Outcomes of children and adolescents 1 year after being seen in a multidisciplinary psychogenic nonepileptic seizures clinic.

OBJECTIVE: Psychogenic nonepileptic seizures (PNES) are paroxysmal events that may involve altered subjective experience and change in motor activity with a psychological cause. The aim of this work is to describe a population of pediatric patients with PNES and identify factors predictive of 12-month outcomes. METHODS: We conducted a prospective observational study of children and adolescents referred to the multidisciplinary Nationwide Children's Hospital PNES clinic between November 2017 and July 2019. Information was collected from patients during clinic visits and semistructured follow-up phone calls. Descriptive statistics and Fisher exact test were used for analysis. RESULTS: Of the 139 consecutive patients referred to the PNES clinic, 104 were seen in clinic and 63 answered 12-month follow-up calls. Patients with comorbid epilepsy had increased rates of participation at 12-month follow-up (p = .04). Complete remission was achieved by 32% (20/63) of patients at 12 months. Combined PNES remission and improvement was 89% (56/63) at 12 months. Patients and families who were linked with counseling at 1 month were more likely to achieve remission at 12 months (p = .005). Less than half (44%, 28/63) of patients reached at 12 months had their events documented on video-electroencephalogram (EEG) at diagnosis; however, those who did were not more likely to be accepting of the diagnosis at 12 months (p = 1.0), be linked with counseling at 12 months (p = .59), or be event-free at 12 months (p = .79). SIGNIFICANCE: Remission occurred in one third of patients by 12 months; however, improvement in events was seen in 89%. Connection to counseling by 1 month was associated with increased remission rates at 12 months. Capturing events on video-EEG was not associated with increased acceptance or event freedom at 12 months. Diagnosis should be followed by strong encouragement to connect with counseling quickly to achieve a goal of increasing 12-month PNES remission rates.

Short-term outcomes in pediatric and adolescent patients with psychogenic nonepileptic events seen by telemedicine during the COVID-19 pandemic.

INTRODUCTION: Psychogenic nonepileptic events (PNEE) are a type of Functional Neurological Symptom Disorder that present with events that appear epileptic but are not associated with abnormal electrical activity in the brain. In response to the global COVID-19 pandemic, our PNEE clinic switched to a telemedicine format, and we present here our experience with providing care to children and adolescents with PNEE in this format. METHODS: The multidisciplinary clinic shifted to a telemedicine platform in March 2020 with the same joint provider format. Follow-up phone calls are completed at one and three months following the visit. Data are presented with descriptive statistics. Referral volume and outcomes data are compared to historical patients, including rates of diagnosis acceptance, linkage to counseling, and change in event frequency. RESULTS: Twenty-three patients were scheduled to be seen via telemedicine or hybrid visits from March through June, twenty completed their visits. Sixteen (70%) were reached for follow-up at one month. Of those reached, twelve (75%) accepted the diagnosis, eight (50%) were linked with counseling, and fourteen (88%) with improvement in event frequency. Of the sixteen reached at three months, eleven (69%) had accepted the diagnosis, ten (63%) were linked with counseling, and all but two reported improvement in event frequency. In comparison, the previously published results showed 3-month rates of 75% of patients accepting the diagnosis, 76% linked with counseling, and 75% with improvement in event frequency. CONCLUSIONS: Video telemedicine visits are a feasible and effective way to provide care for children and adolescents with PNEE. At 3 months, patients seen by telemedicine had similar acceptance rates, decreased connection to counseling, and increased rate of improvement in event frequency. This study suggests telemedicine may have some benefits over traditional clinic visits, such as improved show rates and access to clinic; so should be considered a reasonable alternative to in-person visits.

A Qualitative Analysis of School Nurses' Experience Caring for Students With Psychogenic Nonepileptic Events.

Psychogenic nonepileptic events (PNEE) are paroxysmal changes in behavior resembling epileptic seizures but with no electrographic correlate and are instead caused by psychological factors. In this qualitative study, semistructured interviews were conducted with 10 school nurses to identify how they perceive the experience of caring for a student with PNEE as well as supportive factors and barriers to optimal management of PNEE in schools. Several themes were identified: lack of diagnosis awareness by school staff leading to impressions that the student was "faking" the events, inadequate information provided by a health-care provider regarding the diagnosis in general and specifically about the individual student leading to a reliance on information from the student's family, feelings of doubt and insecurity about the diagnosis and management of the events, and reliance on the school nurse to develop a response plan and to manage the events which can be very time-consuming.

Using quality improvement to implement the CNS/AAN quality measure on rescue medication for seizures.

OBJECTIVE: A multidisciplinary quality improvement (QI) team was established to conduct analysis of data for prescribed seizure rescue medication doses from January 2013 to December 2015 to identify and improve inappropriately low dose prescriptions. The QI team identified areas of focus for improvement opportunities and developed the project objective based on the 2017 American Academy of Neurology (AAN) and Child Neurology Society (CNS) quality measure. METHODS: Within a freestanding children's hospital, the QI team developed key drivers and implemented interventions, such as the midazolam prefilled syringe program with use of standardized dosing, electronic chart tools, monthly pharmacy review of all underdosed prescriptions, and provider and nursing education. The team created an automated monthly report to monitor prescribed seizure rescue medication dosing compliance. The year 2015 was used as the preliminary data baseline period with an average noncompliance rate of 3.5%. RESULTS: From January 2016 to December 2019, the team has decreased and sustained the noncompliance rate to an average of 0.38%. The data for the project included 12,975 seizure rescue medication prescribed by a neurology provider from January 2015 to December 2019. Compliance with properly dosed diazepam orders continues to be the largest area of opportunity. The data demonstrated a centerline shift in January 2019, moving the baseline average of 7.2% noncompliance to the current average rate of 0.22%. In comparison, underdosed midazolam orders occurred at an average rate of 0.037% in the same timeframe. SIGNIFICANCE: Using quality improvement methodologies, the team successfully and substantially decreased provider prescribed and signed underdosed rescue medication orders by an average of 89%. This QI project demonstrates successful implementation and improvement addressing the AAN/CNS quality measure of proper rescue seizure treatment dosing.

Accumulation of metals and polycyclic aromatic hydrocarbons in agricultural soil after additions of street sediment in southern Ontario.

Prior to 2012 street sediment from the Greater Toronto Area was being managed by a local authority and provided to rural landowners under the assumption it was clean fill. The aim of this study was to characterise the chemical and physical composition of that street sediment applied to an agricultural field in southwestern Ontario, Canada and determine if contaminants had migrated to native soil. Soil was sampled from an impact and a background location during the fall of 2016 at four soil depths (0-10, 10-20, 20-30 and 30-40 cm below the surface) to characterise texture, pH, organic content, recoverable metals and total polycyclic aromatic hydrocarbons (PAHs). Textural analysis revealed street sediment was dominated by very coarse and coarse sand which differed from the native silty clay loam and extended to 30 cm below the surface. Some PAHs, including benzo(a)pyrene (1.29 µg g-1) exceeded the typical regional background concentrations. A distinct pattern of high molecular mass PAHs in the native soil below street sediments suggests that PAHs have migrated to native soil. To our knowledge this is the first study to report PAH concentrations in street sediment in Ontario and to show their potential movement and introduction to native soil. Future studies should focus on transport mechanisms and understanding movement of PAHs in native coarse textured soil.

Probability of foliar injury for Acer sp. based on foliar fluoride concentrations.

Fluoride is considered one of the most phytotoxic elements to plants, and indicative fluoride injury has been associated over a wide range of foliar fluoride concentrations. The aim of this study was to determine the probability of indicative foliar fluoride injury based on Acer sp. foliar fluoride concentrations using a logistic regression model. Foliage from Acer nedundo, Acer saccharinum, Acer saccharum and Acer platanoides was collected along a distance gradient from three separate brick manufacturing facilities in southern Ontario as part of a long-term monitoring programme between 1995 and 2014. Hydrogen fluoride is the major emission source associated with the manufacturing facilities resulting with highly elevated foliar fluoride close to the facilities and decreasing with distance. Consistent with other studies, indicative fluoride injury was observed over a wide range of foliar concentrations (9.9-480.0 µg F- g-1). The logistic regression model was statistically significant for the Acer sp. group, A. negundo and A. saccharinum; consequently, A. negundo being the most sensitive species among the group. In addition, A. saccharum and A. platanoides were not statistically significant within the model. We are unaware of published foliar fluoride values for Acer sp. within Canada, and this research provides policy maker and scientist with probabilities of indicative foliar injury for common urban Acer sp. trees that can help guide decisions about emissions controls. Further research should focus on mechanisms driving indicative fluoride injury over wide ranging foliar fluoride concentrations and help determine foliar fluoride thresholds for damage.

Brief Report: Psychogenic Nonepileptic Events in Pediatric Patients with Autism or Intellectual Disability.

This is a retrospective case series of pediatric patients referred to the psychogenic nonepileptic events clinic (PNEE) who had comorbid diagnoses of autism spectrum disorder (ASD) or intellectual disability (ID). We describe 15 patients, nine with ASD and six with ID who had a telephone visit follow-up at 12 months. There were higher rates of male gender (40%) and comorbid epilepsy (53%) compared to the larger PNEE cohort. Eleven patients were available for follow-up and ten patients had improvement in events or were event-free. We report that patients with ASD or ID can develop PNEE and experience improvement from events.

Decreasing Emergency Department Visits for Children With Epilepsy.

BACKGROUND AND OBJECTIVES: Epilepsy and seizures represent a frequent cause of emergency department (ED) visits for patients. By implementing quality improvement (QI) methodology, we planned to decrease ED visits for children and adolescents with epilepsy. METHODS: In 2016, a multidisciplinary team was created to implement QI methodology to address ED visits for patients with epilepsy. Based on previous successes, further ED visit reduction was deemed possible. Our aim statement was to decrease the number of ED visits, per 1000 established patients with epilepsy, from 13.03 to 11.6, by December 2019 and sustain for 1 year. RESULTS: We successfully decreased ED visits for seizure-related care in patients with epilepsy from 13.03% to 10.2% per 1,000 patients, which resulted in a centerline shift. DISCUSSION: Using QI methodology, we improved the outcome measure of decreasing ED visits for children with epilepsy. Implementations of these interventions can be considered at other institutions that may lead to similar results.

Outcomes in Children and Adolescents With Psychogenic Nonepileptic Events Using a Multidisciplinary Clinic Approach.

BACKGROUND: Psychogenic nonepileptic events (PNEE) are paroxysmal events that resemble epileptic seizures but are caused by psychological factors. Coordination of care has been recommended as one strategy to integrate care and improve outcomes. We aim to evaluate patient outcomes in a multidisciplinary pediatric psychogenic nonepileptic events clinic that includes care coordination. METHODS: All patients referred to the multidisciplinary psychogenic nonepileptic events clinic were entered into a prospective database. Follow-up calls were made by the clinic nurse at 1 and 3 months following the visit. RESULTS: A total of 101 unique patients were reviewed. Ninety-six appointments were scheduled, and 83 appointments were completed (86%). Social work identified barriers in 38 patients, and 76% of those assisted completed their appointment. At 1 month, two-thirds of families were reached, 50% were accepting of the diagnosis, and 70% had clinical improvement in events. By 3 months, 75% had clinical improvement, 76% were receiving mental health services, and 73% were accepting of the diagnosis; however, more had also returned to the emergency department. Families needing assistance from social work tended to have worse outcomes. Increase in acceptance was nearly statistically significant (P = .058) from 1 to 3 months; however, it was not so for clinical improvement in events (P = .623). CONCLUSIONS: Implementation of a multidisciplinary team with care coordination allowed for follow-up for children and adolescents with psychogenic nonepileptic events and mitigation of barriers to care and can improve clinical outcomes. After being seen in our clinic, many families had accepted the diagnosis, most of the patients reached had event improvement and were successfully linked with counseling at the 1- and 3-month follow-ups.

Acceptance of the use of diazepam rectal gel in school and day care settings.

This study was conducted to identify how often parents of children with epilepsy encounter barriers to the use of diazepam rectal gel in day care or school settings and how these barriers affect the child and family. Sixty-four parents completed an 18-item questionnaire documenting their experience with asking their child's school to administer diazepam rectal gel. No data regarding its actual use in the school was obtained. Forty-three parents (68%) had asked their school to administer diazepam rectal gel; 35 (81%) reported school agreement, and 8 (19%) reported refusal. In 5 of these refusals, the cited reason was legal concerns, and in 5 cases the refusal had some adverse effect on their family's life. Most children prescribed diazepam rectal gel do not encounter resistance to its use in school and day care settings. Barriers to its use are usually due to legal concerns and significantly affect the family's quality of life.

Barriers to Seizure Management in Schools: Perceptions of School Nurses.

The purpose of this study was to assess school nurses' perceptions of barriers to optimal management of seizures in schools. Eighty-three school nurses completed an electronic survey. Most agreed they felt confident they could identify a seizure (97.6%), give rectal diazepam (83.8%), and handle cluster seizures (67.1%), but fewer were confident they could give intranasal midazolam (63.3%), had specific information about a student's seizures (56.6%), or could swipe a vagus nerve stimulator magnet (47.4%). Nurses were more likely to be available at the time of a seizure in rural (17/20) (85%) versus suburban (21/34) (62%) or urban (8/25) (32%) schools (P = .001). School nurses are comfortable managing seizures in the school setting. However, a specific seizure plan for each child and education on intranasal midazolam and vagus nerve stimulator magnet use are needed. A barrier in urban schools is decreased availability of a nurse to identify seizures and administer treatment.

Reduction of emergency department visits using an urgent clinic for children with established epilepsy.

BACKGROUND: Emergency department (ED) visits and hospitalizations account for a large portion of the cost of care in people with established epilepsy. In an attempt to decrease seizure-related ED visits, we created an urgent epilepsy clinic (UEC) for children with epilepsy. Our aim was to decrease ED visits for patients seen in the clinic by 30% and decrease unplanned hospitalizations by 10% 3 months following an appointment. METHODS: Children at risk for an ED visit or unplanned hospitalization were referred and seen by a nurse practitioner and social worker. Factors influencing the need for the appointment and actions taken were recorded. Cost savings were also calculated. RESULTS: A total of 317 patients were seen in the UEC clinic from October 2013 to July 2015. Ninety-three percent of scheduled patients completed their appointment, compared to 84% in other neurology clinics. Eighty-three percent of patients were seen in the clinic within 5 days of the referral. Children were significantly less likely to come to the ED in the 3 months after an appointment compared to the 3 months before. CONCLUSIONS: An urgent clinic for children with established epilepsy was associated with a reduction in ED visits for seizures and improved adherence to outpatient clinic appointments for seizures. Further research is needed to evaluate the cost-effectiveness of UECs, and to compare health services and clinical outcomes to those of children without access to such services.