Masking for School-Age Children With Epilepsy: We Do Have Consensus!

INTRODUCTION: This study was designed to assess current recommendations from child neurologists and epileptologists on masking for school-age children with epilepsy. METHODS: A 7-item survey was created and sent out to members of the Child Neurology Society and Pediatric Epilepsy Research Consortium in August of 2021 to assess current practice and provider recommendations on masking. RESULTS: One hundred four individuals participated with representation from all regions of the United States. Masking was recommended by 95.1%, with 63.4% (n = 66) noting exception of those with severe intellectual disability, autism, and behavioral problems. Of those who write exemption letters, 54% write these <5% of the time. Only 3% reported potential adverse events associated with masking. CONCLUSION: Nearly all respondents recommended masking for school-age children with epilepsy. Potential risks of masking and adverse events were low. Improved guidance on masking is needed to ensure academic success of our patients with epilepsy.

Pediatric Neurologists' Perspectives on Sexual and Reproductive Health Care for Adolescent and Young Adult Women With Epilepsy and Intellectual Disability.

OBJECTIVE: To explore perspectives of pediatric neurologists regarding sexual and reproductive health care for adolescent women with epilepsy (WWE) and intellectual disability. METHODS: We interviewed pediatric neurologists regarding sexual and reproductive health for WWE with intellectual disability. We audio-recorded and transcribed interviews and conducted qualitative analysis. RESULTS: 16 pediatric neurologists participated. Themes included the following: (1) Pediatric neurologists have differing perspectives about how intellectual disability affects WWE's sexual and reproductive health needs, (2) pediatric neurologists provide sexual and reproductive health counseling variable in content and frequency to this population, (3) pediatric neurologists tend to recommend longer-term methods of contraception for this population, and (4) pediatric neurologists are asked to be involved in decision-making around sterilization, yet express ethico-legal reservations. CONCLUSION: Our findings suggest pediatric neurologists provide variable, often suboptimal, sexual and reproductive health care for WWE and intellectual disability. Themes reveal ethical concerns among neurologists about sexual and reproductive health practices including sterilization. More tailored clinical guidelines and provider training on sexual and reproductive health for this population may be beneficial.

North American survey on impact of the COVID-19 pandemic shutdown on DBS care.

BACKGROUND: The initial COVID-19 pandemic shutdown led to the canceling of elective surgeries throughout most of the USA and Canada. OBJECTIVE: This survey was carried out on behalf of the Parkinson Study Group (PSG) to understand the impact of the shutdown on deep brain stimulation (DBS) practices in North America. METHODS: A survey was distributed through RedCap® to the members of the PSG Functional Neurosurgical Working Group. Only one member from each site was asked to respond to the survey. Responses were collected from May 15 to June 6, 2020. RESULTS: Twenty-three sites participated; 19 (83%) sites were from the USA and 4 (17%) from Canada. Twenty-one sites were academic medical centers. COVID-19 associated DBS restrictions were in place from 4 to 16 weeks. One-third of sites halted preoperative evaluations, while two-thirds of the sites offered limited preoperative evaluations. Institutional policy was the main contributor for the reported practice changes, with 87% of the sites additionally reporting patient-driven surgical delays secondary to pandemic concerns. Pre-post DBS associated management changes affected preoperative assessments 96%; electrode placement 87%; new implantable pulse generator (IPG) placement 83%; IPG replacement 65%; immediate postoperative DBS programming 74%; and routine DBS programming 91%. CONCLUSION: The COVID-19 pandemic related shutdown resulted in DBS practice changes in almost all North American sites who responded to this large survey. Information learned could inform development of future contingency plans to reduce patient delays in care under similar circumstances.

Immigrant Neurologists in the Physician-Scientist Pipeline: An Intervenable Stenosis.

Immigrant neurologists on a visa make up one-fourth of our neurology resident workforce. In this article, we describe the challenges faced by them in pursuit of a career as physician-scientists. We highlight the key role that immigration status plays in various aspects of research advancement early along the neurology pipeline, pertaining to clinical career decisions and the associated delay in achieving these milestones. We conclude with a call to action to address these key roadblocks, which would have the additional potential benefit of improving inclusion and diversity in clinical and translational science. ANN NEUROL 2021;90:542-545.

Content Validation of Clinician-Reported Items for a Severity Measure for CDKL5 Deficiency Disorder.

CDKL5 deficiency disorder (CDD) results in early-onset seizures and severe developmental impairments. A CDD clinical severity assessment (CCSA) was previously developed with clinician and parent-report items to capture information on a range of domains. Consistent with US Food and Drug Administration (FDA) guidelines, content validation is the first step in evaluating the psychometric properties of an outcome measure. The aim of this study was to validate the content of the clinician-reported items in the CCSA (CCSA-Clinician). Eight neurologists leading the USA CDD Center of Excellence clinics were interviewed using the "think aloud" technique to critique 26 clinician-reported items. Common themes were aggregated, and a literature search of related assessments informed item modifications. The clinicians then participated in 2 consensus meetings to review themes and finalize the items. A consensus was achieved for the content of the CCSA-Clinician. Eight of the original items were omitted, 11 items were added, and the remaining 18 items were revised. The final 29 items were classified into 2 domains: functioning and neurologic impairments. This study enabled refinement of the CCSA-Clinician and provided evidence for its content validity. This preliminary validation is essential before field testing and further validation, in order to advance the instrument toward clinical trial readiness.

Consensus disease definitions for neurologic immune-related adverse events of immune checkpoint inhibitors.

Expanding the US Food and Drug Administration-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in therapeutic success and immune-related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1%-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes development of evidence-based treatments and translational research. The objective of this study was to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. A working group of four neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the multidisciplinary Neuro irAE Disease Definition Panel including oncologists and irAE experts. A modified Delphi consensus process was used, with two rounds of anonymous ratings by panelists and two meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. Aggregated survey responses were incorporated into revised definitions. Consensus was based on numeric ratings using the RAND/University of California Los Angeles (UCLA) Appropriateness Method with prespecified definitions. 27 panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for seven core disorders: irMeningitis, irEncephalitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, six descriptors of diagnostic components are used: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation, and presence or absence of concurrent irAE(s). These disease definitions standardize irAE-N classification. Diagnostic certainty is not always directly linked to certainty to treat as an irAE-N (ie, one might treat events in the probable or possible category). Given consensus on accuracy and usability from a representative panel group, we anticipate that the definitions will be used broadly across clinical and research settings.

Quality of Neurologic Care in the United States: Initial Report From the Axon Registry.

OBJECTIVE: To provide the initial description of the quality of outpatient US neurologic care as collected and reported in the Axon Registry. METHODS: We describe characteristics of registry participants and the performance of neurology providers on 20 of the 2019 Axon Registry quality measures. From the distribution of providers' scores on a quality measure, we calculate the median performance for each quality measure. We test for associations between quality measure performance, provider characteristics, and intrinsic measure parameters. RESULTS: There were 948 neurology providers who contributed a total of 6,480 provider-metric observations. Overall, the average quality measure performance score at the provider level was 66 (median 77). At the measure level (n = 20), the average quality measure performance score was 53 (median 55) with a range of 2 to 100 (interquartile range 20-91). Measures with a lower-complexity category (e.g., discrete orders, singular concepts) or developed through the specialty's qualified clinical data registry pathway had higher performance distributions. There was no difference in performance between Merit-Based Incentive Payment System (MIPS) and non-MIPS providers. There was no association between quality measure performance and practice size, measure clinical topic/neurologic condition, or measure year of entry. CONCLUSIONS: This cross-sectional assessment of quality measure performance in 2019 Axon Registry data demonstrates modest performance scores and considerable variability across measures and providers. More complex measures were associated with lower performance. These findings serve as a baseline assessment of quality of ambulatory neurologic care in the United States and provide insights into future measure design.

Managing depression and anxiety in people with epilepsy: A survey of epilepsy health professionals by the ILAE Psychology Task Force.

Objectives: The Psychology Task Force of the Medical Therapies Commission of the International League Against Epilepsy (ILAE) has been charged with taking steps to improve global mental health care for people with epilepsy. This study aimed to inform the direction and priorities of the Task Force by examining epilepsy healthcare providers' current practical experiences, barriers, and unmet needs around addressing depression and anxiety in their patients. Methods: A voluntary 27-item online survey was distributed via ILAE chapters and networks. It assessed practices in the areas of screening, referral, management, and psychological care for depression and anxiety. A total of 445 participants, from 67 countries (68% high income), commenced the survey, with 87% completing all components. Most respondents (80%) were either neurologists or epileptologists. Results: Less than half of respondents felt adequately resourced to manage depression and anxiety. There was a lack of consensus about which health professionals were responsible for screening and management of these comorbidities. About a third only assessed for depression and anxiety following spontaneous report and lack of time was a common barrier (>50%). Routine referrals to psychiatrists (>55%) and psychologists (>41%) were common, but approximately one third relied on watchful waiting. A lack of both trained mental health specialists (>55%) and standardized procedures (>38%) was common barriers to referral practices. The majority (>75%) of respondents' patients identified with depression or anxiety had previously accessed psychotropic medications or psychological treatments. However, multiple barriers to psychological treatments were endorsed, including accessibility difficulties (52%). Significance: The findings suggest that while the importance of managing depression and anxiety in patients with epilepsy is being recognized, there are ongoing barriers to effective mental health care. Key future directions include the need for updated protocols in this area and the integration of mental health professionals within epilepsy settings.

Epilepsy care and COVID-19: A cross-sectional online survey from Lithuania.

BACKGROUND: Changes in epilepsy care during the COVID-19 pandemic required to reassess the patient-specialist interaction in the context of telehealth and future vaccination campaigns. AIMS OF THE STUDY: The aims were to outline changes in neurologists' experience when providing care for patients with epilepsy (PWE) and to investigate how neurologists perceive telehealth and vaccination. METHODS: We conducted an anonymous cross-sectional online survey among members of the Lithuanian Association of Neurology. RESULTS: We received 104 completed forms by adult (74, 71.15%) and pediatric neurologists (30, 28.85%). A decrease in epilepsy consultations was noted by 76 (73.1%) specialists, and up to 26 (25.0%) could not provide diagnostic tests at a usual rate. Most respondents (99, 95.2%) would recommend the COVID-19 vaccine for patients at risk. Telehealth was valued as a useful tool in epilepsy care, especially if combined with timely diagnostic and treatment options (Kruskal-Wallis chi-square = 10.392, p = .034 and F[4,99] = 3.125, p = .018, respectively). According to 85 (81.7%) respondents, video calls could substitute in-person visits in at least half of all consultations. CONCLUSIONS: Despite disrupted epilepsy care, neurologists may benefit from telehealth when providing services for PWE and become vaccination advocates to mitigate the spread of preventable infections.

Impact of COVID-19 pandemic on epilepsy practice in India: A tripartite survey.

OBJECTIVE: To assess the impact of ongoing COVID-19 pandemic on epilepsy care in India. METHODS: We conducted a three-part survey comprising neurologists, people with epilepsy (PWE), and 11 specialized epilepsy centers across India. We sent two separate online survey questionnaires to Indian neurologists and PWE to assess the epilepsy practice, seizures control, and access to care during the COVID-19 pandemic. We collected and compared the data concerning the number of PWE cared for and epilepsy procedures performed during the 6 months periods preceding and following COVID-19 lockdown from epilepsy centers. RESULTS: The survey was completed by 453 neurologists and 325 PWE. One third of the neurologist reported >50 % decline in outdoor visits by PWE and EEG recordings. The cumulative data from 11 centers showed 65-70 % decline in the number of outdoor patients, video-EEG monitoring, and epilepsy surgery. Working in a hospital admitting COVID-19 patients and use of teleconsultation correlated with this decline. Half of PWE had postponed their planned outpatient visits and EEG. Less than 10 % of PWE missed their antiseizure medicines (ASM) or had seizures due to the nonavailability of ASM. Seizure control remained unchanged or improved in 92 % PWE. Half of the neurologists started using teleconsultation during the pandemic. Only 4% of PWE were afflicted with COVID-19 infection. CONCLUSIONS: Despite significant decline in the number of PWE visiting hospitals, their seizure control and access to ASMs were not affected during the COVID-19 pandemic in India. Risk of COVID-19 infection in PWE is similar to general population.

The Pediatric Neurology 2020 Research Workforce Survey: Optimism in a Time of Challenge.

BACKGROUND: The past decades have seen a transformational shift in the understanding and treatment for neurological diseases affecting infants and children. These advances have been driven in part by the pediatric neurology physician-scientist workforce and its efforts. However, pediatric neurology research faces substantial challenges from internal and external forces including work-life balance demands, COVID-19 pandemic effects, and research funding. Understanding the impact of these challenges on the perceptions, planning, and careers of pediatric neurology physician-scientists is needed to guide the research mission. METHODS: Our objective was to survey the research challenges, goals, and priorities of pediatric neurologists. In 2020 we conducted a cross-sectional, 28-question survey emailed to 1,775 members of the Child Neurology Society. RESULTS: One hundred fifty-one individuals responded to the survey. Most respondents were grant investigators (52%) and conducted clinical research (69%). Research areas included epilepsy (23%), neurodevelopmental and autism (16%), neurocritical care and stroke (11%), neurogenetics and neurometabolics (9%), neonatal neurology (8%), and others. The most common funding source was the National Institutes of Health (37%). Shared major research concerns were funding, utilization of remote technology, overcoming disparities, natural history and multicenter studies, global neurology, and diversification of the research portfolio. Commitment to continuing and increasing research efforts was evident. CONCLUSIONS: Our survey demonstrates obstacles for physician-scientist researchers in pediatric neurology, but it also shows optimism about continued opportunity. Creative approaches to address challenges will benefit the research mission, maximize the current and future pool of researchers, and help improve the lives of children with neurological disorders.

Estudio DISCREPA: tratamiento de la enfermedad de Parkinson avanzada y utilización de terapias de segunda línea en Cataluña / DISCREPA study: treatment of advanced Parkinson's disease and use of second-line treatments in Catalonia

INTRODUCCIÓN: El tratamiento de la enfermedad de Parkinson (EP) es complejo y la instauración de terapias de segunda línea en la EP avanzada sigue siendo controvertida. OBJETIVO: Analizar la asistencia de pacientes con EP en Cataluña, con especial atención a la utilización de las terapias de segunda línea en la EP avanzada. Sujetos y métodos: Encuesta en línea autoadministrada a través de la Societat Catalana de Neurología a neurólogos de Cataluña que atendían a pacientes con EP. RESULTADOS: Participaron 72 neurólogos que visitaban una media mensual de 38 pacientes con EP (el 37,3% con complicaciones motoras). El 86% preguntaba rutinariamente por complicaciones motoras. Los principales motivos para indicar terapias de segunda línea fueron la discapacidad en off (83,1%), el impacto de las discinesias (76,9%), el impacto del tiempo en off (75,4%) y el tiempo en off (73,8%). El 70% de los neurólogos declaró limitaciones para instaurar terapias de segunda línea: escasez de recursos en su hospital, falta de tiempo para visitar al paciente o para realizar tareas administrativas y falta de soporte de enfermería (33,3%). No se utilizan terapias de segunda línea en el 72% de los pacientes que podrían ser potencialmente candidatos, sobre todo por rechazo del paciente (37,9%). CONCLUSIONES: La mayoría de los neurólogos en Cataluña que visitan pacientes con EP pregunta rutinariamente por complicaciones motoras sin utilizar herramientas específicas. Aunque los neurólogos conocen bien las indicaciones de instauración de terapias de segunda línea, la negativa del paciente, la falta de tiempo y la falta de protocolos asistenciales definidos para derivar a pacientes pueden contribuir a una menor utilización de terapias de segunda línea en la EP avanzada

INTRODUCTION: The treatment of Parkinson's disease (PD) is complex, and the establishment of second-line therapies in advanced PD remains controversial. AIM: To analyze the assistance of patients with PD in Catalonia, with special attention to the use of second-line therapies in advanced PD. SUBJECTS AND METHODS: Online self-administered survey to neurologists in Catalonia who treated patients with PD, through the Catalan Society of Neurology. RESULTS: 72 neurologists who visited a monthly average of 38 PD patients (37.3% motor complications) participated. 86% routinely asked about motor. The main reasons for indicating second-line therapies were disability in off (83.1%), impact of dyskinesias (76.9%), impact of time in off (75.4%) and time in off (73.8%). 70% of neurologists declared limitations to establish second-line therapies: lack of resources in their hospital, lack of time to visit the patient or to perform administrative tasks and lack nursing support. Second-line therapies is not used in 72% of patients who could potentially be candidates, especially due to patient rejection (37.9%). CONCLUSIONS: The majority of neurologists in Catalonia who visit patients with PD routinely ask about motor complications without using specific tools. Although neurologists are well aware of the indications for the establishment of second-line therapies, the refusal of the patient, the lack of time and the lack of defined care protocols to refer patients, they can contribute to a lower use of second-line therapies in advanced PD

The migraine signature study: Methods and baseline results.

OBJECTIVE: To characterize patients who utilize services for migraine in a large integrated health care network, and describe patterns of care and utilization. BACKGROUND: Within health care systems, migraine is a common reason for seeking primary and neurology care, but relatively little is documented about who seeks care and the factors that explain variation in utilization. METHODS: We conducted a retrospective cohort study using electronic health record (EHR) data from Sutter Health primary care (PC) patients who had at least one office visit to a PC clinic between 2013 and 2017. Migraine status was ascertained from diagnosis codes and medication orders. Control status was assigned to those with no evidence of care for any type of headache. We divided the primary care migraine cohort into two groups: those who received all their care for migraine from PC (denoted PC-M) and those who had ≥1 encounter with a neurologist for migraine (denoted N-M). Migraine cases were also designated as having preexisting migraine if they had an encounter with a migraine diagnosis within (±) 6 months of their first study period PC visit and, otherwise, designated as first migraine consult. Two levels of contrasts included: patients with migraine and controls; and within the group of patients with migraine, PC-M and N-M groups. Comorbid conditions were determined from EHR encounter diagnosis codes. RESULTS: We identified 94,149 patients with migraine (including 21,525 N-M and 72,624 PC-M) and 1,248,763 controls. Comorbidities: Proportions of psychiatric [29.8% (n = 28,054) vs. 11.8% (n = 147,043)], autoimmune [(4.4% (n = 4162) vs. 2.6% (n = 31,981)], pain [13.2% (n = 12,439) vs. 5.8% (n = 72,049)], respiratory [24.6% (n = 23,186) vs. 12.3% (n = 153,692)], neurologic [2.9% (n = 2688) vs. 0.9% (n = 11,321)], and cerebrovascular [1.0% (n = 945) vs. 0.6% (n = 7500)] conditions were higher in the migraine group compared to controls, all p < 0.001. Among patients with migraine, the N-M group was similar to the PC-M group in sex, age, ethnicity, and marital status, but were more likely to have preexisting migraine (49.9% (n = 10,734) vs. 36.2% (n = 26,317), p < 0.001). Proportions of comorbid conditions were higher among the N-M group than the PC-M group {psychiatric [38.5% (n = 8291) vs. 27.2% (n = 19,763)], autoimmune [6.3% (n = 1365) vs. 3.9% (n = 2797)], pain [19.6% (n = 4218) vs. 11.3% (n = 8211)], respiratory [30.3% (n = 6516) vs. 23.0% (n = 16,670)], neurologic [6.0% (n = 1288) vs. 1.9% (n = 1400)], cardiovascular [9.7% (n = 2091) vs. 7.0% (n = 5076)], and cerebrovascular [2.3% (n = 500) vs. 0.6% (n = 445)], all p < 0.001}. Medications: During the study period, 82.6% (n = 77,762) of patients with migraine received ≥1 prescription order for an acute migraine medication [89.4% (n = 19,250) of N-M vs. 80.6% (n = 58,512) of PC]. Opioids were prescribed to 52.9% (n = 49,837) of patients with migraine [63.5% (n = 13,669) for N-M and 49.8% (n = 36,168) for PC-M patients). During the study period, 61.4% (n = 57,810) of patients received ≥1 prescription for a migraine preventive medication [81.4% (n = 17,521) of N-M and 55.5% (n = 40,289) of PC-M patients]. The most commonly prescribed classes of preventive medications were antidepressants. CONCLUSIONS: Among patients with migraine in a large health system, those who were also cared for in neurology were more likely to receive both acute and preventive medication migraine orders than those patients who did not see a neurologist, with triptans and antidepressants the most commonly prescribed classes of acute and preventive pharmacotherapies, respectively. Opioids were prescribed to approximately half of the total sample and more common in the N-M group. Adjusting for demographics, patients with migraine had higher rates of nearly every comorbidity we assessed and were more likely to utilize services compared to those without migraine. Overall, patients with migraine also cared for in neurology practices used more of all health care resource types under consideration and had more medical issues, which may be due in some part to a more severe, frequent and disabling disease state compared to those who sought care exclusively from PC practices.

Experience of South American MS and/or NMOSD experts in practice during the COVID-19 pandemic: Focus on Telemedicine.

BACKGROUND: COVID-19 pandemic has changed the way to manage MS and NMOSD, not only concerning treatment, but also regarding social distance and the increasing use of telemedicine (TM) to minimize the risk of infection. Currently, there is no data regarding TM among MS and NMOSD South American experts. OBJECTIVE: To investigate TM experiences from South American MS and/or NMOSD experts in the follow-up of their patients focusing on TM. METHODS: A cross-sectional study was performed. 141 MS and/or NMOSD experts from Argentina, Chile, Colombia and Brazil were invited to answer an web-based survey. RESULTS: A total of 129 (91.48 %) experts completed the survey. Only 19.4% had experience in TM previous COVID-19 pandemic, while 79.8% are currently using TM, most using video call (52.3%). Using TM, 44.1% of the experts were able to perform neurological examination, 85.6% believed to be able to identify a relapse, 48.6% use Patient Determined Disease Steps and 38.7% kept using the conventional Expanded Disability Status Scale. CONCLUSION: Our survey demonstrates preparedness and responsiveness among South American MS and/or NMOSD experts.  Despite scarce prior TM experience, most experts felt confident to use TM as a new tool for monitoring their patients.

Child Neurology Applicants Place Increasing Emphasis on Quality of Life Factors.

BACKGROUND: Medical education, residency training, and the structure of child neurology residency training programs are evolving. We sought to evaluate how training program selection priorities of child neurology residency applicants have changed over time. METHODS: An electronic survey was sent to child neurology residents and practicing child neurologists via the Professors of Child Neurology distribution list in the summer of 2018. It was requested that the survey be disseminated to current trainees and alumni of the programs. The survey consisted of seven questions assessing basic demographics and a list of factors applicants consider when choosing a residency. RESULTS: There were 284 responses with a higher representation of individuals matriculating into residency in the last decade. More recent medical school graduates had a lower probability of considering curriculum as an important factor for residency selection (odds ratio [OR], 0.746; 95% confidence interval [95% CI], 0.568 to 0.98; P = 0.035) and higher priority placed on interaction with current residents over the course of the interview day (OR, 2.207; 95% CI, 1.486 to 3.278; P < 0.0001), sense of resident happiness and well-being (OR, 2.176; 95% CI, 1.494 to 3.169; P < 0.0001), and perception of city or geography of the residency program (OR, 1.710; 95% CI, 1.272 to 2.298; P < 0.001). CONCLUSIONS: Over time, child neurology residency applicants are putting more emphasis on quality of life factors over curriculum. To accommodate these changes, child neurology residency programs should prioritize interactions with residents during the interview process and resident wellness initiatives throughout residency training.

Characterizing the providers of and reimbursement for chronic migraine chemodenervation among the Medicare population.

OBJECTIVE: To characterize reimbursement trends and providers for chronic migraine (CM) chemodenervation treatment within the Medicare population since the introduction of the migraine-specific CPT code in 2013. METHODS: We describe trends in procedure volume and total allowed charge on cross-sectional data obtained from 2013 to 2018 Medicare Part B National Summary files. We also utilized the 2017 Medicare Provider Utilization and Payment Data to analyze higher volume providers (>10 procedures) of this treatment modality. RESULTS: The total number of CM chemodenervation treatments rose from 37,863 in 2013 to 135,023 in 2018 in a near-linear pattern (r = 0.999) and total allowed charges rose from ~$5,217,712 to $19,166,160 (r = 0.999). The majority of high-volume providers were neurologists (78.4%; 1060 of 1352), but a substantial proportion were advanced practice providers (APPs) (10.2%; 138 of 1352). Of the physicians, neurologists performed a higher mean number of procedures per physician compared to non-neurologists (59.6 [95% CI: 56.6-62.6] vs. 45.4 [95% CI: 41.0-50.0], p < 0.001). When comparing physicians and APPs, APPs were paid significantly less ($146.5 [95% CI: $145.6-$147.5] vs. $119.7 [95% CI: $117.6-$121.8], p < 0.001). As a percent of the number of total beneficiaries in each state, the percent of Medicare patients receiving ≥1 CM chemodenervation treatment from a high-volume provider in 2017 ranged from 0.024% (24 patients of 98,033 beneficiaries) in Wyoming to 0.135% (997 of 736,521) in Arizona, with six states falling outside of this range. CONCLUSION: Chemodenervation is an increasingly popular treatment for CM among neurologists and other providers, but the reason for this increase is unclear. There is substantial geographic variation in its use.

Evaluation of Prescription Practices of Domperidone in Parkinson's Disease: A Cross Sectional Study Among French Neurologists.

BACKGROUND: Domperidone is used to treat gastrointestinal symptoms in patients with Parkinson's disease. Because of an increased risk of cardiac adverse events, the European Medicines Agency has issued recommendations restricting its use mainly in terms of age, dose, and treatment duration. OBJECTIVE: The aim of this study was to investigate current prescription practices of domperidone in Parkinson's disease among French neurologists. METHODS: A cross-sectional study based on a questionnaire was conducted among French neurologists from Parkinson's disease expert centers from the French NS-Park/FCRIN network, general hospitals, and private practice. RESULTS: Among the 253 neurologists who completed the questionnaire, 86 (34%) were physicians from expert centers and 167 (66%) were from other healthcare settings; 209 (83%) were aware of recommendations restricting domperidone use. The majority of neurologists (92%) declared prescribing domperidone regardless of the age of the patients. Sixty-one percent of neurologists prescribed domperidone beyond 7 days in newly diagnosed patients, 33% in patients with orthostatic hypotension, and 79% in patients receiving continuous apomorphine treatment. They did not follow the recommendation on posology in newly diagnosed patients (7% of neurologists), patients with orthostatic hypotension (10%), and patients receiving continuous apomorphine therapy (25%). Finally, only 58% of neurologists declared taking specific precautions before prescribing domperidone. CONCLUSIONS: These findings show most French neurologists who responded to our questionnaire do not fully follow the restrictions on domperidone use, particularly in terms of treatment duration, and in patients receiving continuous apomorphine treatment. This may reflect the unmet need to prevent nausea in patients with Parkinson's disease treated with dopaminergic drugs, particularly continuous apomorphine therapy.

Education Research: Effect of the COVID-19 pandemic on neurology trainees in Italy: A resident-driven survey.

OBJECTIVE: To assess the effect of the coronavirus disease 2019 (COVID-19) outbreak on neurology resident training in Italy. METHOD: We created a web-based survey regarding changes in clinical, research, and educational activity of neurology trainees in Italy during the COVID-19 pandemic and the preventive measures undertaken by local institutions to reduce the risk of contagion. RESULTS: Seventy-nine residents working in Italy completed the survey. A total of 87.3% of trainees reported a substantial reduction in their neurologic duties since COVID-19 appeared in Italy, and 17.8% were also recruited or volunteered for COVID-19-dedicated wards. Likewise, more than 60% of trainees experienced a reduction or interruption in research activity. As regards the perceived effect of the COVID-19 outbreak on their neurologic training, almost 70% of surveyed trainees believe that the COVID-19 pandemic had or will have a negative effect on their formation as neurologists, for different reasons. Furthermore, trainees reported a consistent exposure (69.6%) to confirmed positive COVID-19 cases at work, with divergent surveillance and preventive measures taken by local institutions. CONCLUSIONS: Overall, the survey shows that the COVID-19 pandemic in Italy has had a subjective negative effect on neurology residents on didactics, clinical, and research training as well as training abroad. The COVID-19 outbreak poses many challenges to academic institutions and training programs, and addressing these issues promptly is crucial to ensure continued quality of trainees' neurologic education. Sharing solutions and ideas among the international neurologic community might help neurology training programs worldwide to better counteract these problems.