Components of Mid-clerkship Feedback in a Neurology Clerkship and their Impact on Subsequent Student Performance.

Feedback during clinical rotations can be valuable in improving medical student education, but it is unclear what effect such feedback has on subsequent clinical performance and also which feedback topics are the most important in student growth and education. We compared medical student clinical performance before and after mid-clerkship feedback in a Neurology clerkship, with evaluators at the mid-clerkship and at the end blinded to the others' comments. We found that the most important areas holding back student clinical performance were communication, interpersonal interactions, and work ethic rather than textbook knowledge, or the ability to take a history, and do a physical and neurologic examination. Further, students who had concerning comments at the mid-clerkship feedback session usually continued to have the same problems after the feedback (in an admittedly short clerkship). The results suggest that more attention should be given to communication and other interpersonal skills and involvement in the clinical service during feedback sessions and that feedback continue over a much longer period than during a relatively brief Neurology clerkship alone.

Characteristics and role in outcome prediction of continuous EEG after status epilepticus: A prospective observational cohort.

OBJECTIVE: Continuous electroencephalography (cEEG) is important for treatment guidance in status epilepticus (SE) management, but its role in clinical outcome prediction is unclear. Our aim is to determine which cEEG features give independent outcome information after correction for clinical predictor. METHODS: cEEG data of 120 consecutive adult patients with SE were prospectively collected in three academic medical centers using the 2012 American Clinical Neurophysiology Society's Standardized Critical Care EEG Terminology. Association between cEEG features and two clinical outcome measures (mortality and complete recovery) was assessed. RESULTS: In the first 24 h of EEG recording, 49 patients (40.8%) showed no periodic or rhythmic pattern, 45 (37.5%) had periodic discharges, 20 (16.7%) had rhythmic delta activity, and 6 (5%) had spike-and-wave discharges. Seizures were recorded in 68.3% of patients. After adjusting for known clinical predictive factors for mortality including the STatus Epilepticus Severity Score (STESS) and the presence of a potentially fatal etiology, the only EEG features (among rhythmic and periodic patterns, seizures, and background activity) that remained significantly associated with outcome were the absence of a posterior dominant rhythm (odds ratio [OR] 9.8; p = 0.033) for mortality and changes in stage II sleep pattern characteristics (OR 2.59 for each step up among these categories: absent, present and abnormal, present and normal; p = 0.002) for complete recovery. SIGNIFICANCE: After adjustment for relevant clinical findings, including SE severity and etiology, cEEG background information (posterior dominant rhythm and sleep patterns) is more predictive for clinical outcome after SE than are rhythmic and periodic patterns or seizures.

Practice variability and efficacy of clonazepam, lorazepam, and midazolam in status epilepticus: A multicenter comparison.

OBJECTIVE: Benzodiazepines (BZD) are recommended as first-line treatment for status epilepticus (SE), with lorazepam (LZP) and midazolam (MDZ) being the most widely used drugs and part of current treatment guidelines. Clonazepam (CLZ) is also utilized in many countries; however, there is no systematic comparison of these agents for treatment of SE to date. METHODS: We identified all patients treated with CLZ, LZP, or MDZ as a first-line agent from a prospectively collected observational cohort of adult patients treated for SE in four tertiary care centers. Relative efficacies of CLZ, LZP, and MDZ were compared by assessing the risk of developing refractory SE and the number of antiseizure drugs (ASDs) required to control SE. RESULTS: Among 177 patients, 72 patients (40.62%) received CLZ, 82 patients (46.33%) LZP, and 23 (12.99%) MDZ; groups were similar in demographics and SE characteristics. Loading dose was considered insufficient in the majority of cases for LZP, with a similar rate (84%, 95%, and 87.5%) in the centers involved, and CLZ was used as recommended in 52% of patients. After adjustment for relevant variables, LZP was associated with an increased risk of refractoriness as compared to CLZ (odds ratio [OR] 6.4, 95% confidence interval [CI] 2.66-15.5) and with an increased number of ASDs needed for SE control (OR 4.35, 95% CI 1.8-10.49). SIGNIFICANCE: CLZ seems to be an effective alternative to LZP and MDZ. LZP is frequently underdosed in this setting. These findings are highly relevant, since they may impact daily practice.

Evaluation of a clinical tool for early etiology identification in status epilepticus.

OBJECTIVES: Because early etiologic identification is critical to select appropriate specific status epilepticus (SE) management, we aim to validate a clinical tool we developed that uses history and readily available investigations to guide prompt etiologic assessment. METHODS: This prospective multicenter study included all adult patients treated for SE of all but anoxic causes from four academic centers. The proposed tool is designed as a checklist covering frequent precipitating factors for SE. The study team completed the checklist at the time the patient was identified by electroencephalography (EEG) request. Only information available in the emergency department or at the time of in-hospital SE identification was used. Concordance between the etiology indicated by the tool and the determined etiology at hospital discharge was analyzed, together with interrater agreement. RESULTS: Two hundred twelve patients were included. Concordance between the etiology hypothesis generated using the tool and the finally determined etiology was 88.7% (95% confidence interval (CI) 86.4-89.8) (κ = 0.88). Interrater agreement was 83.3% (95% CI 80.4-96) (κ = 0.81). SIGNIFICANCE: This tool is valid and reliable for identification early the etiology of an SE. Physicians managing patients in SE may benefit from using it to identify promptly the underlying etiology, thus facilitating selection of the appropriate treatment.

The medical system in Ghana.

Ghana is a developing country in West Africa with a population of about 25 million. Medical illnesses in Ghana overlap with those in developed countries, but infection, trauma, and women's health problems are much more prominent. Medical practice in rural Africa faces extremely limited resources, a multiplicity of languages (hundreds in Ghana), and presentation of severe illnesses at later stages than seen elsewhere. Despite these limitations, Ghana has established a relatively successful national medical insurance system, and the quality of medical practice is high, at least where it is available. Ghana also has a well-established and sophisticated administrative structure for the supervision of medical education and accreditation, but it has proven very difficult to extend medical training to rural areas, where health care facilities are particularly short of personnel. Physicians are sorely needed in rural areas, but there are few because of the working conditions and financial limitations. Hospital wards and clinics are crowded; time per patient is limited. This article details some of the differences between medical practice in Ghana and that in wealthier countries and how it functions with very limited resources. It also introduces the medical education and training system in Ghana. The following article describes an attempt to establish and maintain a residency training program in General Medicine in a rural area of Ghana.

Establishment of a general medicine residency training program in rural West Africa.

Ghana, a developing country in West Africa, has major medical burdens in taking care of a large population with limited resources. Its three medical schools produce more than 200 graduates per year, but most emigrate to developed lands after training. Ghana is working to educate and retain locally trained physicians, but it is difficult to get them to work in rural settings where the need is greatest. This article details the establishment of a General Medicine residency at a 150-bed hospital in rural Ghana. Early training comprises 6 months each in Medicine, Surgery, OB/GYN, and Pediatrics; the hospital in Techiman also has a Surgery residency. House officers choose the program for more hands-on experience than they can get in larger centers. They perform many tasks, including surgery, sooner and more independently than do residents in developed countries. The training program includes a morning report, clinical teaching rounds, and rotations on in-patient wards and in the Emergency Department and clinics. Teaching focuses on history, physical examination, good communication, and proper follow-up, with rigorous training in the OR and some clinical research projects pertinent to Ghana. Trainees work hard and learn from one another, from a dedicated faculty, and by evaluating and treating very sick patients. Ghana's rural residencies offer rigorous and attractive training, but it is too soon to tell whether this will help stem the "brain drain" of young physicians out of West Africa.

Treatment of nonconvulsive status epilepticus.

OPINION STATEMENT: Status epilepticus is a neurologic emergency with significant potential morbidity and even mortality. It should be diagnosed and treated as quickly as possible, with concurrent rapid identification of the underlying cause. Nonconvulsive status epilepticus can be difficult to diagnose due to its protean manifestations, so a high index of suspicion is vital to prompt diagnosis and effective management. There are several different types and syndromes of nonconvulsive status epilepticus, and appropriate treatment varies according to those types. Some are relatively benign. Others, particularly the nonconvulsive status encountered in sick, hospitalized patients, can be life-threatening. The latter should be treated much more rapidly and aggressively than the former, sometimes even requiring coma-inducing anesthetic agents.

Minimum Technical Requirements for Performing Ambulatory EEG.

SUMMARY: Ambulatory EEG (AEEG) devices offer portable, multichannel, digital EEG recording with or without video in the patient's natural environment. The technology applied for AEEG recording is like the technology for routine EEG and inpatient long-term video-EEG monitoring but designed to be compact and wearable. Computer-based AEEG technology is well-suited to digital recording, signal processing, and visual display. However, acquiring interpretable EEG outside of the hospital setting presents its own technical challenges. Published guidelines have established technical standards for performing routine EEG and inpatient video-EEG monitoring, but technical standards for AEEG are lacking. Therefore, this guideline provides minimal technical standards for the performance of AEEG which are essential to ensure the quality of studies for clinical and research practice. We expect these minimum standards to evolve over time with improved performance and advances in the technology.

Electroencephalography in clinical epilepsy research.

Electroencephalography (EEG) remains central to the investigation of epilepsy. This review discusses two clinical problems at the temporal extremes of neurophysiologic recording: evaluation of the clinical significance of individual spike discharges in benign epilepsy of childhood with centrotemporal spikes (BECTS), and prolonged (several days) continuous EEG monitoring in the ICU. BECTS is misdiagnosed often, and probably mis-treated often as well. Though the long-term outcome is usually excellent, it remains unclear whether the individual epileptiform discharges have a clinical effect. Answering this question is difficult, in part because of the natural evolution of the epilepsy and its different appearance depending on wakefulness or sleep state, and also due to substantial methodologic problems in measuring short and long-term cognitive effects. Continuous EEG (CEEG) recording has grown remarkably over the last 10 years. It has proved crucial in the diagnosis of nonconvulsive status epilepticus (NCSE), especially in the ICU, given the usual lack of obvious clinical signs of seizures in most of these patients, many of whom are critically ill. Much progress has been made in agreeing on terminology for the EEG findings, but diagnosis is still complicated. More efficient and reliable technology is being developed to help process the massive amount of data captured by CEEG and make it more useful (and in a timely fashion) clinically. Still, it is not completely clear which patients should be monitored, for how long, and what is the best role for CEEG in assessing and adjusting treatment once the diagnosis has been made. Investigators are using CEEG to study "seizure burden," to help determine what are the long-term effects of nonconvulsive seizures and NCSE, and to help guide treatment and improve outcome.

Survivors and nonsurvivors of very prolonged status epilepticus.

Several studies have shown reliable predictive factors for outcome in status epilepticus (SE), especially etiology and presentation in coma. Duration of SE is predictive, but probably only in the first few hours, and there have been many reports of patients treated successfully for SE lasting many days or weeks. Nevertheless, there are many other patients with SE treated for prolonged periods without success, sometimes apparently futilely. We compared clinical features of 10 survivors of prolonged SE with those of a matched cohort treated for similarly prolonged episodes but unsuccessfully, looking for exceptions to known predictive factors. Multiple medical problems (i.e., etiologies) and coma on presentation were confirmed as predictors of a poor outcome. Analysis of individual exceptions to these predictors showed that age, overall background health, and family input on the value of prolonged treatment, on the one hand, and earlier epilepsy plus rapid and accurate diagnosis and treatment, on the other, contributed to results different from what would have been expected.

A comparison of anastrozole and testosterone versus placebo and testosterone for treatment of sexual dysfunction in men with epilepsy and hypogonadism.

Hyposexuality is commonly associated with low bioavailable testosterone (BAT) and relative estradiol elevation in men with epilepsy. This prospective, randomized, double-blind trial compared the effects of depotestosterone+the aromatase inhibitor anastrozole (T-A) versus depotestosterone+placebo (T-P) on sexual function, hormone levels, mood, and seizure frequency in men with epilepsy. Forty men with focal epilepsy, hyposexuality, and hypogonadism were randomized 1:1 to two groups (T-A or T-P) for a 3-month treatment trial of depotestosterone+either anastrozole or matching placebo. Outcomes included both efficacy and safety measures. Normalization of sexual function (S-score) occurred with greater frequency in the T-A (72.2%) than in the T-P (47.4%) group, but the difference was not statistically significant. T-A resulted in significantly lower estradiol levels and S-scores correlated inversely with estradiol levels at baseline and during treatment. Beck Depression Inventory II (BDI-II) scores improved significantly in both groups and changes in S-score correlated inversely with changes in BDI-II score. Changes in seizure frequency correlated with changes in BDI-II score. Seizure frequency decreased with both treatments and showed significant correlations with estradiol levels. Triglyceride levels increased with T-P and decreased with T-A. The difference in triglyceride changes between the two treatments was significant and correlated with changes in estradiol levels. Significant correlations between estradiol levels and S-scores, as well as seizure outcomes and triglyceride levels, suggest further study regarding a potential role for anastrozole in the treatment of men with epilepsy who have hyposexuality and hypogonadism.

Duration of refractory status epilepticus and outcome: loss of prognostic utility after several hours.

PURPOSE: Outcome for patients with status epilepticus (SE) depends strongly on etiology. Duration of SE is also predictive, at least in the first 2 h, but beyond this it is unclear that duration of SE influences outcome significantly. We sought to determine the influence of duration of SE on outcome in patients with prolonged SE, and to compare this influence with that of other factors. METHODS: We reviewed the clinical course and outcome of 119 patients with SE, diagnosed by both clinical manifestations and electroencephalography (EEG) evidence. Using univariate and multivariate analyses, we sought predictors of outcome (survival vs. death or vegetative state) among age, etiology (epilepsy, anoxia or severe hypoxia, or other), presence of earlier epilepsy, multiple medical problems, presentation in coma, and type of SE (focal or generalized). RESULTS: Median duration of SE was 48 h. Survival was greater with a shorter duration, especially when <10 h (69% vs. 31% for longer duration; p < 0.05). Epilepsy as the etiology, and an earlier diagnosis of epilepsy offered a favorable prognosis (p < 0.01), but only the former on multivariate analysis. Coma and SE caused by anoxia/hypoxia were unfavorable factors. Once corrected for etiology, presentation in coma, and type of SE (focal or generalized), duration of SE did not have a significant effect on outcome. Overall mortality was high, 65%, but 10 patients survived SE lasting over 3.5 days. CONCLUSIONS: A duration of <10 h was associated with better outcome in SE, but this was not significant once etiology, presentation in coma, and type of SE were accounted for. Etiology of SE is still the primary determinant of outcome. Unless it follows anoxia, prolonged SE should not be considered a hopeless condition.

Nonconvulsive seizures and nonconvulsive status epilepticus in the neuro ICU should or should not be treated aggressively: A debate.

This article presents a "debate" about the appropriate level of aggressiveness of treatment for nonconvulsive status epilepticus (NCSE), held at the International Congress of Clinical Neurophysiology in Washington D.C. on 4 May 2018. The proposition for discussion was "Nonconvulsive seizures and status epilepticus in the intensive care unit should be treated aggressively." Dr. Andrea O. Rossetti from Lausanne, Switzerland, spoke in support of the proposition and Dr. Lawrence J. Hirsch from New Haven, Connecticut, discussed reasons for rejecting the proposal. Dr. Frank W. Drislane from Boston, Massachusetts, was asked by the conference organizers to add comments and perspective.

Treatment of Refractory and Super-refractory Status Epilepticus.

Refractory and super-refractory status epilepticus (SE) are serious illnesses with a high risk of morbidity and even fatality. In the setting of refractory generalized convulsive SE (GCSE), there is ample justification to use continuous infusions of highly sedating medications-usually midazolam, pentobarbital, or propofol. Each of these medications has advantages and disadvantages, and the particulars of their use remain controversial. Continuous EEG monitoring is crucial in guiding the management of these critically ill patients: in diagnosis, in detecting relapse, and in adjusting medications. Forms of SE other than GCSE (and its continuation in a "subtle" or nonconvulsive form) should usually be treated far less aggressively, often with nonsedating anti-seizure drugs (ASDs). Management of "non-classic" NCSE in ICUs is very complicated and controversial, and some cases may require aggressive treatment. One of the largest problems in refractory SE (RSE) treatment is withdrawing coma-inducing drugs, as the prolonged ICU courses they prompt often lead to additional complications. In drug withdrawal after control of convulsive SE, nonsedating ASDs can assist; medical management is crucial; and some brief seizures may have to be tolerated. For the most refractory of cases, immunotherapy, ketamine, ketogenic diet, and focal surgery are among several newer or less standard treatments that can be considered. The morbidity and mortality of RSE is substantial, but many patients survive and even return to normal function, so RSE should be treated promptly and as aggressively as the individual patient and type of SE indicate.

Lateralized Periodic Discharges: A Literature Review.

The purpose of this article is to provide a comprehensive review of the literature about a particular EEG pattern, lateralized periodic discharges (LPDs), or periodic lateralized epileptiform discharges (PLEDs). The review will discuss the history and terminology of LPDs and provide a detailed summary of the etiologies, pathophysiology, clinical symptoms, and imaging studies related to LPDs. Current controversies about the association of LPDs with seizures and their management will be reviewed. Finally, some unanswered questions and suggestions for future research on LPDs will be discussed.

Treatment strategies after a single seizure : rationale for immediate versus deferred treatment.

What is the rationale for the treatment of an epileptic seizure? More specifically, should a first seizure be treated as soon as it is diagnosed or should one defer treatment until a second seizure occurs? Several studies indicate that the risk of a second (unprovoked) seizure is <50%, but studies vary in methodology and most have reviewed outcome in children only. Also, many patients were maintained on antiepileptic drugs (AEDs) during these studies, meaning that the risk for seizure recurrence was perhaps underestimated compared with the risk if untreated. Most neurologists recommend waiting for a second seizure in order to avoid complications of medications that might prove to be unnecessary. Several large studies show that delaying treatment until a second seizure occurs does not worsen the course of epilepsy or likelihood of eventual seizure control. Seizures attributable to an acute illness ('acute symptomatic', provoked seizures) usually resolve with treatment of the underlying illness and thus long-term AEDs are often unwarranted. Nevertheless, seizures arising in certain circumstances are more likely to recur and there are special considerations for patients with strokes, tumours, infections and dementia, and also after head injury or neurosurgery. Patient preferences with regard to risk and benefit also enter into the decision on whether to initiate AED treatment after a single seizure.