Predictors of seizure outcomes of autoimmune encephalitis: A clinical and morphometric quantitative analysis study.

OBJECTIVE: Autoimmune encephalitis can be followed by treatment-resistant epilepsy. Understanding its predictors and mechanisms are crucial to future studies to improve autoimmune encephalitis outcomes. Our objective was to determine the clinical and imaging predictors of postencephalitic treatment-resistant epilepsy. METHODS: We performed a retrospective cohort study (2012-2017) of adults with autoimmune encephalitis, both antibody positive and seronegative but clinically definite or probable. We examined clinical and imaging (as defined by morphometric analysis) predictors of seizure freedom at long term follow-up. RESULTS: Of 37 subjects with adequate follow-up data (mean 4.3 yrs, SD 2.5), 21 (57 %) achieved seizure freedom after a mean time of 1 year (SD 2.3), and one third (13/37, 35 %) discontinued ASMs. Presence of mesial temporal hyperintensities on the initial MRI was the only independent predictor of ongoing seizures at last follow-up (OR 27.3, 95 %CI 2.48-299.5). Morphometric analysis of follow-up MRI scans (n = 20) did not reveal any statistically significant differences in hippocampal, opercular, and total brain volumes between patients with postencephalitic treatment-resistant epilepsy and those without. SIGNIFICANCE: Postencephalitic treatment-resistant epilepsy is a common complication of autoimmune encephalitis and is more likely to occur in those with mesial temporal hyperintensities on acute MRI. Volume loss in the hippocampal, opercular, and overall brain on follow-up MRI does not predict postencephalitic treatment-resistant epilepsy, so additional factors beyond structural changes may account for its development.

A Quality Improvement Project to Improve Hospital-to-Home Transitions Using Discharge Televisits.

BACKGROUND: Resident-led discharge "televisits" can improve the safety of hospital-to-home transitions by increasing completed follow-up and providing patients access to their inpatient providers to troubleshoot issues. METHODS: This single-center quality improvement study was set in a pediatric unit within an academically affiliated public safety-net hospital. By August 2021, the aim was to use resident-led phone call televisits within 72 hours of discharge to increase completed follow-up from 67% to 85% among patients discharged from the general pediatric unit and compare this to patients scheduled for in person visits. Patients were preferentially scheduled for televisits based on investigator-defined criteria to maximize benefit (eg, prescribed new medications). The process measure was the proportion of televisit slots filled. The balancing measures were 7-day emergency department visits and readmissions. Topics addressed during televisits were categorized to qualitatively assess potential benefits. RESULTS: Three hundred and fifteen (44.5%) patients had televisits, 234 (33.1%) in person visits, and 159 (22.5%) unconfirmed follow-up. The available televisit appointments scheduled were 315 of 434 (72.5%). Completed follow-up was 88.3% for televisits and 63.3% for in person visits, compared with 67% during the baseline period. Completed follow-up was 4.4 (95% confidence interval 2.9 to 6.8) times more likely for televisits compared with in person visits after controlling for confounding variables. Common topics addressed during televisits were test results, medication issues, and appointment issues. Emergency department revisits and readmissions were similar between groups. CONCLUSIONS: Resident-led discharge televisits are an innovative way to increase completeness of discharge follow-up.

Correlation of Warm Handoffs Versus Electronic Referrals and Engagement With Mental Health Services Co-located in a Pediatric Primary Care Clinic.

OBJECTIVE: To analyze the correlation of referral mechanism-warm handoff or electronic referral and attendance at behavioral health appointments in an outpatient pediatric primary care setting. METHODS: A retrospective cohort study was conducted in an inner-city pediatric primary care clinic from January 2019 to December 2019. Adolescent patients who screened positive for depression or anxiety were referred to a Licensed Master Social Worker (LMSW) either via a warm handoff (WH group, n = 148) or an electronic referral (EF group, n = 180). The EF group was contacted by the LMSW via telephone to schedule an appointment. Multiple logistic regression was used to analyze the correlation of type of referral, age, gender, race/ethnicity, primary language, and time between referral and first contact with attendance at three appointments. RESULTS: The WH group was more likely to engage with mental health services compared to the EF group (odds ratio = 3.301, 95% confidence interval = 1.850-5.902, p = .002) while age, gender, race/ethnicity, and primary language had no correlation. Within the EF group, those who were contacted by the LMSW within 3 days (1-3 days group) were more likely to attend appointments (odds ratio = 2.680, 95% confidence interval = 0.414-8.219, p = .040). There was no difference in attendance in the WH group and the 1-3 days group (p = .913) DISCUSSION: A warm handoff between primary care providers and behavioral health clinicians is significantly correlated with engagement with behavioral health services for adolescents who screen positive for depression or anxiety. Contact with the family within 3 days of referral is significantly correlated with engagement compared to a longer duration between referral and family contact.

Impact of ARUBA trial on trends and outcomes in symptomatic non-ruptured brain AVMs: A national sample analysis.

INTRODUCTION: The real-world evolution of management and outcomes of patients with unruptured brain arteriovenous malformations (AVMs) has not been well-delineated following the ARUBA trial findings of no general advantage of initial interventional (surgical/endovascular/radiotherapy) vs. initial conservative medical therapy. METHODS: We analyzed the National Inpatient Sample from 2009-2018, capturing 20% of all admissions in the U.S. Validated ICD-9 and -10 codes defined brain AVMs, comorbidities, and the use of interventional modalities. Analyses were performed by year and for the dichotomized periods of pre-ARUBA (2009-2013) vs. post-ARUBA (2014-2018). RESULTS: Among the national projected 88,037 AVM admissions, 72,812 (82.7%) were unruptured AVMs and 15,225 (17.3%) were ruptured AVMs. Among uAVMs, 51.4% admitted pre-ARUBA and 48.6% in post-ARUBA period. The post-ARUBA patients were mildly older (median age 53.3 vs. 51.8 (p = 0.001) and had more comorbidities including hypertension, diabetes, obesity, renal impairment, and smoking. Before the first platform report of ARUBA (2009-2012), rates of use of interventional treatments during uAVM admissions trended up from 31.8% to 35.4%. Thereafter, they declined significantly to 26.4% in 2018 (p = 0.02). The decline was driven by a reduction in the frequency of endovascular treatment from 18.8% to 13.9% and inpatient stereotactic radiosurgery from 0.5% to 0.1%. No change occurred in the frequency of microsurgery or combined endovascular and surgical approaches. Adjusted multivariable model of uAVMs showed increased odds of discharge to a long-term inpatient facility or in-hospital death [OR 1.14 (1.02-1.28), p = 0.020] in post-ARUBA. A significantly increased proportion of ruptured AVMs from 17.0% to 23.3% was observed consistently in post-ARUBA. CONCLUSION: Nationwide practice in the management of unruptured AVMs changed substantially with the publication of the ARUBA trial in a durable and increasing manner. Fewer admissions with the interventional treatment of unruptured AVMs occurred, and a corresponding increase in admission for ruptured AVMs transpired, as expected with a strategy of watchful waiting and treatment only after an index bleeding event. Further studies are needed to determine whether these trends can be considered to be ARUBA trial effect or are merely coincidental.

Retinal Artery Occlusion and Associated Risk of Cerebrovascular Disease Related Hospitalization: A National Inpatient Study.

Objectives To evaluate the demographic and comorbid risk factors for cerebrovascular disease (CVD) hospitalization in patients with retinal artery occlusion (RAO) and study the impact on hospitalization outcomes. Methods We conducted a retrospective cross-sectional study using the Nationwide Inpatient Sample (NIS, 2019). We included 62,255 adults (age 18-65 years) with the primary diagnosis of CVD. The study sample was divided by the co-diagnosis of RAO (N=1,700). A logistic regression model was used to evaluate the odds ratio (OR) of association for risk factors leading to CVD hospitalization in patients with RAO, with the non-RAO cohort as the reference category. Results The majority of the CVD patients with RAO were elderly (51-65 years, 68%), females (54%), and whites (47%). Yet, demographics did not significantly impact the association with CVD hospitalization between RAO and non-RAO patients. There was a significant difference in the geographic distribution of CVD hospitalizations with RAO, with the highest prevalence in the East North Central Atlantic (21%) and South Atlantic (18%) regions, and the lowest in the Mountain (4%) and East South Central (4%) regions. Comorbid diabetes with complications (69%), and complicated hypertension (55%) were most prevalent in patients with RAO thereby increasing the risk for CVD hospitalization by 7.8 (95% CI 6.9-8.8) and 1.8 times (95% CI 1.6-1.9), respectively. Patients with RAO and having major severity of illness were at increased risk of CVD hospitalization (OR 2.8, 95% CI 1.9-3.9). Patients with RAO had a significant difference in adverse disposition, including transfer to the skilled nursing facility (SNF)/intermediate care facility (ICF) (32% vs. 24%) and requiring home health care (16% vs. 11%) compared to non-RAO patients. Conclusion The prevalence of RAO in CVD hospitalization was 2.7%, and demographics did not have any impact on the increasing risk of CVD. Comorbid diabetes (by 685%) and hypertension (by 78%) potentially increase the risk of CVD hospitalization in patients with RAO. These patients have a major severity of illness, leading to an adverse disposition. This calls for a collaborative care model to improve the quality of life in these at-risk patients with RAO.

Relationship Between Cerebrovascular Diseases and Vasculitis: A Cross-Sectional Nationwide Inpatient Study.

Objectives To evaluate the risk factors and hospitalization outcomes for cerebrovascular diseases (CVD) in patients with vasculitis. Methods We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS), 2019. We included 26,855 adults (aged 18 to 65 years, average age 48.57 ± 12.79 years) with a co-diagnosis of vasculitis, and the sample was divided by the primary diagnosis of CVD (N = 670, 2.5%). A demographic-adjusted logistic regression model was used to evaluate the odds ratio (OR) of association with CVD in patients with vasculitis by comparing it to the non-CVD cohort. Results The majority of the vasculitis patients with CVD were elders (51 to 65 years, 46%), females (62%), and whites (52%). There was a significant difference in the geographic distribution of CVD with vasculitis with the highest prevalence in the South Atlantic (23%) and Middle Atlantic (16%), and the lowest in the Mountain (4%) and New England (2%). Vasculitis patients with comorbid lymphoma (OR 2.46, P<0.001), peripheral vascular diseases (PVD (OR 1.54, P<0.001)), and complicated hypertension (OR 1.31, P<0.001) were associated with increasing the likelihood for CVD-related hospitalization. The mean length of stay was 13 days and the mean cost was $169,440 per CVD-related hospitalization in vasculitis patients. Cerebrovascular diseases in patients with vasculitis resulted in a major loss of body functioning (80%) leading to adverse disposition including transfer to a skilled nursing facility/intermediate care facility (22%) and requiring home health care (13%). Conclusion The prevalence of CVD-related hospitalization in vasculitis patients was 2.5% and females were observed to be at higher risk. Comorbid lymphoma, PVD, and hypertension further increase the risk for CVD with vasculitis. They have a higher loss of functioning that affects patient quality of life and require increased care after hospital discharge.

Modified body mass index z-scores in children in New York City during the COVID-19 pandemic.

OBJECTIVES: Determine whether the negative impact of the COVID-19 pandemic on weight gain trajectories among children attending well-child visits in New York City persisted after the public health restrictions were reduced. STUDY DESIGN: Multicenter retrospective chart review study of 7150 children aged 3-19 years seen for well-child care between 1 January 2018 and 4 December 2021 in the NYC Health and Hospitals system. Primary outcome was the difference in annual change of modified body mass index z-score (mBMIz) between the pre-pandemic and early- and late-pandemic periods. The mBMIz allows for tracking of a greater range of BMI values than the traditional BMI z-score. The secondary outcome was odds of overweight, obesity, or severe obesity. Multivariable analyses were conducted with each outcome as the dependent variable, and year, age category, sex, race/ethnicity, insurance status, NYC borough, and baseline weight category as independent variables. RESULTS: The difference in annual mBMIz change for pre-pandemic to early-pandemic = 0.18 (95% confidence interval [CI]: 0.15, 0.20) and for pre-pandemic to late-pandemic = 0.04 (95% CI: 0.01, 0.06). There was a statistically significant interaction between period and baseline weight category. Those with severe obesity at baseline had the greatest mBMIz increase during both pandemic periods and those with underweight at baseline had the lowest mBMIz increase during both pandemic periods. CONCLUSION: In NYC, the worsening mBMIz trajectories for children associated with COVID-19 restrictions did not reverse by 2021. Decisions about continuing restrictions, such as school closures, should carefully weigh the negative health impact of these policies.

Comparison of PHQ-9 and PHQ-2 as Screening Tools for Depression and School Related Stress in Inner City Adolescents.

BACKGROUND: Major depressive disorder is associated with significant morbidity and mortality in adolescents. Suicide is one of the leading causes of mortality between 15 and 19 years. Both AAP and USPSTF recommend routine depression screening of adolescents. Patient Health Questionnaire-2 (PHQ-2) and Patient Health Questionnaire-9 (PHQ-9) are widely used in primary care practice, however, PHQ-2 does not screen for suicidality. School-related factors are known to affect adolescent mental health. PURPOSE: To compare PHQ-2 and PHQ-9 for depression screening in adolescents, with respect to age, gender, chronic illness over the course of 9 months. METHODS: As a QI initiative, we compared screening results in our inner-city pediatric practice using PHQ-2 and PHQ-9 from Jun'18 to Feb'19. EMR of 2364 patients 12 to 21 years were reviewed. We considered the PHQ-2 score of ≥2 and PHQ-9 of ≥10 as positive. Pre-existing chronic medical and mental illnesses were noted. RESULTS: Of these 61.5% of patients were females, 95% were Black/Hispanic, and 96% were insured by Medicaid. About 10.6% of PHQ-9 tests were positive whereas 7.4% PHQ2 were positive. Logistic regression was performed to ascertain the effects of age, gender, and chronic illness. Females were more likely to have a positive screen, as were patients with chronic illness. Age had no effect on the outcome. The screening yield for both tests was comparable in the summer months. PHQ9 yield increased while schools were in session while PHQ 2 remained stable. CONCLUSION: PHQ9 is superior as a screening test compared to PHQ2. Repeat screening should be targeted toward patients with chronic medical conditions and/or mental health diagnoses. PHQ9 may be better at screening for school-related stress.

Burden of acute symptomatic seizures in cerebral venous sinus thrombosis: A nationwide United States analysis.

INTRODUCTION: Acute symptomatic seizures (ASS) are seen in one-third of cerebral venous sinus thrombosis (CVT) cases either as the presenting symptom or shortly after diagnosis in the acute phase. The goal of our study was to assess the trends in recognition of ASS in CVT over the years and to determine factors predictive of ASS in the patients with CVT for early identification of candidates who would benefit from anti-seizure medications (ASM). MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS) database was accessed to identify adult inpatient admissions with a primary or secondary diagnosis of CVT. Comorbidities, complications, risk factors, and procedures pertaining to these hospitalizations were compared between CVT patients with and without ASS. RESULTS: A total of 53,710 CVT-related hospitalizations were identified, of which 18.1% of patients had a burden of ASS at presentation or subsequently during hospitalization. CVT patients with ASS had a longer average duration of hospitalization and higher overall morbidity and mortality. CONCLUSIONS: Our study showed ~one in five patients (18.1%) with CVT had ASS. ASS patients had higher odds of mortality and disability at discharge, requiring post-discharge rehabilitation care. It is crucial to identify risk factors of ASS in the CVT population to avoid future preventable revisit related to seizures. Additional research is required for risk stratification of patients with CVT for primary and secondary seizure prophylaxis and determining the appropriate choice and duration of ASM in these patients.

Readmission Trends Related to Unruptured Intracranial Aneurysm Treatment.

Background and Purpose: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality. Prophylactic treatment of the unruptured intracranial aneurysm (UIA) is considered in a select group of patients thought to be at high for aneurysmal rupture. Hospital readmission rates can serve as a surrogate marker for the safety and cost-effectiveness of treatment options for UIAs; we present an analysis of the 30-day rehospitalization rates and predictors of readmission following UIA treatment with surgical and endovascular approaches. Methods: We retrospectively analyzed data from the National Readmission Database (NRD) derived from the Healthcare Cost and Utilization Project for the year 2014. The cohort included patients with a primary discharge diagnosis of a treated unruptured aneurysm. The primary outcome variable was the 30-day readmission rate in open surgical vs. endovascularly treated groups. The secondary outcomes included predictors of readmissions, and causes of 30-day readmissions in these two groups. Results: The 30-day readmission rate for the surgical group was 8.37% compared to 4.87% for the endovascular group. The index hospitalization duration was longer in the surgical group. A larger proportion of the patients readmitted following surgical treatment were hypertensive (76.35, vs. 63.43%), but the prevalence of other medical comorbidities was comparable in the two treatment groups. Conclusions: There is a higher likelihood for 30-day readmission, longer duration of initial hospitalization and a lower likelihood of discharge home following surgical treatment of UIAs when compared to endovascular treatment. These findings, however, do not demonstrate long-term superiority of one specific treatment modality.

Neurosyphilis presenting with a large vessel occlusion: A case report.

We describe a case of a 36-year-old man who presented with stroke in the right paramedian pons in the pontine perforator territory, manifesting as intermittent headache, slurred speech, left-sided weakness, and paresthesia. This case highlights the diagnostic challenge in identifying neurosyphilis as a cause of stroke in young individuals. Clinicians should maintain vigilance for this uncommon etiology through conducting a detailed history and investigation in susceptible patients with key risk factors. Once the diagnosis was confirmed in our case, a multidisciplinary approach was used for management with neurologists, infectious disease specialists, and the neurointerventional team. Our patient ultimately underwent successful therapy with mechanical thrombectomy for basilar artery thrombosis from meningovascular syphilis.

Trends in hospitalizations and epidemiological characteristics of adults Moyamoya disorder in the United States.

BACKGROUND AND PURPOSE: There has been an increasing prevalence of Moyamoya disorder (MMD) reported from recent US literature. There is a paucity of data available regarding trends of prevalence and epidemiological factors in the United States. To goal of this study was to test the hypotheses that racial-, sex-specific MMD hospitalizations and epidemiological factors have been increasing in the United States over the last decade. METHODS: In this retrospective observational study, using the National Inpatient Sample (NIS) database from 2005 to 2016, MMD-related hospitalizations in patients aged ≥18 years were identified. Trends of epidemiological factors were analyzed over time using the linear regression model with the significance of differences in trend over time assessed using the Wald test. Sex- and race-specific burden of MMD were calculated using the annual US Census data. Joinpoint regression model was used to evaluate trends of hospitalizations over time. RESULTS: A total of 24,484 adult hospitalizations were identified from January 2005 to September 2015 after excluding <18 years. Among them, approximately ~90% were aged ≤60 years, and 73.5% were females. The most common vascular and non-vascular presentations were ischemic stroke (17.3%) and seizures (21%), respectively. The trend of antithrombotic therapy has increased, while extracranial-intracranial bypass has remained stagnant. The actual average hospitalizations of MMD was 10.4 cases/ million population/year (range 4.1-17.9) and varied significantly by sex (females 14.7 [range 6.2-23.6] and males 5.9 [range 1.8-11.9]) over the 2005 to 2016 study period. The burden of hospitalizations also differed by race (African Americans 40.6 [range 32.8-63.7], Asians 24.8 [15.4-34.8], Non-Hispanic Whites 8.1 [range 6.4-11.5], and Hispanics 8.4 [2.8-12.8]) over the 2010 to 2016 study period. Joinpoint regression analysis showed an increasing overall MMD trend across the study period (+11.7%; P < 0.001), which was higher in males (+14.5% vs. +10.7%; P < 0.001). The Hispanic group had significantly increased hospitalizations over the years (+20.2%; P < 0.001). CONCLUSION: Although overall more prevalent in females, MMD-related hospitalizations are increasing more rapidly in males. Among the racial subpopulations, African Americans had the highest MMD-related hospitalizations, even higher than Asian Americans. MMD-related hospitalizations have increased quicker in Hispanics than in any other racial group.

Respiratory complications and 30-day unplanned hospital readmissions in patients with epilepsy.

BACKGROUND: To help mitigate the burden of health care on US economy, public policymakers and health care legislation have been focusing on reducing hospital readmissions. Respiratory complications have been identified among the commonest of adverse events in neurologic patients. The goal of our study was to better understand respiratory complications and their contribution to rehospitalizations in patients with seizures. METHODS: We used the 2013 Nationwide Readmission Database to analyze unplanned 30-day readmission rate (30RR). The study population comprised of patients with index hospital discharge diagnosis of generalized convulsive epilepsy and status epilepticus. Patients under 18 years of age, who died during hospitalization or who had missing demographic data, were excluded. Patients hospitalized in December were also excluded due to lack of 30-day follow-up. The primary outcome of interest was 30-day readmission. The causes of readmission were determined by corresponding International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS: The 30RR was highest in patients with index hospitalization discharge diagnosis of status epilepticus, followed by generalized convulsive epilepsy (intractable), followed by generalized convulsive epilepsy (nonintractable). While seizure was the most common reason for readmission, contribution of respiratory complications to readmissions was 7.85%, 12.39%, and 6.93%, respectively. Pneumonia/aspiration pneumonitis and respiratory insufficiency accounted for the majority of the readmissions in all subgroups. CONCLUSIONS: Respiratory complications are the leading nonseizure cause of 30-day unplanned readmissions in patients with generalized convulsive epilepsy and status epilepticus. Further research on identifying appropriate interventions to reduce readmissions from respiratory causes may improve outcomes for patients in these epilepsy subgroups.

Thirty-day readmissions in multiple sclerosis: An age and gender-based US national retrospective analysis.

BACKGROUND: Hospital readmission rate is an important indicator of the quality of care, healthcare economic burden, and post-discharge care. Multiple sclerosis (MS) is a potentially progressive neurological disease predominantly affecting young women. The natural history of the disease involves intermittent relapses and/or accrued baseline disability overtime especially in older patients contributing to frequent hospitalizations. The readmission metrics for patients with MS have not been studied. OBJECTIVE: To estimate nationwide 30-day readmission (30-DR) rate among patients hospitalized with MS and to study the predictors of readmission based on age and gender. METHODS: This was a retrospective observational cohort study of patients hospitalized with primary discharge diagnosis of MS using 2013 Nationwide Readmission Database (NRD). The cases were identified by ICD 9-CM code (340) linked to MS diagnosis. We used patient unique identifiers 'NRD visit link' to identify MS index hospitalizations and readmissions. Age (<40 vs. >40 years) and gender-based analyses were performed using multivariable logistic regression adjusting co-variables to identify the patient/system-specific factors associated with 30-DR. RESULTS: The overall 30-day readmission rate (30-DRR) was 10.2%. No gender difference was seen in the readmission rates (men 10.7% vs. women 10.1%, p = 0.56); higher readmission rates were observed in older patients (11.2% vs. 8.8%; p = 0.0055). However, readmission cost was higher in younger age group (≈ $ 12,586 vs. ≈$ 11,827; p = 0.62) and among women (≈$ 12,217 vs. ≈$ 11,746; p = 0.75). The common causes of 30-DR were MS exacerbation (42.5%), sepsis (13.7%) and respiratory complications (7.3%). The predictors of higher 30-DRR in younger patients were diabetes (OR 1.87, p = 0.02), intravenous immunoglobulin (IVIG) use (OR 3.64, p = 0.016), and discharge to a nursing facility (OR 1.66, p = 0.03), whereas in older age group, higher Charlson-Deyo Comorbidity Index (CCI) (OR 1.15, p = 0.0057), and plasma exchange (PLEX) (OR 2.38, p = 0.03) were predictive of higher readmission rate. The longer length of stay (LOS) during index admission (OR 1.81, p = 0.03) in men and higher CCI (OR 1.15, p = 0.007) and intravenous immunoglobulin (IVIG) use (OR 2.27, p = 0.04) in women increased the odds of readmission. CONCLUSION: The overall 30-day readmission rate among patients following hospitalization for MS was 10.2%. The readmission rate was higher in older (>40 years) patients. The common causes of readmission were MS exacerbation, respiratory complications, and sepsis. A higher systemic disease burden, longer length of stay, and treatment with IVIG and PLEX were associated with higher risk of readmission. The readmissions were associated with higher cost of care and longer LOS compared to index admissions highlighting the economic impact of readmissions. Future strategies to lower the risk of readmissions in patients with MS should focus on optimal management of medical co-morbidities and infections.

National Survey of Pediatric Care Providers: Assessing Time and Impact of Coding and Documentation in Physician Practice.

BACKGROUND: Documentation and billing/coding are essential to medical practice. Physicians spend significant time documenting to meet coding and medicolegal requirements, potentially reducing time for patient care and learning. We sought to assess time spent charting in pediatric practice and provider understanding and comfort level regarding billing/coding. METHODS: An anonymous web-based survey was emailed to members of American Academy of Pediatrics Section of Pediatric Trainees practicing in the United States. RESULTS: A total of 601 trainees responded to the survey. Thirty-seven percent of trainees spent more than half of patient encounter time documenting in outpatient settings while 62% ( P < .01) in inpatient settings. There was a positive correlation between trainees' apprehension about documentation and reporting increased stress due to documentation ( r = 0.32, P < 0.001). Sixty-two percent respondents had no prior training of billing/coding, and >70% feel necessity of including billing/coding in the medical curriculum ( P < 0.0001). CONCLUSIONS: Our study highlights increasing burden of documentation in practice. Majority of pediatric trainees feel the need to including billing/coding skills as a part of medical curriculum.

Objectifying eye movements during rapid number naming: Methodology for assessment of normative data for the King-Devick test.

OBJECTIVE: Concussion is a major public health problem and considerable efforts are focused on sideline-based diagnostic testing to guide return-to-play decision-making and clinical care. The King-Devick (K-D) test, a sensitive sideline performance measure for concussion detection, reveals slowed reading times in acutely concussed subjects, as compared to healthy controls; however, the normal behavior of eye movements during the task and deficits underlying the slowing have not been defined. METHODS: Twelve healthy control subjects underwent quantitative eye tracking during digitized K-D testing. RESULTS: The total K-D reading time was 51.24 (±9.7) seconds. A total of 145 saccades (±15) per subject were generated, with average peak velocity 299.5°/s and average amplitude 8.2°. The average inter-saccadic interval was 248.4 ms. Task-specific horizontal and oblique saccades per subject numbered, respectively, 102 (±10) and 17 (±4). Subjects with the fewest saccades tended to blink more, resulting in a larger amount of missing data; whereas, subjects with the most saccades tended to make extra saccades during line transitions. CONCLUSIONS: Establishment of normal and objective ocular motor behavior during the K-D test is a critical first step towards defining the range of deficits underlying abnormal testing in concussion. Further, it sets the groundwork for exploration of K-D correlations with cognitive dysfunction and saccadic paradigms that may reflect specific neuroanatomic deficits in the concussed brain.

Optic neuropathy in late-onset neurodegenerative Chédiak-Higashi syndrome.

BACKGROUND: The classic form of Chédiak-Higashi syndrome (CHS), an autosomal recessive disorder of lysosomal trafficking with childhood onset caused by mutations in ITALIC! LYST, is typified ophthalmologically by ocular albinism with vision loss attributed to foveal hypoplasia or nystagmus. Optic nerve involvement and ophthalmological manifestations of the late-onset neurodegenerative form of CHS are rarely reported and poorly detailed. METHODS: Case series detailing ophthalmological and neurological findings in three adult siblings with the late-onset form of CHS. RESULTS: All three affected siblings lacked features of ocular albinism and demonstrated significant optic nerve involvement as evidenced by loss of colour and contrast vision, central visual field loss, optic nerve pallor, retinal nerve fibre layer thinning by optical coherence tomography (OCT) and abnormal visual evoked potential, with severity corresponding linearly to age of the sibling and severity of neurological disease. Further, unusual prominence of a 'third line' on macular OCT that may be due to abnormal melanosomes was seen in all three siblings and in their father. Neurological involvement included parkinsonism, cerebellar ataxia and spastic paraparesis. CONCLUSIONS: This report expands the ophthalmological phenotype of the late-onset neurodegenerative form of CHS to include optic neuropathy with progressive vision loss, even in the absence of ocular albinism, and abnormal prominence of the interdigitation zone between cone outer segment tips and apical processes of retinal pigment epithelium cells on macular OCT.