A randomized controlled educational pilot trial of interictal epileptiform discharge identification for neurology residents

OBJECTIVE

To assess the effectiveness of an educational program leveraging technology-enhanced learning and retrieval practice to teach trainees how to correctly identify interictal epileptiform discharges (IEDs).

METHODS

This was a bi-institutional prospective randomized controlled educational trial involving junior neurology residents. The intervention consisted of three video tutorials focused on the six IFCN criteria for IED identification and rating 500 candidate IEDs with instant feedback either on a web browser (intervention 1) or an iOS app (intervention 2). The control group underwent no educational intervention ("inactive control"). All residents completed a survey and a test at the onset and offset of the study. Performance metrics were calculated for each participant.

RESULTS

Twenty-one residents completed the study: control (n = 8); intervention 1 (n = 6); intervention 2 (n = 7). All but two had no prior EEG experience. Intervention 1 residents improved from baseline (mean) in multiple metrics including AUC (.74; .85; p < .05), sensitivity (.53; .75; p < .05), and level of confidence (LOC) in identifying IEDs/committing patients to therapy (1.33; 2.33; p < .05). Intervention 2 residents improved in multiple metrics including AUC (.81; .86; p < .05) and LOC in identifying IEDs (2.00; 3.14; p < .05) and spike-wave discharges (2.00; 3.14; p < .05). Controls had no significant improvements in any measure.

SIGNIFICANCE

This program led to significant subjective and objective improvements in IED identification. Rating candidate IEDs with instant feedback on a web browser (intervention 1) generated greater objective improvement in comparison to rating candidate IEDs on an iOS app (intervention 2). This program can complement trainee education concerning IED identification.

Individuals with chronic epilepsy have elevated P-wave heterogeneity comparable to patients with atrial fibrillation

OBJECTIVE

Identification of epilepsy patients with elevated risk for atrial fibrillation (AF) is critical given the heightened morbidity and premature mortality associated with this arrhythmia. Epilepsy is a worldwide health problem affecting nearly 3.4 million people in the United States alone. The potential for increased risk for AF in patients with epilepsy is not well appreciated, despite recent evidence from a national survey of 1.4 million hospitalizations indicating that AF is the most common arrhythmia in people with epilepsy.

METHODS

We analyzed inter-lead heterogeneity of P-wave morphology, a marker reflecting arrhythmogenic nonuniformities of activation/conduction in atrial tissue. The study groups consisted of 96 patients with epilepsy and 44 consecutive patients with AF in sinus rhythm before clinically indicated ablation. Individuals without cardiovascular or neurological conditions (n = 77) were also assessed. We calculated P-wave heterogeneity (PWH) by second central moment analysis of simultaneous beats from leads II, III, and aVR ("atrial dedicated leads") from standard 12-lead electrocardiography (ECG) recordings from admission day to the epilepsy monitoring unit (EMU).

RESULTS

Female patients composed 62.5%, 59.6%, and 57.1% of the epilepsy, AF, and control subjects, respectively. The AF cohort was older (66 ± 1.1 years) than the epilepsy group (44 ± 1.8 years, p < .001). The level of PWH was greater in the epilepsy group than in the control group (67 ± 2.6 vs. 57 ± 2.5 μV, p = .046) and reached levels observed in AF patients (67 ± 2.6 vs. 68 ± 4.9 μV, p = .99). In multiple linear regression analysis, PWH levels in individuals with epilepsy were mainly correlated with the PR interval and could be related to sympathetic tone. Epilepsy remained associated with PWH after adjustments for cardiac risk factors, age, and sex.

SIGNIFICANCE

Patients with chronic epilepsy have increased PWH comparable to levels observed in patients with AF, while being ~20 years younger, suggesting an acceleration in structural change and/or cardiac electrical instability. These observations are consistent with emerging evidence of an "epileptic heart" condition.

Acute symptomatic seizures and status epilepticus in older adults: A narrative review focusing on management and outcomes

A clear narrative of acute symptomatic seizures (ASyS) in older adults is lacking. Older adults (≥60 years) have the highest incidence of seizures of all age groups and necessitate a tailored approach. ASyS has a bimodal peak in infancy and old age (82.3–123.2/100,000/year after 65 years of age). ASyS can represent half of the new-onset seizures in older adults and can progress to acute symptomatic status epilepticus (ASySE) in 52–72% of the patients. Common etiologies for ASyS in older adults include acute stroke and metabolic disturbances. For ASySE, common etiologies are acute stroke and anoxic brain injury (ABI). Initial testing for ASyS should be consistent with the most common and urgent etiologies. A 20-min electroencephalogram (EEG) is less sensitive in older adults than in younger adults and might not help predict chronic epilepsy. The prolonged postictal phase is an additional challenge for acute management. Studies note that 30% of older adults with ASyS subsequently develop epilepsy. The risk of wrongly equating ASyS as the first seizure of epilepsy is higher in older adults due to the increased long-term challenges with chronic anti-seizure medication (ASM) treatment. Specific challenges to managing ASyS in older adults are related to their chronic comorbidities and polypharmacy. It is unclear if the prognosis of ASyS is dependent on the underlying etiology. Short-term mortality is 1.6 to 3.6 times higher than younger adults. ASySE has high short-term mortality, especially when it is secondary to acute stroke. An acute symptomatic etiology of ASySE had five times increased risk of short-term mortality compared to other types of etiology.

Automation of Quantifying Axonal Loss in Patients with Peripheral Neuropathies through Deep Learning Derived Muscle Fat Fraction

BACKGROUND

Axonal loss denervates muscle, leading to an increase of fat accumulation in the muscle. Therefore, fat fraction (FF) in whole limb muscle using MRI has emerged as a monitoring biomarker for axonal loss in patients with peripheral neuropathies. In this study, we are testing whether deep learning-based model can automate quantification of the FF in individual muscles. While individual muscle is smaller with irregular shape, manually segmented muscle MRI images have been accumulated in this lab; and make the deep learning feasible.

PURPOSE

To automate segmentation on muscle MRI images through deep learning for quantifying individual muscle FF in patients with peripheral neuropathies.

STUDY TYPE

Retrospective.

SUBJECTS

24 patients and 19 healthy controls.

FIELD STRENGTH/SEQUENCES

3T; Interleaved 3D GRE.

ASSESSMENT

A 3D U-Net model was implemented in segmenting muscle MRI images. This was enabled by leveraging a large set of manually segmented muscle MRI images. B1+ and B1- maps were used to correct image inhomogeneity. Accuracy of the automation was evaluated using Pixel Accuracy (PA), Dice Coefficient (DC) in binary masks; and Bland-Altman and Pearson correlation by comparing FF values between manual and automated methods.

STATISTICAL TESTS

PA and DC were reported with their median value and standard deviation. Two methods were compared using the ± 95% confidence intervals (CI) of Bland-Altman analysis and the Pearson's coefficient (r2 ).

RESULTS

DC values were from 0.83 ± 0.17 to 0.98 ± 0.02 in thigh and from 0.63 ± 0.18 to 0.96 ± 0.02 in calf muscles. For FF values, the overall ± 95% CI and r2 were [0.49, -0.56] and 0.989 in thigh and [0.84, -0.71] and 0.971 in the calf.

DATA CONCLUSION

Automated results well agreed with the manual results in quantifying FF for individual muscles. This method mitigates the formidable time consumption and intense labor in manual segmentations; and enables the use of individual muscle FF as outcome measures in upcoming longitudinal studies.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 1.

Recommending Inequality? Patterns of US Healthcare Providers' HPV Vaccine Recommendations

Purpose: Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future provider- training programs, our study sought to synthesize the findings of existing studies of disparities in provider recommendation of HPV vaccination among adolescents. Methods: We conducted a systematic review of studies that quantitatively assessed the prevalence of provider recommendation of HPV vaccination among US parents of adolescents aged 9–17. We excluded studies that were not empirical, not peer-reviewed, or collected data before 2012. Following PRISMA guidelines, two independent coders extracted and screened 3,158 unique titles and abstracts from multiple databases. Next, two independent coders reviewed the full text of eligible studies, systematically collecting data using a standardized abstraction form. We resolved coding disagreements via discussion with the whole team. Results: Fifty-four of 252 reviewed studies met eligibility criteria, including 33 studies of parents and 21 studies of providers. Parental report of receiving a provider recommendation for HPV vaccination ranged from 22% to 78%. These studies most often assessed disparities by adolescents' sex, with almost all finding that provider recommendations were less common for boys vs. girls. Most studies of provider reports confirmed disparate recommendations by sex. Fewer studies stratified recommendation disparities by income or race/ethnicity; these studies found that recommendations were less common among lower-income households, but reported mixed findings by race/ethnicity. Geographic assessments found variation across states and urbanicity, with recommendations being lower including in some Southern states and in rural areas. Conclusion: Findings suggest differences in provider recommendation by sex, household income, geography, and possibly race/ethnicity, in spite of national guidelines for routine HPV vaccination. National efforts to improve provider communication about HPV vaccination should focus on improving recommendation consistency, especially for populations such as lower-income and rural adolescents who are at higher risk for future HPV cancers.

Racial and ethnic trends in antiseizure medications trial enrolment: A systematic review using ClinicalTrials.gov

OBJECTIVE

To describe the racial and gender distribution in antiseizure medications (ASM) clinical trials using a systemic review of clinical trial registry database.

METHODS

We searched ClinicalTrials.gov database for ASM trials registered from September 1988 to January 2019. All randomized and non-randomized trials investigating ASM for epilepsy were included. Trials with intervention other than ASM or condition other than epilepsy were excluded. Data on age, race, ethnicity, and gender were extracted directly from database and from published data where available. Study location, trial identifier, year of completion, and funding sources were also collected. Meta-analysis of proportions was conducted using R software.

RESULT

Two hundred and thirty studies conducted globally with 39,576 participants were included. Overall, there are 53 % male on all registered ASM studies globally. For trials conducted in the United States (61 studies/5126 participants), 52 % of the participants were male with the following weighted racial distribution (80 % White 13 % Black 3% Asian 7% Hispanic). Subgroup analysis revealed that non-pharma-sponsored studies (50 studies, 4296 participants) have a higher representation of minorities as compared to pharma-sponsored studies (180 studies, 35,280 participants), including Hispanic (9% vs 3% respectively) and Black (18 % vs 11 % respectively). Temporal trends in racial distribution were noted when the duration of 2007-2019 was split into two groups: 2007-2013 (0% Asian, 5% Hispanic, 20 % Black); 2014-2019 (4% Asian, 7% Hispanic, 8% Black).

CONCLUSION

In this systematic review, participation of racial and ethnic minorities of Asian and Hispanic background was under-represented. Disparities of all minorities including Black participants was more notable over time and in studies sponsored by industry. Generalizability of ASM clinical trials to certain subgroups should be further examined.

The association between serum prolactin levels and interleukin-6 and systemic lupus erythematosus activity

Based on the recent evidence of association between hyperprolactinemia and systemic lupus erythematosus disease activity (SLEDAI), a study was conducted to analyze the association of hyperprolactinemia with lupus nephritis disease activity. In this cross-sectional study, the analysis was conducted on SLE patients who visited the University Kebangsaan Malaysia Medical Centre (UKMMC) Nephrology Clinic from August 2015 till February 2016. The disease activity was measured using the SLEDAI score, with more than 4 indicating active lupus nephritis. Basal resting prolactin level was analyzed in 43 patients with lupus nephritis, in 27.9% of them had raised serum prolactin. The median of serum prolactin level at 0 minutes was 19.91 ng/mL (IQR: 15.95-22.65 ng/ mL) for active lupus nephritis, which was significantly higher compared to the median of serum prolactin level of 14.34 ng/mL (IQR: 11.09-18.70 ng/mL) for patients in remission (p=0.014). The serum prolactin level positively correlated with SLEDAI (rhos: 0.449, p=0.003) and the UPCI level in lupus nephritis patients (rhos: 0.241, p=0.032). The results were reproduced when the serum prolactin was repeated after 30 minutes. However, the serum prolactin levels at 0 minutes were higher than those taken after 30 minutes (p=0.001). An assessment of serum IL-6 levels found that the active lupus nephritis patients had a higher median level of 65.91 pg/ mL (IQR: 21.96-146.14 pg/mL) compared to the in-remission level of 15.84 pg/mL (IQR: 8.38-92.84 pg/mL), (p=0.039). Further correlation analysis revealed that there was no statistical correlation between the interleukin (IL)-6 levels with serum prolactin, SLEDAI and other lupus nephritis parameters. An ROC curve analysis of serum prolactin at 0 minutes and serum prolactin after 30 minutes and IL-6 levels for prediction of SLE disease activity provided the cutoff value of serum prolactin at 0 minutes, which was 14.63 ng/mL with a sensitivity of 91.7% and specificity of 58.1% and AUC of 0.74 (p=0.015). This study concurred with the previous findings that stated that hyperprolactinemia is prevalent in SLE patients and correlated with clinical disease activity and UPCI level. The baseline of the fasting serum prolactin level was found to be a sensitive biomarker for the evaluation of lupus nephritis disease activity.

Intravenous Thrombolysis for Acute Ischemic Stroke due to Cervical Internal Carotid Artery Occlusion

BACKGROUND

Internal carotid artery (ICA) occlusions are poorly responsive to intravenous thrombolysis with tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). Most study populations have combined intracranial and extracranial ICA occlusions for analysis; few have studied purely cervical ICA occlusions. We evaluated AIS patients with acute cervical ICA occlusion treated with IV-tPA to identify predictors of outcomes.

METHODS

We studied 550 consecutive patients with AIS who received IV-tPA and identified 100 with pure acute cervical ICA occlusion. We evaluated the associations of vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and leptomeningeal collateral vessel status via 3 different grading systems, with functional recovery at 90 days, mortality, recanalization of the primary occlusion, and symptomatic intracranial hemorrhage (SICH). Modified Rankin Scale score 0-1 was defined as an excellent outcome.

RESULTS

The 100 patients had mean age of 67.8 (range 32-96) and median NIHSS score of 19 (range 4-33). Excellent outcomes were observed in 27% of the patients, SICH in 8%, and mortality in 21%. Up to 54% of the patients achieved recanalization at 24 hours. On ordinal regression, good collaterals showed a significant shift in favorable outcomes by Maas, Tan, or ASPECTS collateral grading systems. On multivariate analysis, good collaterals also showed reduced mortality (OR .721, 95% CI .588-.888, P = .002) and a trend to less SICH (OR .81, 95% CI .65-1.007, P = .058). Interestingly, faster treatment was also associated with favorable functional recovery (OR 1.028 per minute, 95% CI 1.010-1.047, P = .001).

CONCLUSIONS

Improved outcomes are seen in patients with early acute cervical ICA occlusion and better collateral circulation. This could be a valuable biomarker for decision making.

Incidence of needlestick injuries among medical students after implementation of preventive training

INTRODUCTION

Structured training for the prevention of needlestick injuries (NSIs) among medical students was implemented in Singapore in 1998. In this study, we determined the incidence of NSIs and the knowledge and practice of managing and reporting NSIs among first-year clinical students in a medical school in Singapore, as well as the adequacy of the training provided for these students, 14 years after preventive training was instituted.

METHODS

All third-year medical students (n = 257) from the Yong Loo Lin School of Medicine, National University of Singapore, Singapore, who had completed their first clinical year posting were enrolled in this cross-sectional study. A self-administered questionnaire was answered by the students one month after completion of their last clinical posting. Students who repeated their first clinical year were excluded from the study.

RESULTS

237 students completed the questionnaire. However, 9 of these students were excluded because they repeated their first clinical year. The response rate was 91.9%. Although 8 (3.5%) students reported one NSI each, only 2 (25.0%) of these 8 students reported the incident to the relevant authority. Among the students surveyed, 65.8% reported using gloves at all times during venepuncture procedures, 48.7% felt that improvements could be made to the current reporting system and procedures, and 53.2% felt that the training provided before commencement of clinical posting could be enhanced.

CONCLUSION

There was a decrease in the incidence of NSIs among medical undergraduates in their first clinical year when compared to the incidences reported in earlier studies conducted in the same centre (35.1% in 1993 and 5.3% in 2004). The current reporting system could use a more user-friendly platform, and training on NSIs could be improved to focus more on real-life procedures and incident reporting.

Fabrication and electrochemical properties of hemisphere structured 3D Li(Li0.2Mn0.54Co0.13Ni0.13)O2 cathode thin film for all-solid-state lithium battery

The Li[Li0.2Mn0.54Ni0.13Co0.13]O2 cathode thin films were deposited on planar, hemisphere, linked hemisphere, and isolated hemisphere structured Pt current collector thin films to investigate the effect of 3-dimensional (3-D) structure for the electrochemical properties of active cathode thin films. The films of linked hemisphere structure shows the highest initial discharge capacity of 140 microA h/cm2-microm which is better than those of planar (62 microA h/cm2-microm), hemisphere (94.6 microA h/cm2-microm), and isolated hemisphere (135 microA h/cm2-microm) films due to increase of surface area for cathode thin films. Linked hemisphere shows the biggest capacity and the best retention rate because 6 nanobridges of each hemisphere bring strong connection.

Polymorphisms of the serotonin transporter gene and post-stroke depression: a meta-analysis

BACKGROUND

Polymorphisms of the gene encoding the serotonin transporter-specifically, length variation in the serotonin--transporter-linked polymorphic region (5-HTTLPR), a single-nucleotide polymorphism in the 5-HTTLPR (rs25531), and variable number of tandem repeats (VNTR) in the second intron 2 (STin2)--have been implicated in the development of post-stroke depression (PSD).

OBJECTIVE

To evaluate the association between polymorphisms of the serotonin transporter gene and PSD in the medical literature.

METHODS

Random-effects meta-analyses were conducted on cross-sectional, case-control and cohort studies examining relations between polymorphisms of the gene encoding the serotonin transporter and the risk of developing PSD.

RESULTS

Four studies comprising 260 stroke patients with PSD and 381 without were included. Our analyses showed a significant and positive association between the homozygous short variation (S) allele genotype of the 5-HTTLPR (SS) and PSD (random-effects pooled OR 2.05, 95% CI 1.41 to 2.98, z=3.79, p<0.001). Our analyses also showed a significant and negative association between the homozygous long variation (L) allele genotype of the 5-HTTLPR (LL) and PSD (random-effects OR 0.52, 95% CI 0.27 to 0.97, z=-2.07, p=0.039). No statistically significant association of PSD with heterozygous S and L allele genotype for 5-HTTLPR or other polymorphisms with rs25531 and STin2 VNTR was found. Heterogeneity and publication bias were not statistically significant. The major limitation of this meta-analysis is that we could not assess the interaction between stroke, environmental stress and PSD.

CONCLUSIONS

The 5-HTTLPR SS genotype may be a risk factor for PSD. The 5-HTTLPR LL genotype showed a significant negative association with PSD. Further research to assess the sensitivity and specificity of predicting the risk of developing PSD by screening for the 5-HTTLPR genotype in stroke patients is required.

[The changes of right ventricular function in the course of COPD induced cor pulmonale]

A study on pulmonary hemodynamics, radionuclide right ventricular ejection fraction and blood gas analysis in 62 cases of COPD induced cor pulmonale at different stages showed the following results: 1. In early stage of cor pulmonale, stroke volume could not increase after exercise, it proved that cardiac reserve has been reduced; 2. With the progression of the disease, cardiac stroke volume reduced but cardiac output increased gradually, it could be considered as the evolutionary characteristic of cardiac function in chronic cor pulmonale; 3. The right ventricular stroke work was normal and could increase with the rise of after-load, reflecting the relatively effective functional compensation; 4. In acute exacerbation of cor pulmonale, the cardiac failure should be attributed to hyperdynamic type with hypervolemia; 5. Correlation analyses suggested that cardiac output decreased along with the increase of right ventricular afterload only in acute exacerbation of late cor pulmonale; PaO2 and PaCO2 have only slight influence on right ventricular function.

Appearance of exogenous epidermal growth factor in liver, bile, and intestinal lumen of suckling rats

This study was performed to investigate the distribution and the degradation of IV administered [125I]rat epidermal growth factor (rEGF) in the liver and gastrointestinal tract of suckling rats. The bile duct of anesthetized rats was cannulated, and [125I]rEGF was injected (with or without 2500-fold excess unlabeled rEGF) into the femoral vein. After 5, 30, 60, and 120 minutes, the radioactivity in the liver, stomach, small intestine, blood, kidney, bile, and luminal contents of the stomach and small intestine was measured. The extracted radioactivity was then analyzed by immunoaffinity chromatography and binding to EGF-specific receptors. High levels of radioactivity were found in the liver (57% of total administered) and small intestine (10%) at 5 minutes, which gradually decreased. On the contrary, radioactivity secreted in the bile and luminal contents of the small intestine increased with time. The radioactivity in the bile represented 2.4% and 4.5% of the total administered at 60 and 120 minutes, respectively. During the first 60 minutes, more than 90% of the radioactivity in the liver, small intestine, bile, and intestinal contents was immunoreactive. Thirty-four to seventy percent of the radio-activity in the bile and liver and 20%-41% of radioactivity in the small intestinal wall and contents were capable of binding to EGF-specific receptors. Radioactivity detected in the liver, bile, small intestine, and intestinal contents was profoundly reduced by the coinjection excess of unlabeled EGF. These studies show that IV administered [125I]rEGF is rapidly taken up by the liver and the gastrointestinal tract and secreted into the bile and intestinal luminal contents of suckling rats in form(s) capable of binding to anti-EGF antibody and EGF-specific receptors. The uptake and secretion by the liver and the small intestine appear to be receptor mediated.

Trenbolone alters the responsiveness of skeletal muscle satellite cells to fibroblast growth factor and insulin-like growth factor I

The potential role of satellite cells in mediating the effect of trenbolone [17 beta-hydroxyestra-4,9-11-trien-3-one (TBOH)] on skeletal muscle hypertrophy was examined. Young female Sprague-Dawley rats received TBOH injections daily for 2 weeks; growth, body composition, and the composition of selected muscles were assessed. Treated rats grew more rapidly and deposited less body lipid and more protein. The semimembranosus muscle from treated rats was larger and had approximately 60% more DNA per muscle than muscles from control rats. The addition of trenbolone directly to the medium of cultured satellite cells did not stimulate cell proliferation, nor did it augment the stimulatory response of these cells to fibroblast growth factor (FGF) or insulin-like growth factor I (IGF-I). In contrast, satellite cells cultured from TBOH-treated rats exhibited greater proliferative responses to FGF and IGF-I than satellite cells from control rats. In addition, serum from TBOH-treated rats stimulated greater cell proliferation in satellite cell cultures than serum from control rats. These experiments suggest that one possible mechanism responsible for the ability of TBOH to stimulate skeletal muscle hypertrophy may be through enhanced proliferation and differentiation of satellite cells as a result of the increased sensitivity of these cells to IGF-I and FGF.