A Multisite Assessment of Inpatient Safety Event Rates During the Coronavirus Disease 2019 Pandemic

To date, there has been a notable lack of peer-reviewed or publicly available data documenting rates of hospital quality outcomes and patient safety events during the coronavirus disease 2019 pandemic era. The dearth of evidence is perhaps related to the US health care system triaging resources toward patient care and away from reporting and research and also reflects that data used in publicly reported hospital quality rankings and ratings typically lag 2-5 years. At our institution, a learning health system assessment is underway to evaluate how patient safety was affected by the pandemic. Here we share and discuss early findings, noting the limitations of self-reported safety event reporting, and suggest the need for further widespread investigations at other US hospitals. During the 2-year study period from January 1, 2020, through December 31, 2021 across 3 large US academic medical centers at our institution, we documented an overall rate of 25.8 safety events per 1000 inpatient days. The rate of events meeting "harm" criteria was 12.4 per 1000 inpatient days, the rate of nonharm events was 11.1 per 1000 inpatient days, and the fall rate was 2.3 per 1000 inpatient days. This descriptive exploratory analysis suggests that patient safety event rates at our institution did not increase over the course of the pandemic. However, increasing health care worker absences were nonlinearly and strongly associated with patient safety event rates, which raises questions regarding the mechanisms by which patient safety event rates may be affected by staff absences during pandemic peaks.

A Learning Health System Approach to Hospital Quality Performance Benchmarking: The Composite Hospital Quality Index

US hospital quality rankings and ratings use disparate methodologies and are weakly correlated. This causes confusion for patients and hospital quality staff. At the authors' institution, a Composite Hospital Quality Index (CHQI) was developed to combine hospital quality ratings. This approach is described and a calculator is shared here for other health systems to explore their performance. Among the US News and World Report Top 50 Hospitals, hospital-specific numeric summary scores were aggregated from the 2021 Centers for Medicare and Medicaid Services (CMS) Hospital Overall Star Rating, the Spring 2021 Leapfrog Safety Grade, and the April 2021 Hospital Consumer Assessment of Healthcare Providers and Systems Star Rating. The CHQI is the hospital-specific sum of the national percentile-rankings across these 3 ratings. In this example, mean (SD) percentiles were as follows: CMS Stars 74 (19), Hospital Consumer Assessment of Healthcare Providers and Systems 63 (19), Leapfrog 65 (24), with mean (SD) CHQI of 202 (49). The CHQI is used at the authors' institution to identify improvement opportunities and ensure that high-quality care is delivered across the health system.

A Stroke Alert With Unexpected Outcome

INTRODUCTION

Observational studies have suggested that intravenous (IV) thrombolysis may be unfavorable in patients with high-grade gliomas. However, current literature on thrombolysis outcomes in patients with primary brain tumors is largely limited to case reports and may be influenced by publication bias.

CASE REPORT

A 69-year-old male presented with acute left hemiplegia, left hemisensory loss, neglect, dysarthria and right gaze preference (National Institutes of Health Stroke Scale 22). An emergent noncontrast head computerized tomography showed hypoattenuation in the right parietal lobe of unclear chronicity and IV thrombolysis with tissue plasminogen activator was administered within the 4.5 hour window. Following IV thrombolysis, a computerized tomography angiogram of the head and neck revealed no large vessel occlusion. However, a marginally enhancing, and centrally nonenhancing mass within the right parietal lobe associated with vasogenic edema was elucidated. Subsequently, the patient developed abnormal left hemibody tonic-clonic motor activity, left gaze preference and left-beating nystagmus concerning for focal motor status epilepticus. An emergent electroencephalogram, following administration of IV levetiracetam, showed right hemispheric electrographic seizures and right hemispheric periodic lateralized epileptiform discharges. Brain magnetic resonance imaging with gadolinium revealed 2.5 cm ring-enhancing mass in the right parietal lobe. The patient underwent right sided craniotomy with resection of the mass and pathology revealed Glioblastoma.

CONCLUSION

We report a case of thrombolysis administered in a patient with high-grade glioma with no apparent complications.

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system

BACKGROUND

Patient Safety Indicator (PSI)-12, a hospital quality measure designed by Agency for Healthcare Research and Quality (AHRQ) to capture potentially preventable adverse events, captures perioperative venous thromboembolism (VTE). It is unclear how COVID-19 has affected PSI-12 performance.

OBJECTIVE

We sought to compare the cumulative incidence of PSI-12 in patients with and without acute COVID-19 infection.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study including PSI-12-eligible events at three Mayo Clinic medical centers (4/1/2020-10/5/2021).

EXPOSURE, MAIN OUTCOMES, AND MEASURES

We compared the unadjusted rate and adjusted risk ratio (aRR) for PSI-12 events among patients with and without COVID-19 infection using Fisher's exact χ²  test and the AHRQ risk-adjustment software, respectively. We summarized the clinical outcomes of COVID-19 patients with a PSI-12 event.

RESULTS

Our cohort included 50,400 consecutive hospitalizations. Rates of PSI-12 events were significantly higher among patients with acute COVID-19 infection (8/257 [3.11%; 95% confidence interval {CI}, 1.35%-6.04%]) compared to patients without COVID-19 (210/50,143 [0.42%; 95% CI, 0.36%-0.48%]) with a PSI-12 event during the encounter (p < .001). The risk-adjusted rate of PSI-12 was significantly higher in patients with acute COVID-19 infection (1.50% vs. 0.38%; aRR, 3.90; 95% CI, 2.12-7.17; p < .001). All COVID-19 patients with PSI-12 events had severe disease and 4 died. The most common procedure was tracheostomy (75%); the mean (SD) days from surgical procedure to VTE were 0.12 (7.32) days.

CONCLUSION

Patients with acute COVID-19 infection are at higher risk for PSI-12. The present definition of PSI-12 does not account for COVID-19. This may impact hospitals' quality performance if COVID-19 infection is not accounted for by exclusion or risk adjustment.

Quantifying the Importance of COVID-19 Vaccination to Our Future Outlook

Predictive models have played a critical role in local, national, and international response to the COVID-19 pandemic. In the United States, health care systems and governmental agencies have relied on several models, such as the Institute for Health Metrics and Evaluation, Youyang Gu (YYG), Massachusetts Institute of Technology, and Centers for Disease Control and Prevention ensemble, to predict short- and long-term trends in disease activity. The Mayo Clinic Bayesian SIR model, recently made publicly available, has informed Mayo Clinic practice leadership at all sites across the United States and has been shared with Minnesota governmental leadership to help inform critical decisions during the past year. One key to the accuracy of the Mayo Clinic model is its ability to adapt to the constantly changing dynamics of the pandemic and uncertainties of human behavior, such as changes in the rate of contact among the population over time and by geographic location and now new virus variants. The Mayo Clinic model can also be used to forecast COVID-19 trends in different hypothetical worlds in which no vaccine is available, vaccinations are no longer being accepted from this point forward, and 75% of the population is already vaccinated. Surveys indicate that half of American adults are hesitant to receive a COVID-19 vaccine, and lack of understanding of the benefits of vaccination is an important barrier to use. The focus of this paper is to illustrate the stark contrast between these 3 scenarios and to demonstrate, mathematically, the benefit of high vaccine uptake on the future course of the pandemic.

Adult EEG

This chapter reviews the key characters of epileptiform activity and provides classic examples of such activity on standard electroencephalographic (EEG) recordings. The clinician evaluating patients with suspected seizures or neurologic spells typically relies on the use of standard EEG recording as a diagnostic tool, especially early in the evaluation process. Accurate recognition of true epileptiform activity versus potential mimics, combined with the proper reporting of such activity, continues to have important implications for the diagnosis and treatment of epilepsy, neurologic spells and seizures. This chapter presents common and less commonly seen examples of epileptiform activity that are often useful in clinical practice.

Deployment of an Interdisciplinary Predictive Analytics Task Force to Inform Hospital Operational Decision-Making During the COVID-19 Pandemic

In March 2020, our institution developed an interdisciplinary predictive analytics task force to provide coronavirus disease 2019 (COVID-19) hospital census forecasting to help clinical leaders understand the potential impacts on hospital operations. As the situation unfolded into a pandemic, our task force provided predictive insights through a structured set of visualizations and key messages that have helped the practice to anticipate and react to changing operational needs and opportunities. The framework shared here for the deployment of a COVID-19 predictive analytics task force could be adapted for effective implementation at other institutions to provide evidence-based messaging for operational decision-making. For hospitals without such a structure, immediate consideration may be warranted in light of the devastating COVID-19 third-wave which has arrived for winter 2020-2021.

Refractory Left Focal Motor Status Epilepticus as Initial Clinical Presentation of Acute Basilar Artery Thrombosis

Seizures are uncommon with posterior circulation strokes. They are more often associated with anterior circulation strokes, with only a limited number of cases of status epilepticus reported to be related to brain stem ischemia. The literature includes case reports of generalized tonic-clonic seizures and associated status epilepticus as an initial presentation of acute basilar artery thrombosis. However, there are only rare cases reporting focal motor seizure as status epilepticus in the setting of acute basilar artery thrombosis, an important clinical presentation that should prompt evaluation for acute brain stem ischemia.

Nine-year prospective efficacy and safety of brain-responsive neurostimulation for focal epilepsy

OBJECTIVE

To prospectively evaluate safety and efficacy of brain-responsive neurostimulation in adults with medically intractable focal onset seizures (FOS) over 9 years.

METHODS

Adults treated with brain-responsive neurostimulation in 2-year feasibility or randomized controlled trials were enrolled in a long-term prospective open label trial (LTT) to assess safety, efficacy, and quality of life (QOL) over an additional 7 years. Safety was assessed as adverse events (AEs), efficacy as median percent change in seizure frequency and responder rate, and QOL with the Quality of Life in Epilepsy (QOLIE-89) inventory.

RESULTS

Of 256 patients treated in the initial trials, 230 participated in the LTT. At 9 years, the median percent reduction in seizure frequency was 75% (p < 0.0001, Wilcoxon signed rank), responder rate was 73%, and 35% had a ≥90% reduction in seizure frequency. We found that 18.4% (47 of 256) experienced ≥1 year of seizure freedom, with 62% (29 of 47) seizure-free at the last follow-up and an average seizure-free period of 3.2 years (range 1.04-9.6 years). Overall QOL and epilepsy-targeted and cognitive domains of QOLIE-89 remained significantly improved (p < 0.05). There were no serious AEs related to stimulation, and the sudden unexplained death in epilepsy (SUDEP) rate was significantly lower than predefined comparators (p < 0.05, 1-tailed χ2).

CONCLUSIONS

Adjunctive brain-responsive neurostimulation provides significant and sustained reductions in the frequency of FOS with improved QOL. Stimulation was well tolerated; implantation-related AEs were typical of other neurostimulation devices; and SUDEP rates were low.

CLINICALTRIALSGOV IDENTIFIER

NCT00572195.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that brain-responsive neurostimulation significantly reduces focal seizures with acceptable safety over 9 years.

Usage of EpiFinder clinical decision support in the assessment of epilepsy

BACKGROUND

The diagnosis of epilepsy is at times elusive for both neurologists and nonneurologists, resulting in delays in diagnosis and therapy. The development of screening methods has been identified as a priority in response to this diagnostic and therapeutic gap. EpiFinder is a novel clinical decision support tool designed to enhance the process of information gathering and integration of patient/proxy respondent data. It is designed specifically to take key terms from a patient's history and incorporate them into a heuristic algorithm that dynamically produces differential diagnoses of epilepsy syndromes.

OBJECTIVE

The objective of this study was to test the usability and diagnostic accuracy of the clinical decision support application EpiFinder in an adult population.

METHODS

Fifty-seven patients were prospectively identified upon admission to the Epilepsy Monitoring Unit (EMU) for episode classification from January through June of 2017. Based on semiologic input, the application generates a list of epilepsy syndromes. The EpiFinder-generated diagnosis for each subject was compared to the final diagnosis obtained via continuous video electroencephalogram (cVEEG) monitoring.

RESULTS

Fifty-three patients had habitual events recorded during their EMU stay. A diagnosis of epilepsy was confirmed (with cVEEG monitoring) in 26 patients while 27 patients were found to have a diagnosis other than epilepsy. The algorithm appropriately predicted differentiation between the presence of an epilepsy syndrome and an alternative diagnosis with 86.8% (46/53 participants) accuracy. EpiFinder correctly identified the presence of epilepsy with a sensitivity of 86.4% (95% confidence interval [CI]: 65.0-97.1) and specificity of 85.1% (95% CI: 70.2-96.4).

CONCLUSION

The initial testing of the EpiFinder algorithm suggests possible utility in differentiating between an epilepsy syndrome and an alternative diagnosis in adult patients.

Detection of generalized tonic-clonic seizures using surface electromyographic monitoring

Objective

A prospective multicenter phase III trial was undertaken to evaluate the performance and tolerability in the epilepsy monitoring unit (EMU) of an investigational wearable surface electromyographic (sEMG) monitoring system for the detection of generalized tonic–clonic seizures (GTCSs).

Methods

One hundred ninety‐nine patients with a history of GTCSs who were admitted to the EMU in 11 level IV epilepsy centers for clinically indicated video‐electroencephalographic monitoring also received sEMG monitoring with a wearable device that was worn on the arm over the biceps muscle. All recorded sEMG data were processed at a central site using a previously developed detection algorithm. Detected GTCSs were compared to events verified by a majority of three expert reviewers.

Results

For all subjects, the detection algorithm detected 35 of 46 (76%, 95% confidence interval [CI] = 0.61–0.87) of the GTCSs, with a positive predictive value (PPV) of 0.03 and a mean false alarm rate (FAR) of 2.52 per 24 h. For data recorded while the device was placed over the midline of the biceps muscle, the system detected 29 of 29 GTCSs (100%, 95% CI = 0.88–1.00), with a detection delay averaging 7.70 s, a PPV of 6.2%, and a mean FAR of 1.44 per 24 h. Mild to moderate adverse events were reported in 28% (55 of 199) of subjects and led to study withdrawal in 9% (17 of 199). These adverse events consisted mostly of skin irritation caused by the electrode patch that resolved without treatment. No serious adverse events were reported.

Significance

Detection of GTCSs using an sEMG monitoring device on the biceps is feasible. Proper positioning of this device is important for accuracy, and for some patients, minimizing the number of false positives may be challenging.

Adult EEG

Epileptiform discharges present on routine EEG recordings highly correlate with a tendency for clinical seizures. When present, they can help confirm a diagnosis of epilepsy and classify epilepsy type, localization, and syndrome. EEG’s sensitivity for detecting epileptiform activity depends on many factors, including the site of seizure origin and seizure frequency. Even in persons with known epilepsy, a routine EEG can often be normal; thus a normal interictal EEG should not be used to exclude an epilepsy diagnosis. Misinterpretation or “over-reading” of artifacts and normal background activity on the EEG as epileptiform is common by inexperienced readers. Unfortunately, this can lead to misdiagnosis and inappropriate treatment. The EEG reader should be familiar with the commonly encountered epileptiform patterns of generalized spike and wave, generalized slow spike and wave, generalized paroxysmal fast activity, focal spike and sharp waves, and temporal intermittent rhythmic delta activity.

Fall prevention and bathroom safety in the epilepsy monitoring unit

Falls are one of the most common adverse events occurring in the epilepsy monitoring unit (EMU) and can result in significant injury. Protocols and procedures to reduce falls vary significantly between institutions as it is not yet known what interventions are effective in the EMU setting. This study retrospectively examined the frequency of falls and the impact of serial changes in fall prevention strategies utilized in the EMU between 2001 and 2014 at a single institution. Overall fall rate was 2.81 per 1000 patient days and varied annually from 0 to 9.02 per 1000 patient days. Both seizures and psychogenic nonepileptic events occurring in the bathroom were more likely to result in falls compared with events occurring elsewhere in the room. With initiation of increased patient education, hourly nurse rounding, nocturnal bed alarms, having two persons assisting for high fall risk patients when out of bed, and immediate postfall team review between 2001 and 2013, there was a trend of decreasing fall frequency; however, no specific intervention could be identified as having a particular high impact. In late 2013, a ceiling lift system extending into the bathroom was put in place for use in all EMU patients when out of bed. In the subsequent 15 months, there have been zero falls. The results reinforce both the need for diligent safety standards to prevent falls in the EMU as well as the challenges in identifying the most effective practices to achieve this goal.

Quality of life in psychogenic nonepileptic seizures and epilepsy: the role of somatization and alexithymia

It is clear that many individuals with psychogenic nonepileptic seizures (PNESs) often present with poorer quality of life compared with those with epileptic seizures (ESs). However, the mechanisms linking seizure diagnosis to quality-of-life outcomes are much less clear. Alexithymia and somatization are emotional markers of psychological functioning that may explain these differences in quality of life. In the current study, patients from an epilepsy monitoring unit with vEEG-confirmed diagnosis of PNESs or ESs were compared on measures of alexithymia, somatization, quality of life, and a variety of demographic and medical variables. Two models using alexithymia and somatization individually as mediators of the relations between diagnosis and quality of life were tested. Results indicated that patients with PNESs had significantly poorer quality of life compared with those with ESs. Alexithymia was associated with poor quality of life in both groups but did not differentiate between diagnostic groups. Further, alexithymia did not mediate the relationship between diagnosis and quality of life. Somatization was associated with poor quality of life, and patients with PNESs reported greater somatization compared with patients with ESs. Somatization also significantly mediated the relationship between diagnosis and quality of life. In conclusion, somatization may be one mechanism affecting poor quality of life among patients with PNESs compared with ESs and should be a target of comprehensive treatments for PNESs. Alexithymia proved to be an important factor impacting quality of life in both groups and should also be targeted in treatment for patients with PNESs and patients with ESs.

The influence of impression management scales on the Personality Assessment Inventory in the epilepsy monitoring unit

The Somatic Complaints scale (SOM) and Conversion subscale (SOM-C) of the Personality Assessment Inventory perform best in classifying psychogenic non-epileptic seizures (PNES) from epileptic seizures (ES); however, the impact of positive impression management (PIM) and negative impression management (NIM) scales on SOM and SOM-C classification has not been examined. We studied 187 patients from an epilepsy monitoring unit with confirmed PNES or ES. On SOM, the best cut score was 72.5 T when PIM was elevated and 69.5 T when there was no bias. On SOM-C, when PIM was elevated, the best cut score was 67.5 T and 76.5 T when there was no bias. Negative impression management elevations (n=9) were too infrequent to analyze separately. Despite similarities in classification accuracy, there were differences in sensitivity and specificity with and without PIM, impacting positive and negative predictive values. The presence of PIM bias generally increases positive predictive power of SOM and SOM-C but decreases negative predictive power.

Autoimmune epilepsy: clinical characteristics and response to immunotherapy

OBJECTIVE

To describe clinical characteristics and immunotherapy responses in patients with autoimmune epilepsy.

DESIGN

Observational, retrospective case series.

SETTING

Mayo Clinic Health System.

PATIENTS

Thirty-two patients with an exclusive (n=11) or predominant (n=21) seizure presentation in whom an autoimmune etiology was suspected (on the basis of neural autoantibody [91%], inflammatory cerebrospinal fluid [31%], or magnetic resonance imaging suggesting inflammation [63%]) were studied. All had partial seizures: 81% had failed treatment with 2 or more antiepileptic drugs and had daily seizures and 38% had seizure semiologies that were multifocal or changed with time. Head magnetic resonance imaging was normal in 15 (47%) at onset. Electroencephalogram abnormalities included interictal epileptiform discharges in 20; electrographic seizures in 15; and focal slowing in 13. Neural autoantibodies included voltage-gated potassium channel complex in 56% (leucine-rich, glioma-inactivated 1 specific, 14; contactin-associated proteinlike 2 specific, 1); glutamic acid decarboxylase 65 in 22%; collapsin response- mediator protein 5 in 6%; and Ma2, N-methyl-D-aspartate receptor, and ganglionic acetylcholine receptor in 1 patient each.

INTERVENTION

Immunotherapy with intravenous methylprednisolone; intravenous immune globulin; and combinations of intravenous methylprednisolone, intravenous immune globulin, plasmapheresis, or cyclophosphamide.

MAIN OUTCOME MEASURE

Seizure frequency.

RESULTS

After a median interval of 17 months (range, 3-72 months), 22 of 27 (81%) reported improvement postimmunotherapy; 18 were seizure free. The median time from seizure onset to initiating immunotherapy was 4 months for responders and 22 months for nonresponders (P<.05). All voltage-gated potassium channel complex antibody-positive patients reported initial or lasting benefit (P<.05). One voltage-gated potassium channel complex antibody-positive patient was seizure free after thyroid cancer resection; another responded to antiepileptic drug change alone.

CONCLUSION

When clinical and serological clues suggest an autoimmune basis for medically intractable epilepsy, early-initiated immunotherapy may improve seizure outcome.

Randomized comparison of the Personality Assessment Inventory and the Minnesota Multiphasic Personality Inventory-2 in the epilepsy monitoring unit

The two most common personality measures used in evaluation of patients on epilepsy monitoring units (EMUs) are the Personality Assessment Inventory (PAI) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Both have been evaluated separately for their ability to distinguish patients with epilepsy from patients with psychogenic events, but they have never been compared directly. The primary aim of this study was to provide comparison data in an EMU population between the PAI, MMPI-2, and the MMPI-2-RF (MMPI-2 Restructured Form). Results show that the PAI Somatic Complaints (SOM) scale and the Conversion subscale (SOM-C), with classification rates of 79%, outperform other indicators from the PAI and indicators from the MMPI-2 and the MMPI-2-RF. Given its other strengths combined with better diagnostic validity performance, the PAI may be the better personality assessment measure for use in distinguishing patients with epilepsy from those with psychogenic seizures in the EMU.

Iatrogenic seizures during intracranial EEG monitoring

Cerebral edema with declining neurologic status is a known complication of intracranial electroencephalography (EEG) monitoring. The frequency and consequences of iatrogenic edema that is not clinically evident are presently poorly defined. We investigated the potential for intracranial electrodes to cause subclinical cerebral edema, and for such edema to cause iatrogenic seizures. In a retrospective review of 33 adults who had head magnetic resonance imaging (MRI) while undergoing epilepsy surgery evaluation with intracranial EEG, 28% (6 of 21) depth electrode implantations had subclinical vasogenic edema. Of these, 50% (3 of 6) had nonhabitual electrographic seizures that appear to result from iatrogenic edema. No long-term adverse sequelae were noted, however, if unrecognized, iatrogenic seizures could lead to unnecessary exclusion from definitive surgical intervention for refractory epilepsy.

Code blue: seizures

Eyewitnesses frequently perceive seizures as life threatening. If an event occurs on the hospital premises, a "code blue" can be called which consumes considerable resources. The purpose of this study was to determine the frequency and characteristics of code blue calls for seizures and seizure mimickers. A retrospective review of a code blue log from 2001 through 2008 identified 50 seizure-like events, representing 5.3% of all codes. Twenty-eight (54%) occurred in inpatients; the other 22 (44%) events involved visitors or employees on the hospital premises. Eighty-six percent of the events were epileptic seizures. Seizure mimickers, particularly psychogenic nonepileptic seizures, were more common in the nonhospitalized group. Only five (17.9%) inpatients had a known diagnosis of epilepsy, compared with 17 (77.3%) of the nonhospitalized patients. This retrospective survey provides insights into how code blues are called on hospitalized versus nonhospitalized patients for seizure-like events.

Seizures: diagnosis and management in the outpatient setting

Epilepsy and seizures are common, and can significantly affect quality of life. A careful history and guided evaluation is necessary to avoid misdiagnosis, to establish causation, and to determine prognosis. Medical therapy is effective in controlling seizures in two thirds of people with epilepsy. In choosing which antiepileptic drug to use, it is important to consider epilepsy type, side effect profile, and cost. Even when seizures are controlled, dose-related side effects from antiepileptic medication, such as fatigue and imbalance, can negatively impact health-related quality of life. Teratogenic side effects are also of concern for women of childbearing age. Monotherapy is generally preferred, and with dose titration, a successful balance between efficacy and tolerability can be reached in the majority of patients. Epilepsy that is medically refractory may respond to epilepsy surgery or vagus nerve stimulation.

Frequency of physician counseling and attitudes toward driving motor vehicles in people with epilepsy: comparing a mandatory-reporting with a voluntary-reporting state

Driving for the person with epilepsy (PWE) remains an important issue. Requirements for reporting PWE to driving authorities vary across the United States. We studied the prior experiences of PWE regarding counseling for driving in a reporting state (37% in New Jersey) and a nonreporting state (52% in Arizona). A prospective voluntary anonymous survey was conducted among patients with new-onset epilepsy at two epilepsy referral centers. Subjects were queried about prior interactions with health care professionals regarding attitudes toward and knowledge of driving regulations. Practitioners caring for PWE are in the position to provide advice and counsel regarding driving regulations. Fifty percent or fewer subjects were appropriately counseled, regardless of residence requirements. PWE felt they were honest with their physician and 10% of subjects have driven against medical advice. A performance gap exists in the appropriate counseling regarding driving for PWE that has potentially significant safety and legal implications.

Treatment of epilepsy in postmenopausal women

Menopausal women represent a rapidly growing proportion of the population. Epidemiologic evidence for the increased incidence of epilepsy in elderly patients suggests that with global aging of the population, there is likely to be a growing need for healthcare workers to manage seizures in older women. Unfortunately, there has been relatively little scientific investigation into the unique concerns of postmenopausal woman with epilepsy. There is some evidence that women may experience increased seizure activity during the menopausal transition owing to the effects of estrogen and progesterone on neuronal excitability. During perimenopause and menopause, use of hormone-replacement therapy can also worsen seizure control. Menopausal women are particularly vulnerable to osteoporosis and fragility fractures, both of which demonstrate increased risk following exposure to antiepileptic drugs. Optimization of epilepsy therapy to avoid both seizures and falls caused by antiepileptic drug-induced imbalance is crucial in order to minimize fracture risk in this group of women. Elderly patients are more susceptible to adverse medication side effects owing to drug interactions and the physiologic changes of aging that result in altered drug pharmacokinetics.

The Minnesota Multiphasic Personality Inventory-2-Restructured Form in the epilepsy monitoring unit

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) is a restructuring of the MMPI-2 that has improved the psychometric characteristics of the test. The primary aim of this study was to provide diagnostic utility data on the MMPI-2-RF in an epilepsy monitoring unit population (N=429). Mean comparisons revealed group differences on Validity Scales Fs and FBS-r; Restructured Clinical Scales RC1 and RC3; and Somatic Scales MLS, GIC, HPC, and NUC. Diagnostic utility data are provided for those scales with the largest effect sizes: RC1, FBS-r, and NUC. On RC1, sensitivity was 76% and specificity was 60%, similar to values found when applying published decision rules to the MMPI-2. RC1 explains unique variance in diagnosis beyond that explained by demographic or medical history risk factors. We provide likelihood ratios for scores on RC1, FBS-r, and NUC that can be used by the clinician to calculate posttest odds and probability of nonepileptic seizures using the base rate of nonepileptic seizures in his/her population.

Safety of long-term video-electroencephalographic monitoring for evaluation of epilepsy

OBJECTIVE

To determine the rate of medical complications from long-term video-electroencephalographic (EEG) monitoring for epilepsy.

PATIENTS AND METHODS

We reviewed the medical records of 428 consecutive adult patients with epilepsy who were admitted for diagnostic scalp video-EEG monitoring at Mayo Clinic's site in Arizona from January 1, 2005, to December 31, 2006; 149 met inclusion criteria for the study. Seizure number and type as well as timing and presence of seizure-related adverse outcomes were noted.

RESULTS

Of the 149 adult patients included in the study, seizure clusters occurred in 35 (23%); 752 seizures were recorded. The mean time to first seizure was 2 days, with a mean length of stay of 5 days. Among these patients, there was 1 episode of status epilepticus, 3 potentially serious electrocardiographic abnormalities, 2 cases of postictal psychosis, and 4 vertebral compression fractures during a generalized convulsion, representing 11% of patients with a recorded generalized tonic-clonic seizure. No deaths, transfers to the intensive care unit, falls, dental injuries, or pulmonary complications were recorded. An adverse event requiring intervention or interfering with normal activity occurred in 21% of these patients. Length of stay was not affected by occurrence of adverse events.

CONCLUSION

Prolonged video-EEG monitoring is an acceptably safe procedure. Adverse events occur but need not result in substantial morbidity or increase length of hospitalization. Appropriate precautions must be in place to prevent falls and promptly detect and treat seizure clusters, status epilepticus, serious electrocardiographic abnormalities, psychosis, and fractures.

Utility of subtraction ictal SPECT when video-EEG fails to distinguish atypical psychogenic and epileptic seizures

This study was designed to evaluate the utility of subtraction ictal SPECT coregistered to MRI (SISCOM) in atypical psychogenic nonepileptic seizures (PNES). Video-EEG monitoring (vEEG) is the gold standard for PNES diagnosis but, like any modality, has limitations. In difficult cases in which the diagnosis is suspected but remains in question after vEEG, a complementary study that could help differentiate epilepsy from PNES would be desirable. Thirteen SISCOM studies performed in patients with a final diagnosis of PNES were retrospectively reviewed. Common indications for SISCOM were semiology consistent with partial epilepsy (9/13), abnormal head MRI (5/13), and reported abnormal routine EEG (5/13). SISCOM was negative in 85% (11/13) of patients and was helpful in increasing the diagnostic certainty of PNES in these exceptional cases.

Safety of long-term video-electroencephalographic monitoring for evaluation of epilepsy

OBJECTIVE

To determine the rate of medical complications from long-term video-electroencephalographic (EEG) monitoring for epilepsy.

PATIENTS AND METHODS

We reviewed the medical records of 428 consecutive adult patients with epilepsy who were admitted for diagnostic scalp video-EEG monitoring at Mayo Clinic's site in Arizona from January 1, 2005, to December 31, 2006; 149 met inclusion criteria for the study. Seizure number and type as well as timing and presence of seizure-related adverse outcomes were noted.

RESULTS

Of the 149 adult patients included in the study, seizure clusters occurred in 35 (23%); 752 seizures were recorded. The mean time to first seizure was 2 days, with a mean length of stay of 5 days. Among these patients, there was 1 episode of status epilepticus, 3 potentially serious electrocardiographic abnormalities, 2 cases of postictal psychosis, and 4 vertebral compression fractures during a generalized convulsion, representing 11% of patients with a recorded generalized tonic-clonic seizure. No deaths, transfers to the intensive care unit, falls, dental injuries, or pulmonary complications were recorded. An adverse event requiring intervention or interfering with normal activity occurred in 21% of these patients. Length of stay was not affected by occurrence of adverse events.

CONCLUSION

Prolonged video-EEG monitoring is an acceptably safe procedure. Adverse events occur but need not result in substantial morbidity or increase length of hospitalization. Appropriate precautions must be in place to prevent falls and promptly detect and treat seizure clusters, status epilepticus, serious electrocardiographic abnormalities, psychosis, and fractures.

Seizures among public figures: lessons learned from the epilepsy of Pope Pius IX

Epilepsy is one of the most stigmatizing of neurological conditions. Understanding how epilepsy affects the lives of important historical figures illuminates the psychosocial burden of disease for modern-day patients. Pius IX, one of the most consequential Popes in Catholic history, was reported to have epilepsy. Thus, this study aimed to assess how epilepsy influenced Pope Pius IX's life and his papacy. Librarians from Mayo Clinic, Library of Congress, and Vatican Library were consulted to identify all sources pertaining to Pius IX's health history. Twenty-one sources were consulted, and we conclude that Pius IX had partial epilepsy, likely a temporal lobe focus with secondarily generalized seizures. A near-drowning event in his youth coupled with a preexisting central nervous system lesion (as evidenced by photos showing facial asymmetry) likely contributed to his epilepsy. Epilepsy played an important role in Pius IX's life because it led him to the Papacy. At least one doctrine (the immaculate conception of the Virgin Mary) was influenced by his seizures, but there is no direct evidence that epilepsy played any role in the creation of other Catholic dogma ratified during his reign. Analysis of bias in references showed that favorable views of the Pope tended to minimize any discussions of his epilepsy, whereas negative references discussed his epilepsy at length. Pius IX's life holds lessons for modern-day epilepsy advocacy.

Gender-Specific Challenges in the Management of Epilepsy in Women

The management of epilepsy in women encompasses a complex interplay between seizures, sex steroid hormones, and antiepileptic drugs (AEDs). These interactions impact every aspect of the sexual and reproductive health of women with epilepsy throughout their lifetimes. Neurologists comfortable treating seizures may feel unprepared to handle questions related to reproductive health. Several cases are provided to illustrate commonly encountered queries from women with epilepsy about catamenial epilepsy, pregnancy, breast-feeding, contraception, menopause, and bone health. Available evidence is reviewed, and guidelines for management are provided.

Frequency of seizures in patients with newly diagnosed brain tumors: A retrospective review

Brain tumors may lead to symptomatic epilepsy. A retrospective analysis was undertaken to evaluate the frequency of seizure as the presenting symptom leading to brain tumor diagnosis in adults. One hundred and forty-seven consecutive patients with newly diagnosed brain tumors were analyzed regarding the frequency of seizures as the initial presenting symptoms and those subsequently developing seizures. One hundred twelve patients had primary central nervous system tumors (CNS) and 35 had metastatic lesions. Statistical evaluation was carried out using the Chi-square test with p values of <0.05 considered to be statistically significant. Astrocytomas and meningiomas were the most common primary CNS tumors in this study. Of these, oligodendrogliomas and grade 2 astrocytomas were significantly more likely to present with seizures (p<0.001). Seizures were a frequent presenting symptom, occurring in over 38% of those with primary brain neoplasms and 20% of those with cerebral metastases. Primary location of tumor also correlated amongst primary CNS tumors and was associated with a trend in seizure risk: parietal (80%); temporal (74%); frontal (62%); and occipital (0%) (p<0.5). The findings highlight the importance of obtaining appropriate evaluation for underlying malignancy in adults with new-onset seizures as well as provide more information to the patient for prognosis and counseling.

Mechanisms underlying status epilepticus

Status epilepticus is a state of prolonged or recurrent seizure activity that is associated with significant mortality and morbidity. At a cellular level, status epilepticus results from a failure of normal inhibitory pathways, primarily mediated by gamma-n-aminobutyric acid (GABA) acting via GABA(A) receptors. This loss of inhibitory drive allows the activation of excitatory feedback loops, leading to repetitive, synchronous firing of large groups of neurons. As seizure activity continues, there is further decline in GABAergic function. Continued excitatory input mediated primarily by glutamate leads to neuronal cell death. These alterations in inhibitory and excitatory pathways have important implications for the pharmacologic management of status epilepticus. Currently recommended agents act primarily through the GABA(A) receptor and have been shown to become less effective in status epilepticus of longer duration. Agents designed to inhibit glutamate activity show promise both in the treatment of status epilepticus and in the prevention of associated neuronal injury.

Cardiac pathology in status epilepticus

Massive catecholamine release resulting in the formation of cardiac contraction bands may represent the cause of death in status epilepticus (SE). We reviewed the cardiac pathology of patients who died during SE to asses for contraction bands. Eight of 11 patients who died during SE had identifiable myocardial contraction bands compared with 5 of 22 control patients (p < 0.05, Fisher's exact t test). These findings delineate a pathological substrate and provide compelling evidence that excessive catecholamine release is the mechanism responsible for death in SE.

Requirements for measles virus induction of RANTES chemokine in human astrocytoma-derived U373 cells

Interferons and chemokines play a critical role in regulating the host response to viral infection. Measles virus, a member of the Paramyxoviridae family, induces RANTES expression by astrocytes. We have examined the mechanism of this induction in U373 cells derived from a human astrocytoma. RANTES was induced in a dose- and time-dependent manner by measles virus infection. Inhibition of receptor binding by the anti-CD46 antibody TRA-2.10 and of virus-membrane fusion by the tripeptide X-Phe-Phe-Gly reduced RANTES expression. Formalin-inactivated virus, which can bind but not fuse, and extensively UV-irradiated virus, which can bind and fuse, were both ineffective. Therefore, virus binding to the cellular receptor CD46 and subsequent membrane fusion were necessary, but not sufficient, to induce RANTES. UV irradiation of virus for less than 10 min proportionally inhibited viral transcription and RANTES expression. RANTES induction was decreased in infected cells treated with ribavirin, which inhibits measles virus transcription. However, RANTES mRNA was superinduced by measles virus in the presence of cycloheximide. These data suggest that partial transcription of the viral genome is sufficient and necessary for RANTES induction, whereas viral protein synthesis and replication are not required. This hypothesis was supported by the fact that RANTES was induced through transient expression of the measles virus nucleocapsid gene but not by measles genes encoding P or L proteins or by leader RNA in A549 cells. Thus, transcription of specific portions of measles virus RNA, such as the nucleocapsid gene, appears able to generate the specific signaling required to induce RANTES gene expression.

Mechanisms of murine RANTES chemokine gene induction by Newcastle disease virus

We have previously defined the lipopolysaccharide (LPS)-responsive element (LRE) in the promoters of murine RANTES (regulated on activation normal T-cell expressed) (MuRantes) and murine IP-10/crg-2, chemokines which have potent chemotactic properties for inflammatory cells including monocytes and T lymphocytes. In the present work, we studied the transcriptional mechanism of MuRantes gene induction by virus and compared it with that of LPS in an effort to understand the host responses to virus and bacterial toxins at the molecular level. MuRantes mRNA expression is induced by Newcastle disease virus (NDV) and LPS in the RAW 264.7 macrophage cell line and peritoneal macrophages of LPS-responsive C3HeB/FeJ mice. In LPS-hyporesponsive C3H/HeJ mice, only NDV induces this chemokine gene, indicating that the pathways of transcriptional activation by NDV and LPS are not identical. Using a transient transfection assay, the minimal virus-responsive element (VRE) was localized between nt -175 and -116. The VRE contains previously defined LRE motif 1 (TCAYRCTT) and motif 3 ((T/A)GRTTTCA(G/C)TTT), which were shown to also be important for initiation of transcription by virus. NDV-stimulated nuclear extracts were tested for trans-activating factors able to bind the VRE. The chromosomal protein HMG-I(C) was shown to bind the 3'-A.T-rich domains of the VRE, and the presence of HMG-I(C) was demonstrated in the VRE-protein complex formed with nuclear extracts from NDV-stimulated, but not unstimulated cells. These findings demonstrate the role of HMG-I(C) in activation of MuRantes promoter by NDV.