially reversible causes were followed and reversal actually seen was not always examined. In 11 studies (34%) that provided follow-up, 11% of dementias resolved, either partially (8%) or fully (3%). The commonest reversible causes were drugs, 28.2%; depression, 26.2%; and metabolic, 15.5%. Due to the presence of various biases (selection, lack of "blinded" investigators, and others) in the surveyed works, it is probable that the true incidence of reversible dementias in the community is even lower than that reported. Research implications as well as a conservative approach to the workup of a new case of dementia are offered.

Comparison of telemedicine versus in-person visits for persons with multiple sclerosis: A randomized crossover study of feasibility, cost, and satisfaction

BACKGROUND

Telemedicine, the remote delivery of health care services, increases access to care for patients with mobility or geographic limitations. Virtual house calls (VHCs) are one type of telemedicine in which clinical visits are conducted remotely using an audio-visual connection with the patient at home. Use of VHCs is more established in other neurologic disorders but is only recently being formally evaluated in multiple sclerosis (MS). This randomized crossover study systematically assessed VHCs compared with in-clinic visits in persons with MS.

METHODS

Recruitment occurred in a university based MS clinic. Each subject completed one VHC and one in-clinic follow-up visit. A 1:1 randomization determined whether the VHC or in-clinic follow-up visit occurred first. Baseline surveys included demographics and MS history; post-visit surveys elicited subject responses regarding each visit type to assess feasibility, satisfaction, and cost differences. Outcomes were compared using t-tests for continuous variables and Fisher's exact test for proportions.

RESULTS

Thirty-six participants completed both study visits and both post-visit surveys. VHC feasibility was demonstrated by a lack of statistically significant difference in the number of completed VHCs as compared with in-clinic visits. VHCs provided both cost and time savings to participants. The majority of participants reported that they would recommend telemedicine visits to others (97.1%) and rated it easy to connect via telemedicine (94.3%). In qualitative comments, participants expressed appreciation for VHCs due to convenience and similarity to in-clinic visits.

CONCLUSIONS

VHCs were found to be feasible, cost-effective, and appealing to persons with MS and physicians, supporting their utility as a care delivery method for MS.

Donal Munro Lecture: Functional and neurologic recovery following acute SCI

Patient management in the current health care environment requires the provider to make reliable and valid clinical decisions regarding patient care, decisions that are cost effective and will lead to optimal functional improvement. Neurologic examination, according to the Standards for Neurological and Functional Classification of Spinal Injury developed by the American Spinal Injury Association, provides every clinician with simple clinical tools that are highly predictive of functional recovery following a spinal cord injury. The ability to predict motor recovery provides a rational basis to help support the provider's recommendation for the patient's goals and care planning, as well as differentiates care that is essential for improving functional outcomes from care that is not.

Dopamine transporter imaging and SPECT in diagnostic work-up of Parkinson's disease: A decision-analytic approach

As a diagnostic test for patients with suspected Parkinson's disease (PD), single photon emission computed tomography (SPECT) using [(123)I]FP-CIT tracer has better sensitivity but is more expensive than regular clinical examination (CE). Our objective was to evaluate the clinical and economic impacts of different diagnostic strategies involving [(123)I]FP-CIT SPECT. We developed a decision tree model to predict adequate treatment-month equivalents (ATME), costs, and incremental cost-effectiveness ratio (ICER) during a 12-month time horizon in patients with suspected PD referred to a specialized movement disorder outpatient clinic. In our cost- effectiveness analysis, we adopted the perspective of the German health care system and used data from a German prospective health care utilization study (n = 142) and published diagnostic studies. Compared strategies were CE only (EXAM+), SPECT only (SPECT+), SPECT following negative CE (SINGLE+), and SPECT following positive CE (DOUBLE+). Costs of SPECT amounted to euro;789 per investigation. Based on our model, expected costs (and ATME) were euro;946 (52.85 ATME) for EXAM+, euro;1352 (53.40 ATME) for DOUBLE+, euro;1731 (32.82 ATME) for SINGLE+, and euro;2003 (32.96 ATME) for SPECT+; performance of SPECT was induced in 0%, 54%, 56%, and 100% of the patients, respectively. DOUBLE+ was more effective and less expensive than SINGLE+ or SPECT+; thus these two do not offer reasonable choices. The ICER of DOUBLE+ compared to EXAM+ was euro;733 per ATME gained. In sensitivity analyses, the ICER of DOUBLE+ versus EXAM+ ranged from euro;63 to euro;2411 per ATME gained. Whether the diagnostic work-up of patients referred to a specialized movement disorder clinic with a high prevalence of PD should include [(123)I]FP-CIT SPECT depends on patient preferences and the decision maker's willingness to pay for adequate early treatment. SPECT should be used as a confirmatory test before treatment initiation and limited to patients with a positive test result in the clinical examination. These results should be adjusted to the specific setting and individual patient preferences.

Cost and outcome in a series of shunted premature infants with intraventricular hemorrhage

This study examines cost and outcome in a series of 50 low birthweight infants who suffered severe intraventricular-periventricular hemorrhage and subsequently required ventriculoperitoneal shunting. Although nearly one third of these children might achieve some degree of self-sufficiency, a cost-benefit analysis in this shunted population is not encouraging.

Magnetic resonance imaging: a cost-effective first line investigation in the detection of vestibular schwannomas

Magnetic resonance imaging (MRI) is currently the 'gold-standard' investigation in patients with a unilateral sensorineural hearing loss. The procedure, however, is expensive and of limited availability. Instead, such patients often undergo a series of audiovestibular tests and computed tomography in an attempt to exclude or diagnose a vestibular schwannoma. We describe seven cases of unilateral vestibular schwannoma in which conventional assessment was either equivocal or failed to demonstrate a tumour subsequently diagnosed by magnetic resonance imaging. Two patients with neurofibromatosis type 2 are also reported to show how magnetic resonance imaging confirmed the presence of a second vestibular schwannoma despite CT that showed only a unilateral lesion. We also illustrate how limited protocol MRI of patients is slightly more expensive yet much more cost effective than the usual battery of tests and propose that it should be the first line investigation for patients in whom the clinical picture requires exclusion of a retrocochlear lesion. Not all of these early diagnosed tumours have been immediately removed. In some of the more elderly or infirm patients a 'wait and rescan' policy has been adopted. Nevertheless, the early establishment of the correct diagnosis facilitates the subsequent management of these patients.

Preplacement Nerve Testing for Carpal Tunnel Syndrome: Is it Cost Effective?

Is not hiring otherwise-qualified workers who have an abnormal post-offer preplacement (POPP) median nerve test a cost-effective strategy to reduce workers' compensation expenses related to carpal tunnel syndrome (CTS)? We performed a retrospective dynamic cohort study based on 2150 workers hired at a company between January 1996 and December 2001 and who underwent POPP median nerve testing. Workers were followed until they left the company or until follow-up ended in May 2003.

RESULTS

Thirty-five cases of work-related CTS occurred during follow-up, and 9.13 cases could have been avoided. However, if the company had not hired workers with abnormal POPP nerve test results, it would have suffered a net loss of $357,353.

CONCLUSION

Not hiring workers with abnormal POPP nerve tests to reduce costs of work-related CTS is not a cost-effective strategy for employers.

Laboratory testing in peripheral nerve disease

Selecting appropriate laboratory tests in diagnosing peripheral neuropathies is important because it increases the yield of correct diagnoses and is cost effective. A large number of tests are available. This article provides a guide to selecting appropriate tests and reviews the clinical situations that suggest specific tests. Electrodiagnostic testing is valuable in almost all patients with peripheral neuropathy. Quantitative sensory testing adds additional information and is especially useful in patients with small fiber neuropathy. On occasion, routine blood tests may discover metabolic disorders causing a patient's neurologic disorder. A number of antibody assays for neuropathies are available commercially, with the most useful being anti-MAG, anti-GM1, anti-GQ1b, anti-Hu, and anticalcium channel antibodies, but only in very select situations and not as "screening studies". The role of cutaneous nerve and skin biopsies in selected disorders is discussed.

Transportation savings and medical benefits of a teleneuroradiological network

Since 1996, Turku University Central Hospital has offered teleradiology consultations regarding computerized tomography examinations of the brain to three regional hospitals in Finland, in which neurosurgical or neuroradiological specialist services are not available, in order to avoid unnecessary patient transportation. We performed a retrospective survey of the teleconsultations performed in 1998. Medical records and the relevant radiology images were obtained. During the study period, teleconsultations were carried out for a total of 83 patients, of whom 16 were transported to the university hospital (i.e. 81% of these patients had avoided unnecessary transportation). The total savings amounted to 42,100 ECU. Of the 16 transported patients, 12 were immediately operated on in the university hospital. It was judged that, because of the consultation service, the patients undergoing an operation had benefited from a more rapid and a more complete recovery. In 1998 the teleradiology consultation service was established as part of the routine work of the Medical Imaging Centre and a fee for its services was adopted.

Preoperative evaluation of the adult neurosurgical patient

The purpose of this chapter is to provide the anesthesiologist with a focused review of the information needed to rationally approach the preoperative evaluation of the neurosurgical patient. The anesthesia preoperative assessment is a neuromedical evaluation of the patient's current condition integrated with the anesthesiologist's knowledge of the potential clinical and operative events that may occur. The neurosurgical patient presents the anesthesiologist with significant clinical challenges in providing the most appropriate care and the best outcome possible. The foundation of this challenge begins with the anesthesia preoperative evaluation.

Test Utilization and Value in the Evaluation of Peripheral Neuropathies

Peripheral neuropathies can be classified as typical or atypical. Patients with atypical neuropathy have one or more of the following features: acute/subacute onset, non-length dependence, motor predominance, or asymmetry. This classification is important because it informs the appropriate diagnostic evaluation of this highly prevalent condition. The evaluation of a typical peripheral neuropathy, also known as distal symmetric polyneuropathy, requires a thorough history, neurologic examination, and focused laboratory testing. Electrodiagnostic testing and MRI account for the majority of costs but rarely lead to changes in diagnosis or management. These costs are increasingly being passed on to patients, especially those with high-deductible health plans. In contrast, patients with atypical neuropathy require more extensive testing, including electrodiagnostic tests. These tests are much more likely to lead to the use of disease-modifying therapies in these patients compared to in those with typical peripheral neuropathy. This article describes two cases to illustrate the appropriate diagnostic workup of those with typical or atypical neuropathy.

Cost analysis of therapy for patients with multiple sclerosis (MS) in Poland

Multiple sclerosis (MS) is a neurological disease of the central nervous system in which dissipated demyelination lesions develop. The currently available pharmacotherapy and rehabilitation for this disease aims to preserve the patients' physical abilities and prevent disease progression and nervous system damage. The study evaluated the direct and indirect costs associated with two different treatment regimens for multiple sclerosis diagnosed patients by comparing two groups of 60 subjects (Group A--patients receiving continuous interferon therapy (Betaferon) and steroids during relapses, and Group B--patients receiving steroid-only (Solu-Medrol, Metypred) treatment). The study was conducted over two years (2004-2005). The pharmacotherapy costs for MS patients were: PLN 4,555,360.68 (1,171,043.88euro) total for Group A and PLN 75,922.68 (19,517.40euro) per patient, and PLN 72,582.00 (18,658.61euro) total for Group B and PLN 1,209.70 (310.98euro) per patient. Total direct and indirect costs for Group A and Group B amounted to PLN 5,595,968.58 (1,438,552.33euro) and PLN 1,655,658.30 (425,619.10euro), respectively.

Neurologic assessment: you can make a difference in cost

Neurological assessment is one way of decreasing patient hospital costs. By conducting thorough, systematic neurologic assessments both on admission and continuing throughout the hospital stay, the neuroscience nurse may be able to discover complications early so that treatment is not delayed. Thus, long-term problems could be avoided which might lead to further costs to the patient.

Evaluation of the patient with epilepsy

Accurate evaluation of the patient with epilepsy is the first step toward developing an effective treatment regimen. Many problems can occur when patients who have had seizures are not assessed properly. A seizure may be caused by conditions other than epilepsy. If epilepsy is the cause, knowing the type of seizure and identifying epilepsy syndromes as early as possible is vital. An incorrect diagnosis can leave the patient with uncontrolled disease, leading to debilitating morbidity that in most cases can be treated effectively. Patients who would be good candidates for surgical intervention benefit by being identified early to prevent long periods, perhaps years, with uncontrolled disease. Understanding the type of seizure or epilepsy syndrome also determines the type of antiepileptic drugs that should be selected. Early, accurate evaluation and diagnosis are 2 of the most important aspects of treatment.

Utility of neurosurgical consultation for mild traumatic brain injury

Trauma patients presenting with a Glasgow Coma Scale (GCS) score of 14-15 are considered to have mild traumatic brain injury (TBI) with overall good neurologic outcomes. Current practice consists of initial stabilization, followed by a head CT, and neurosurgical consultation. Aside from serial neurologic examinations, patients with a GCS of 15 rarely require neurosurgical intervention. In this study, we examined the added value of neurosurgical consultation in the care of patients after TBI with a GCS of 15. We retrospectively reviewed the medical records of patients presenting after blunt trauma with an abnormal head CT and GCS of 15 between January 2004 and January 2005. Patients with a normal head CT and <48 hours hospital stay were excluded. Data included demographics, mechanisms of injury, Injury Severity Score, the radiologists' dictated interpretations of the head CT, and neurosurgical interventions. Fifty-six patients met the inclusion criteria. The mean age was 41+/-2.3 years, and the mean Injury Severity Scores was 10.2 +/-0.6. Mechanisms of injury included 64 per cent motor vehicle crash, 16 per cent motorcycle crash, 13 per cent fall, and 7 per cent all-terrain vehicle crash. The initial CT scans showed 43 per cent parenchymal contusions, 38 per cent subarachnoid hemorrhage, 14 per cent subdural hematomas, and 5 per cent epidural hematomas. All patients received a routine follow-up head CT, and 16 per cent showed changes (five improved and four were worse compared with initial CT scans). None of these patients received a neurosurgical intervention, and two were transferred to a rehabilitation service. In this era of limited resources, trauma patients who present with a GCS score of 15 after mild TBI can be safely managed without neurosurgical consultation, even in the presence of an abnormal head CT scan.