Should Physicians Be Able to Refuse to Care for Patients Insured by Medicare?

This commentary on a case considers whether and to what extent refusal to care for Medicare patients is a form of "turfing." Medicare is a federal program to provide insurance for people over age 65, those who have certain disabilities, and those with end-stage renal disease; eligibility criteria include contributions from wages and salaries during a patient's working career. Although all clinicians in the United States can care for Medicare patients, some opt out, resulting in harms to eligible patients and in oversubscription of remaining clinical practices. Opting out should be reconsidered, given that resident training is supported by Medicare funding. Although patients who receive services upon engaging with a health care practice might believe that they are under the care of a clinician, any harms of administrative nonadherence to practice guidelines accrue to the clinician.

Mood and Anxiety Disorders and Suicidality in Patients With Newly Diagnosed Focal Epilepsy: An Analysis of a Complex Comorbidity.

BACKGROUND AND OBJECTIVES: Mood, anxiety disorders, and suicidality are more frequent in people with epilepsy than in the general population. Yet, their prevalence and the types of mood and anxiety disorders associated with suicidality at the time of the epilepsy diagnosis are not established. We sought to answer these questions in patients with newly diagnosed focal epilepsy and to assess their association with suicidal ideation and attempts. METHODS: The data were derived from the Human Epilepsy Project study. A total of 347 consecutive adults aged 18-60 years with newly diagnosed focal epilepsy were enrolled within 4 months of starting treatment. The types of mood and anxiety disorders were identified with the Mini International Neuropsychiatric Interview, whereas suicidal ideation (lifetime, current, active, and passive) and suicidal attempts (lifetime and current) were established with the Columbia Suicidality Severity Rating Scale (CSSRS). Statistical analyses included the t test, χ2 statistics, and logistic regression analyses. RESULTS: A total of 151 (43.5%) patients had a psychiatric diagnosis; 134 (38.6%) met the criteria for a mood and/or anxiety disorder, and 75 (21.6%) reported suicidal ideation with or without attempts. Mood (23.6%) and anxiety (27.4%) disorders had comparable prevalence rates, whereas both disorders occurred together in 43 patients (12.4%). Major depressive disorders (MDDs) had a slightly higher prevalence than bipolar disorders (BPDs) (9.5% vs 6.9%, respectively). Explanatory variables of suicidality included MDD, BPD, panic disorders, and agoraphobia, with BPD and panic disorders being the strongest variables, particularly for active suicidal ideation and suicidal attempts. DISCUSSION: In patients with newly diagnosed focal epilepsy, the prevalence of mood, anxiety disorders, and suicidality is higher than in the general population and comparable to those of patients with established epilepsy. Their recognition at the time of the initial epilepsy evaluation is of the essence.

Clarifying a Clinical Ethics Service's Value, the Visible and the Hidden.

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un-Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic.

Cardiac electrical instability in newly diagnosed/chronic epilepsy tracked by Holter and ECG patch.

OBJECTIVE: We hypothesized that cardiac electrical instability and abnormal autonomic tone result from cumulative cardiac injury sustained in recurrent seizures. We tested this hypothesis by comparing T-wave alternans (TWA) and heart rate variability (HRV), both established markers of sudden cardiac death (SCD) risk, in patients with chronic as compared to newly diagnosed epilepsy. METHODS: In this prospective, observational cohort study, patients (newly diagnosed epilepsy, n = 6, age 41.8 ± 6.8 years; chronic epilepsy, n = 6, age 40.2 ± 5.6 years [p = 0.85]) were monitored either with Holter recorder alone or simultaneously with 14-day Zio XT extended continuous ECG patch monitor. TWA was assessed by Food and Drug Administration-cleared Modified Moving Average analysis; HRV was calculated by rMSSD. RESULTS: TWA levels in chronic epilepsy were significantly higher than in newly diagnosed epilepsy (62 ± 5.4 vs 35 ± 1.3 µV, p < 0.002); the latter did not differ from healthy control adults. In all patients with chronic epilepsy, TWA exceeded the established ≥47-µV TWA cutpoint and rMSSD HRV was inversely related to TWA levels. Patients with chronic epilepsy exhibited elevated TWA levels equivalently on Holter and ECG patch recordings (p = 0.38) with a high correlation (r 2 = 0.99, p < 0.01) across 24 hours. CONCLUSION: Based on the limited number of patients studied, it appears that chronic epilepsy, the common use of sodium channel antagonists, or other factors are associated with higher TWA levels and simultaneously with lower rMSSD HRV, which is suggestive of autonomic dysfunction or higher sympathetic tone. The ECG patch monitor used has equivalent accuracy to Holter monitoring for TWA and HRV and permits longer-term ECG sampling.

Using mobile location data in biomedical research while preserving privacy.

Location data are becoming easier to obtain and are now bundled with other metadata in a variety of biomedical research applications. At the same time, the level of sophistication required to protect patient privacy is also increasing. In this article, we provide guidance for institutional review boards (IRBs) to make informed decisions about privacy protections in protocols involving location data. We provide an overview of some of the major categories of technical algorithms and medical-legal tools at the disposal of investigators, as well as the shortcomings of each. Although there is no "one size fits all" approach to privacy protection, this article attempts to describe a set of practical considerations that can be used by investigators, journal editors, and IRBs.

Epilepsy.

This issue provides a clinical overview of epilepsy, focusing on diagnosis, prevention, treatment, and further considerations. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

When religious beliefs prohibit a surgical patient's acceptance of blood transfusion.

A 49-year-old man who was a Jehovah's Witness presented with intractable epilepsy due to a brain tumor. The neurologist wanted to refer him for tumor resection but was concerned about requesting surgery for someone who would not accept blood products. The neurologist must balance his obligation of beneficence and nonmaleficence with respect for the patient's autonomous decision not to receive blood products.Good communication between patient and doctor is crucial to allow patients to make informed decisions about a choice to refuse transfusion, and doctors must accept the patient's autonomy, even when it conflicts with the moral imperative to provide treatment if it is available.

Interictal 12-lead electrocardiography in patients with epilepsy.

Interictal electrocardiographic predictors of sudden unexpected death in epilepsy (SUDEP) are unknown. This study was designed to identify the unique features of the interictal 12-lead electrocardiogram (EKG) in patients with epileptic seizures. We conducted a retrospective chart review of adult patients below the age of 65 admitted to our epilepsy monitoring unit. Using EEG telemetry data, we classified patients as having nonepileptic seizures (NESs), probable epilepsy (PE), or definite epilepsy (DE) and analyzed 12-lead EKGs obtained on admission. Patients with NESs were assigned as the control group. We included patients taking antipsychotic and/or antidepressant medications but excluded patients with medical conditions or taking other medications that would otherwise confound EKG measurements. Out of the 1007 charts reviewed, 195 patients were included in our analysis, and extensive subgroup analyses were performed. We found that patients with definite localization-related epilepsy displayed a significantly longer average PR interval (162.1 ms) than patients with NESs (148.8 ms). This effect was pronounced in female patients and did not vary with the number of antiepileptic drugs (AEDs) prescribed. In contrast to previous studies, mean QTc intervals were not significantly different between DE (428 ms) and NESs (422.6 ms). However, within females, this difference reached statistical significance (DE: 434.6 ms, NESs: 424.6 ms). Antiepileptic drug polytherapy was associated with a significantly lower QTc interval (416 ms in patients on 4-6 drugs and 436.4 ms in patients on 0-1 drugs). Levetiracetam was the most commonly used AED and was associated with the longest average PR (163 ms) and QTc (432 ms) intervals. The mean QRS axis displayed a significant leftward shift in patients with localization-related epilepsy (35.6° versus 54.3° in patients with NESs) and also in female patients with DE (42.1° versus 55.4° in female patients with NESs). No differences were observed between patients with left versus right hemisphere seizure foci. Overall, these findings may reflect cardiac structural changes and/or alterations in autonomic tone that deserve closer study. Further, longer-term prospective studies are required to understand how these electrocardiographic signatures may predict sudden unexpected death in epilepsy.

Managing epilepsy during pregnancy: assessing risk and optimizing care.

OPINION STATEMENT: Epilepsy is the most common neurologic condition found in pregnancy. As such, all neurologists, internists, and obstetricians should know how to counsel women with epilepsy as they are considering pregnancy. While all of the usual recommendations for women of childbearing potential apply, including preconceptual and ongoing use of folic acid, calcium, and vitamin D, additional consideration must be given to the need for adjustment or change of anticonvulsant therapy. Monotherapy with the lowest dose of medication needed to control seizures should be prescribed prior to conception. Most anticonvulsants have a favorable profile when used in pregnancy; older anticonvulsants such as valproate and carbamazepine should be avoided, as they are associated with higher rates of fetal malformation, and in the case of valproate, with proven cognitive deficits in children exposed to this medication in utero. With use of any anticonvulsant medication, dosing throughout pregnancy will need to be adjusted to maintain an appropriate serum concentration. Dosing of anticonvulsants needs to be decreased after delivery to avoid medication-related toxicity, although sleep deprivation and hormonal fluctuation can increase the risk of seizures in postpartum women. With proper management, the majority of women with epilepsy can have uneventful pregnancies and healthy babies.

Sleep spindle alterations in patients with malformations of cortical development.

Malformations of cortical development are disorders of altered brain anatomy and architecture that arise from abnormalities in the usual processes of cerebral cortical development. Although they often lead to epilepsy, cognitive delay, and motor impairment, little is known about their effect on sleep. Since malformations may anatomically or functionally disrupt the cerebral circuits that mediate sleep spindles, we hypothesized that these disorders would be associated with abnormal spindle characteristics. We analyzed the density, maximum frequency, laterality and distribution of sleep spindles seen in routine and long-term electroencephalographic recordings performed in ten brain malformation subjects and ten matched controls. There were no significant differences in spindle density or maximum frequency between the two groups, but malformation subjects had a significantly lower proportion of bilateral spindles and a significantly higher proportion of anterior and diffuse spindles compared to controls. In addition, unilateral malformations appeared to be associated with a skewing of unilateral spindles toward the contralateral side. Our findings suggest that brain malformations disrupt the thalamocortical circuits responsible for sleep spindle generation, and support the need for further studies on the relationships between cortical maldevelopment and sleep.

Pregnancy and epilepsy:update on pregnancy registries.

In the United States, about 1 million women of childbearing age have epilepsy. Estimates vary as to the percentage of these women who consider pregnancy, but epilepsy is the most common neurologic condition encountered in pregnancy. Women with epilepsy express significant interest in receiving guidance about pregnancy and the effects of seizures and anticonvulsant treatments on the developing fetus, but clinicians often are hard-pressed to find accurate and relevant information to share. In our practice, we devote many hours of clinical time to the counseling required when such a request is made. We begin by providing information about the risks of pregnancy for any woman, comparing the data for women with and without epilepsy; this gives patients perspective on the increase in the risk of fetal malformations associated with anticonvulsant therapy. We then proceed with an evaluation of whether the patient could consider withdrawing one or more anticonvulsants, particularly during the first trimester of gestation. For women who must continue taking anticonvulsants to prevent seizures, we explain that the increase in metabolism during pregnancy will require an increase in oral dosing to maintain prepregnancy concentrations of anticonvulsants. It is hoped that by maintaining prepregnancy blood levels during pregnancy, a woman with epilepsy can maintain the same level of seizure control during pregnancy that she had before conception. Additional time is spent discussing the need for adequate hydration, regular meals, and proper sleep during pregnancy and in the postpartum time to avoid behavioral alterations that can trigger seizures. As seizure medicines will need to be decreased after delivery, when a patient will be sleep-deprived and under the influence of hormonal changes that can increase the seizure tendency, our nurses meet with patients throughout pregnancy to develop plans for partner or family assistance with care of the neonate. Patients report appreciation for this type of personalized counseling but express frustration that we cannot provide absolute guidance with respect to the use of anticonvulsants in pregnancy. Therefore we often have to return several times to the topic of the limitations of scientific research regarding decision-making in pregnancy. Much of the information we have about the safety of anticonvulsant use in pregnancy comes from the registry studies discussed in this article. These studies can be difficult to interpret and compare because of the diversity of the methods used.