Teratogenesis, Perinatal, and Neurodevelopmental Outcomes After In Utero Exposure to Antiseizure Medication: Practice Guideline From the AAN, AES, and SMFM.

This practice guideline provides updated evidence-based conclusions and recommendations regarding the effects of antiseizure medications (ASMs) and folic acid supplementation on the prevalence of major congenital malformations (MCMs), adverse perinatal outcomes, and neurodevelopmental outcomes in children born to people with epilepsy of childbearing potential (PWECP). A multidisciplinary panel conducted a systematic review and developed practice recommendations following the process outlined in the 2017 edition of the American Academy of Neurology Clinical Practice Guideline Process Manual. The systematic review includes studies through August 2022. Recommendations are supported by structured rationales that integrate evidence from the systematic review, related evidence, principles of care, and inferences from evidence. The following are some of the major recommendations. When treating PWECP, clinicians should recommend ASMs and doses that optimize both seizure control and fetal outcomes should pregnancy occur, at the earliest possible opportunity preconceptionally. Clinicians must minimize the occurrence of convulsive seizures in PWECP during pregnancy to minimize potential risks to the birth parent and to the fetus. Once a PWECP is already pregnant, clinicians should exercise caution in attempting to remove or replace an ASM that is effective in controlling generalized tonic-clonic or focal-to-bilateral tonic-clonic seizures. Clinicians must consider using lamotrigine, levetiracetam, or oxcarbazepine in PWECP when appropriate based on the patient's epilepsy syndrome, likelihood of achieving seizure control, and comorbidities, to minimize the risk of MCMs. Clinicians must avoid the use of valproic acid in PWECP to minimize the risk of MCMs or neural tube defects (NTDs), if clinically feasible. Clinicians should avoid the use of valproic acid or topiramate in PWECP to minimize the risk of offspring being born small for gestational age, if clinically feasible. To reduce the risk of poor neurodevelopmental outcomes, including autism spectrum disorder and lower IQ, in children born to PWECP, clinicians must avoid the use of valproic acid in PWECP, if clinically feasible. Clinicians should prescribe at least 0.4 mg of folic acid supplementation daily preconceptionally and during pregnancy to any PWECP treated with an ASM to decrease the risk of NTDs and possibly improve neurodevelopmental outcomes in the offspring.

Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease Practice Guideline Summary: A Report of the AAN Guideline Subcommittee.

BACKGROUND AND OBJECTIVES: To review the current evidence on the options available for initiating dopaminergic treatment of motor symptoms in early-stage Parkinson disease and provide recommendations to clinicians. METHODS: A multidisciplinary panel developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. RESULTS: Initial treatment with levodopa provides superior motor benefit compared to treatment with dopamine agonists, whereas levodopa is more likely than dopamine agonists to cause dyskinesia. The comparison of different formulations of dopamine agonists yielded little evidence that any one formulation or method of administration is superior. Long-acting forms of levodopa and levodopa with entacapone do not appear to differ in efficacy from immediate-release levodopa for motor symptoms in early disease. There is a higher risk of impulse control disorders associated with the use of dopamine agonists than levodopa. Recommendations on initial therapy for motor symptoms are provided to assist the clinician and patient in choosing between treatment options and to guide counseling, prescribing, and monitoring of efficacy and safety.

The Honest Palm Sign: Detecting Incomplete Effort on Physical Examination.

BACKGROUND: We investigated a simple, novel diagnostic test for detecting incomplete effort during the motor portion of the neurological examination. METHODS: The results from the honest palm sign (HPS) were evaluated for 162 consecutive neuro-oncology patients who had undergone upper extremity strength testing. Deltoid, bicep, and wrist extensor strength was assessed in all patients. During the examination, patients were repeatedly encouraged to "try as hard as possible" and to "resist with all your strength." The absence of nail prints on the palms constituted a positive HPS test result (i.e., indicative of incomplete effort). The presence of nail prints constituted a negative HPS test result (i.e., indicative of full effort). RESULTS: A total of 162 patients were tested. Their mean age was 55.5 ± 14.9 years, the median Karnofsky performance scale score was 80 (range, 60-100), and 63 patients (39%) were men. Of the 162 patients, 102 (63%) had malignant gliomas, 28 (17%) had brain metastases, 21 (13%) had other primary brain tumors, and 11 (6.8%) had primary central nervous system lymphomas. Of the 162 patients, 48 (30%) had positive HPS test results. The test sensitivity (84.6%), specificity (75.2%), positive likelihood ratio (3.41), and negative likelihood ratio (0.205) were good. After excluding 33 patients with characteristics that rendered them unsuitable for testing, the results from the remaining 129 patients were analyzed. The sensitivity was unchanged (84.6%), but the specificity (96.6%), positive likelihood ratio (24.5), and negative likelihood ratio (0.16) improved dramatically. CONCLUSIONS: The HPS test is a simple, sensitive, and very specific test for detecting incomplete effort during the motor portion of neurological evaluations.

Blindness and the age of enlightenment: Diderot's letter on the blind.

Several months after anonymously publishing an essay in 1749 with the title "Letter on the Blind for the Use of Those Who Can See," the chief editor of the French Encyclopédie was arrested and taken to the prison fortress of Vincennes just east of Paris, France. The correctly assumed author, Denis Diderot, was 35 years old and had not yet left his imprint on the Age of Enlightenment. His letter, which recounted the life of Nicolas Saunderson, a blind mathematician, was intended to advance secular empiricism and disparage the religiously tinged rationalism put forward by Rene Descartes. The letter's discussion of sensory perception in men born blind dismissed the supposed primacy of visual imagery in abstract thinking. The essay did little to resolve any philosophical controversy, but it marked a turning point in Western attitudes toward visual disability.

A program to improve secondary stroke prevention: the Colorado Neurological Institute stroke preventing recurrence of thromboembolic events through coordinated treatment program.

The key to secondary stroke prevention often lies in improved control of traditional stroke risk factors. Studies have shown that there is an evidence-practice gap, for both physicians and patients, when it comes to adhering to national stroke prevention guidelines. We developed a program to reinforce stroke prevention messages for 1 year after a patient's ischemic stroke or transient ischemic attack. Our results show encouraging improvement in our patients' adherence to treatment guidelines for 1 year after the event, as well as a reduction in recurrent strokes as compared with the number expected.

The curious blindness of Charles F. Lummis.

Generations of disabled persons were inspired by the miraculous recovery Charles Fletcher Lummis made following a series of devastating strokes that began at the age of 28. The famed author, editor, and social activist was struck by misfortune again at 51 when he went bilaterally blind. At the height of his career, Lummis never let the loss of vision interfere with his many professional responsibilities or his personal life. The cause of Lummis's stroke and blindness has been the subject of speculation for nearly a century and involves one of the most sensitive and perplexing diagnoses in medicine.

Quality of care for in-hospital stroke: analysis of a statewide registry.

BACKGROUND AND PURPOSE: approximately 4% to 17% of all adult strokes have onset in the hospital. Previous research indicates significant in-hospital evaluation delays and lower adherence to some measures of quality care compared to out-of-hospital strokes. METHODS: quality of care for in-hospital ischemic strokes compared to stroke with out-of-hospital onset was examined using cohort analysis of a statewide stroke database maintained by the Colorado Stroke Alliance. RESULTS: one-hundred sixteen in-hospital strokes were compared to 4946 out-of-hospital strokes. Patients with in-hospital strokes were significantly more likely to have history of coronary artery disease (36.7% vs 26.5%; P=0.02), and in-hospital strokes were more severe (NIHSS score 9.5 vs 7.0; P=0.01). Time to brain imaging was not significantly different (54 minutes vs 43 minutes; P=0.13) between groups. Patients with in-hospital stroke were significantly more likely to have documentation of stroke education (90.4% vs 73.1%; P=0.0002) and assessment for rehabilitation (67.7% vs 45.2%; P<0.0001). Total deficit-free care defined as adherence to all Get With the Guidelines Stroke (GWTG-Stroke) measures was better for in-hospital strokes compared to strokes in the community (52.8% vs 32.3%; P<0.0001). CONCLUSIONS: adherence to GWTG-Stroke performance measures was better for in-hospital strokes in this statewide registry. Variability in reporting by participating hospitals suggests in-hospital strokes are under-recognized or under-reported. In-hospital stroke evaluation times remain more than twice the recommended benchmark of 25 minutes, representing an opportunity for process improvement.

Gender differences in the Colorado Stroke Registry.

BACKGROUND AND PURPOSE: Gender differences in stroke are matters of increasing interest. The American Stroke Association's patient management tool, Get with the Guidelines-Stroke (GGS) is widely used to increase adherence to quality indicators in stroke care, but it also provides an opportunity to analyze gender differences in the acute stroke setting. METHODS: We used a state-wide database, based on GGS, to explore gender differences in stroke in Colorado. We analyze demographics, risk factors, lifestyles, treatments, and responses to treatment. RESULTS: Of 126 data elements examined, statistically significant gender differences were noted for 47 (37%). As compared to men, women in Colorado were older and more significantly impacted by acute stroke. Risk factor profiles differed between the 2 genders, with men having a higher incidence of coronary artery disease, dyslipidemia, diabetes, carotid stenosis and tobacco smoking, while women had a higher incidence of atrial fibrillation and hypertension. Lipids were less aggressively treated and antithrombotics were less commonly used in women. Overall, acute stroke treatment of women appeared "less aggressive" than for men. CONCLUSIONS: GGS may be used not only for quality improvement initiatives in individual hospitals. It can also give an overview of clinical aspects of stroke at a state level, and may shed light on gender differences.

Production and Characterization of Monoclonal Antibodies To Detect Vibrio cholerae Serogroup O1 in a Rapid Enzyme-Linked Immunosorbent Assay.

Monoclonal antibodies (MAbs) were developed for a rapid and efficient screening procedure to detect cultures of Vibrio cholerae serogroup O1. Spleen cells of BALB/c mice previously immunized with an attenuated control strain of V. cholerae were fused with mouse myeloma cell line SP2/0. An enzyme-linked immunosorbent assay (ELISA) was used to test cultural hybridoma secretions of two MAbs against 120 strains of V. cholerae O1, 38 strains of V. cholerae non-O1, 15 strains of other Vibrio spp., and 20 strains of other bacterial species. Results of tests using both MAbs were identical. The MAbs successfully detected all of the confirmed serotype O1 strains. Three additional V. cholerae strains that agglutinated antisera and the saline control were considered serologically inconclusive. Of these, one was detected as positive for V. cholerae by both MAbs. The MAbs gave no false-positive reactions when tested against the confirmed non-O1 strains, other Vibrio spp., and other bacterial species. Use of this ELISA will enhance the speed and accuracy needed for detecting V. cholerae O1 cultures.