Patient Handoff Practices at the Epilepsy Centers in the United States: A Survey of the Medical Directors.

PURPOSE: Communication failure is one of the most significant causes of medical errors. Providing care to patients with seizures at comprehensive epilepsy centers requires uninterrupted coverage and a multidisciplinary approach. However, handoff practices in these settings have not been comprehensively assessed, and recommendations for their standardization are currently lacking. The aim of this observational study was to define the scope of existing practices for patient handoffs across epilepsy centers in the United States and provide relevant recommendations. METHODS: A 79-question survey was developed to establish the patterns of transition of care for patients undergoing continuous EEG recording, including the periodicity of handoffs and specifics of the relevant workflow. With permission from the National Association of Epilepsy Centers (NAEC), the survey was distributed to the medical directors of all Level 3 and 4 NAEC-accredited epilepsy centers in the United States. RESULTS: The responses were obtained from 70 institutions yielding a survey response rate of 26%. Of these, more than 77% had established weekly handoff processes for both the epilepsy monitoring unit and continuous EEG (cEEG) monitoring services. However, only 53% and 43% of centers had procedures for daily service transfers for the patients admitted to the epilepsy monitoring unit or the patients undergoing cEEG, respectively. The patterns of handoffs were complex and utilized group handoffs in < 50% of institutions. In most centers (>70%), patient data transmitted through handoffs included history, clinical information, and EEG findings. However, templates were not applied to standardize this information. All participants agreed or strongly agreed that a culture of patient safety was maintained in their place of practice; however, 12% of participants felt that insufficient time was allowed to discuss these patients or carry out the handoffs without interruptions. CONCLUSIONS: Existing handoff practices are not uniform or fully established across epilepsy centers in the United States. This study recommends that guidelines for formal handoff procedures be developed and introduced as a quality metric for all NAEC-accredited epilepsy centers.

IPV survivors' and service providers' perspectives on brain injury screening/evaluation process and impact.

This study explores the perspectives of intimate partner violence (IPV) survivors and staff of brain injury (BI) screening, and the neuropsychological evaluation (NPE) process. We gathered qualitative data from 17 participants - 10 IPV survivors, at risk for a BI, who had received BI screening and a NPE and a total of 7 staff in IPV-serving organizations. Interviews were recorded, transcribed verbatim and analysed for key themes using thematic analysis. Survivors were over 18 years of age; the majority were between 19 and 45 years old, unemployed, unmarried, and had children. Survivors were angry, scared, and embarrassed to learn that they might have an IPV-related BI. They were thankful to have an explanation for some of their cognitive symptoms, which disrupted their daily activities, social relationships, and overall quality of life. Staff were pleased to be able to provide valuable information to their clients that could have a positive impact on their wellbeing. Overall, screening for a BI and participation in the NPE were well tolerated by IPV survivors with a possible BI. Inclusion of the perspectives of IPV survivors and support staff is an essential first step to better understanding their needs so interventions can be developed to aid their recovery.

Differences in Symptom Report by Survivors With and Without Probable Intimate Partner Violence-Related Brain Injury.

Survivors of intimate partner violence (IPV) are at heightened risk of sustaining a brain injury (BI). Problematically, a high overlap between BI and trauma symptoms leads to difficulties in identifying when an IPV-related BI has occurred. This paper investigated differences in symptom reports between survivors with (n = 95) and without (n = 42) probable IPV-related BI. Chi-squared analyses isolated a constellation of symptoms found to be specifically associated with BI status. These symptomatic markers may assist professionals in discerning BI from other comorbid conditions present in IPV, and thus help survivors access BI-specific treatments and resources.

Neurocognitive function and quality-of-life in patients with colorectal cancer.

OBJECTIVE: Colorectal cancer (CRC) survivors report significant long-term physical and cognitive declines post-treatment. Our purpose was to combine task-evoked Event-Related Potential (ERP) and resting state functional magnetic resonance imaging (rsf/MRI) methodologies to characterize the physiological underpinnings and cognitive sequelae of chemotherapy-related cognitive impairment, including changes in Quality-Of-Life (QOL) in patients with CRC, as compared to healthy control (HC) participants. METHODS: This descriptive study recruited and obtained baseline data from patients with CRC at medical and surgical oncology visits four to six weeks post-op and followed them at 12- and 24-weeks. Procedures employed ERP, pencil and paper neuropsychological testing (N-P), structural/functional rsf/MRI, and self-report QOL methodologies. Data analyses included correlations, one-way ANOVA, Chi-square tests, and linear mixed models. RESULTS: Study participants (n = 40) across groups (n = 15, 11, 14) were balanced on age, sex, education, and race, but not marital status Several significant associations were found between changes in Dorsal Attention Network (DAN)-related ERP measures (P2, N2, N2P2, N2pc amplitudes), with QOL measures between baseline and last visits (p < 0.05-0.001). Additionally, rsf/MRI findings showed increased network activity in a single node of the DAN post-treatment, which was associated with poorer performance on N-P tests of attention and working memory, as well as a focal decline in grey matter volume in the area. CONCLUSIONS: Our methodology revealed structural and functional changes within the DAN associated with altered spatial attention, working memory, and ability to inhibit. These disruptions may be responsible for decreased QOL ratings in patients with CRC. This study provides a putative mechanism of understanding how altered brain structural/functional relationships impact cognition, QOL, and nursing care in patients with CRC. NCI TRIAL ID: NCI-2020-05952, University of Nebraska Medical Center, Clinical Trials.gov ID NCT03683004.

Survey of depressive symptomatology in brain injury resulting from intimate partner violence.

OBJECTIVE: A high prevalence of depression exists in specific sub-samples of survivors of brain injury (BI) sustained from intimate partner violence (IPV). However, the experience of depression by survivors of IPV-related BI from general civilian populations remains unclear. This study documents the symptom profile of depression reported by individuals who screened positive for sustaining an IPV-related BI. METHODS: 36 individuals who screened positive for possible IPV-related BI completed the Beck Depression Inventory-2nd Edition (BDI-II). Subscales characterizing the nature of the symptoms were created. Frequency and descriptive statistics were calculated for item responses on the BDI-II. Participants were also assigned to high or low symptom severity groups to examine between-group differences. RESULTS: Participants endorsed experiencing somatic symptoms more severely than self-evaluative and affective symptoms. Additionally, self-evaluative and cognitive symptoms correlated with total BDI-II scores for the high symptom severity group but not for the low symptom severity group. CONCLUSIONS: The findings highlight somatic symptoms of depression, in particular as a common experience among survivors of IPV-related BI. Further, self-evaluative and cognitive symptoms may be more sensitive in detecting depression after IPV-related BI. These results may aid in the development of guidelines to better diagnose and treat depression in IPV-related BI.

Intimate Partner Violence and Brain Injury Screening.

The study examined rates of possible brain injury among survivors of intimate partner violence. Of the 171 women screened, 91% indicated they had been hit in the head or strangled, and 31% reported it happened more than six times in their life. Only 35% of women who were hit in the head or strangled received medical treatment, and 64% reported losing consciousness or experienced a period of being dazed and confused. Organizations serving intimate partner violence survivors should routinely screen survivors for brain injury so they can obtain timely referrals for neurorehabilitation services to improve their quality of life.

Association between kinetic semiology of psychogenic nonepileptic spells and seizure type in dual disorder.

PURPOSE: Epilepsy is diagnosed in 20% of patients with psychogenic nonepileptic spells (PNES). The semiology of PNES and epileptic seizures (ES) overlaps in some patients. It is unclear whether the motor phenotype of PNES predicts the type of ES. METHODS: Video segments of EEGs in patients with PNES and ES treated in the Epilepsy Monitoring Unit at the University of Nebraska Medical Center were reviewed. Videos were categorized according to the validated motor-based classification of PNES. Ratings of kinetic PNES events were analyzed to determine if there was an association with focal or generalized ES. If available, the video segments of ES were categorized as hypokinetic or hyperkinetic based on the constellation of focal or generalized movements and other semiological features. RESULTS: Among 43 patients with documented PNES-ES (median age 34, interquartile range (IQR) 26-45), 27.9% were male. The largest proportion of patients (39.5%) had focal temporal epilepsy (TE). Other diagnostic groups included focal frontal (FE, 25.6%), generalized (GE, 25.6%), or other (9.3%) epilepsies. Thirty-three PNES patients (82.5%) were rated as having a hypokinetic phenotype. On average, hypokinetic PNES patients were receiving a median of 3 (IQR 2-4) anticonvulsants, compared to a median of 2 (IQR 2-3) in hyperkinetic PNES patients (p = 0.06). While the group with coexisting FE had a higher prevalence of hyperkinetic semiology (45.4%) than either the TE (11.7%) or GE (18.1%) patients, there was no significant association between the ES type and kinetic status of PNES. Among 20 patients who had video recordings of both PNES and ES, 40% displayed the concordant hypokinetic phenotypes for PNES and seizures while 15% had hyperkinetic presentation of both event types. Among additional 16 patients with scalp EEG-negative suspected nonepileptic events and documented ES, 6 had the recordings of seizures and 3 have presented with concordant hypokinetic PNES and ES. CONCLUSION: In patients with PNES and ES, the hypokinetic semiology of PNES prevails over hyperkinetic semiology in TE and GE syndromes. The motor status of PNES does not predict the phenotype of coexisting ES. The concordant kinetic semiology is present in more than half of the patients with dual diagnosis and available video data.

Utilization of brain imaging in evaluating patients with psychogenic nonepileptic spells.

BACKGROUND: Psychogenic nonepileptic spells (PNES) are paroxysmal movements or sensory events that resemble epileptic seizures but lack corresponding ictal electrographic changes. A confirmed diagnosis of PNES is only accomplished via video electroencephalogram (vEEG) monitoring. Prior to diagnosis, patients are often assessed with neurodiagnostic imaging and their conditions treated with anticonvulsant medications, both of which are of limited clinical value and contribute to the higher cost of care. In this study, we assessed the relationship between the semiological features of PNES, medication regimen, or psychiatric comorbidities and the frequency of referrals for brain imaging tests prior to diagnosis of PNES. METHODS: This is a retrospective chart review of 224 adult patients diagnosed as having PNES at a level 4 epilepsy care center from 2012 to 2017. Patients with coexisting epilepsy were excluded. The 882 segments of vEEG records were reviewed for semiology of spells, and patients were categorized into one of seven distinct phenotypic classes according to the accepted clinical classification. The frequency of neurodiagnostic tests completed for each patient prior to vEEG was correlated with PNES phenotype and other clinical characteristics. RESULTS: There were 68 (30%) males and 156 (70%) females diagnosed as having PNES with a median age of 36 years. Seventy-four percent of patients were receiving one or several anticonvulsant medications, and 67% of patients were treated with psychotropic medications other than benzodiazepines. The most prevalent PNES events were characterized by semirhythmic small amplitude movements in the extremities (class 2; 34%) followed by those resembling tonic-clonic seizures (class 4; 28%). Neurodiagnostic imaging tests including computed tomography (CT) and magnetic resonance imaging (MRI) of the brain were performed at least once in 60% of patients and 4 times or more in 11% prior to vEEG. There was a significant association between the frequency of neurodiagnostic tests and the PNES phenotype (p = 0.02). Specifically, patients with sensory changes (class 6) had more imaging tests than those with primitive gesturing and truncal posturing (classes 1 and 5, respectively). Additionally, patients diagnosed with 3 or more psychiatric disorders underwent significantly more neurodiagnostic tests relative to patients diagnosed with two or fewer psychiatric disorders (p = 0.03). Furthermore, patients whose conditions were treated with anticonvulsant medications tended to undergo more imaging scans prior to vEEG as compared with the patients whose conditions were not being treated with anticonvulsants. CONCLUSIONS: These findings suggest that the frequency of brain imaging obtained prior to the definitive diagnosis of PNES is influenced by semiology of spells and the psychiatric health of patients. Patients who demonstrate minimal paroxysmal movements in the settings of multiple psychiatric comorbidities represent a particularly challenging patient phenotype which is linked to more frequent referrals for brain imaging. These patients should be promptly referred for vEEG to improve diagnostic accuracy and prevent treatment with anticonvulsants as well as referrals for serial neurodiagnostic tests.

Apathy Is Associated With Ventral Striatum Volume in Schizophrenia Spectrum Disorder.

Apathy is prevalent in schizophrenia, but its etiology has received little investigation. The ventral striatum (VS), a key brain region involved in motivated behavior, has been implicated in studies of apathy. We therefore evaluated whether apathy is associated with volume of the VS on MRI in 23 patients with schizophrenia using voxel-based morphometry. Results indicated that greater self-reported apathy severity was associated with smaller volume of the right VS even when controlling for age, gender, depression, and total gray matter volume. The finding suggests that apathy is related to abnormality of brain circuitry subserving motivated behavior in patients with schizophrenia.

Differences in Regional Brain Volumes Two Months and One Year after Mild Traumatic Brain Injury.

Conventional structural imaging is often normal after mild traumatic brain injury (mTBI). There is a need for structural neuroimaging biomarkers that facilitate detection of milder injuries, allow recovery trajectory monitoring, and identify those at risk for poor functional outcome and disability. We present a novel approach to quantifying volumes of candidate brain regions at risk for injury. Compared to controls, patients with mTBI had significantly smaller volumes in several regions including the caudate, putamen, and thalamus when assessed 2 months after injury. These differences persisted but were reduced in magnitude 1 year after injury, suggesting the possibility of normalization over time in the affected regions. More pronounced differences, however, were found in the amygdala and hippocampus, suggesting the possibility of regionally specific responses to injury.

Performance on the Cognitive Estimation Test in schizophrenia.

The Cognitive Estimation Test (CET) is generally considered to be a measure of executive function, but there is little information with respect to its clinical utility in patients with schizophrenia. In the present investigation, we evaluated the clinical utility of the CET in 42 patients with schizophrenia relative to 42 healthy comparison subjects matched for age, gender, and parental education. Construct validity of the CET was examined though correlation with other tests of executive and nonexecutive cognitive functions. Patients with schizophrenia performed more poorly on the CET compared with the healthy comparison group, which could not be accounted for by greater level of depression in the patient sample. In the schizophrenia group, CET was correlated with measures of executive function but also general intellectual functioning, verbal learning, and auditory attention. CET performance was not associated with depression or overall severity of psychopathology in the patient sample. These findings provide support for the clinical utility of the CET in schizophrenia but indicate that both executive and nonexecutive cognitive functions contribute to performance on the measure. Thus, the integrity of other cognitive processes should be taken into consideration when interpreting the presence of a deficit in cognitive estimation in patients with schizophrenia.

Inferential-reasoning impairment in schizophrenia-spectrum disorders.

The performance of 15 participants with schizophrenia-spectrum disorders (SCZ) on an inferential-reasoning task was compared with that of 15 healthy-control participants (HC). The SCZ group showed poorer inferential reasoning than HCs, independent of their negative or positive symptoms. These findings are consistent with previous research showing deficits of reasoning in schizophrenia, and indicate that this deficit is independent of severity of delusions.

Regional gray matter correlates of perceived emotional intelligence.

Coping with stressful life events requires a degree of skill in the ability to attend to, comprehend, label, communicate and regulate emotions. Individuals vary in the extent to which these skills are developed, with the term 'alexithymia' often applied in the clinical and personality literature to those individuals most compromised in these skills. Although a frontal lobe model of alexithymia is emerging, it is unclear whether such a model satisfactorily reflects brain-related patterns associated with perceived emotional intelligence at the facet level. To determine whether these trait meta-mood facets (ability to attend to, have clarity of and repair emotions) have unique gray matter volume correlates, a voxel-based morphometry study was conducted in 30 healthy adults using the Trait Meta Mood Scale while co-varying for potentially confounding sociodemographic variables. Poorer Attention to Emotion was associated with lower gray matter volume in clusters distributed primarily throughout the frontal lobe, with peak correlation in the left medial frontal gyrus. Poorer Mood Repair was related to lower gray matter volume in three clusters in frontal and inferior parietal areas, with peak correlation in the left anterior cingulate. No significant volumetric correlations emerged for the Clarity of Emotion facet. We discuss the localization of these areas in the context of cortical circuits known to be involved in processes of self-reflection and cognitive control.

Subjective rating of working memory is associated with frontal lobe volume in schizophrenia.

BACKGROUND: Patients with schizophrenia commonly show deficits in working memory on objective neuropsychological measures, and brain imaging studies have documented neural abnormalities during performance of working memory tasks. It remains unclear to what extent such patients are able to accurately gauge the integrity of their working memory in their daily lives. AIMS: We evaluated the relationship between subjective rating of working memory integrity in daily life and volumes of the frontal, temporal, and parietal lobes in patients with schizophrenia. METHODS: Participants included 29 patients with schizophrenia and 26 healthy comparison subjects. Participants completed a structural magnetic resonance imaging (MRI) scan, the Self Report form of the Behavioral Rating Inventory of Executive Function - Adult version (BRIEF-A), and Digit Span Backwards as an objective measure of working memory. Lobar volumes were obtained using an automated processing package and adjusted for total intracranial volume. RESULTS: The patient group reported worse working memory in daily life, and performed worse on Digit Span Backwards, than the comparison group. Within the patient group, poorer working memory in daily life was associated with smaller left and right frontal lobe volumes. Shorter backwards digit span was associated with smaller left frontal and left and right temporal lobe volumes. CONCLUSIONS: The significant relationship between frontal lobe volumes and subjective working memory in daily life provides some support for the validity of self report measures of cognitive functioning in patients with schizophrenia, and provides further evidence for a contribution of frontal lobe abnormality to executive dysfunction in the illness.