Use of postictal respiratory pattern to discriminate between convulsive psychogenic nonepileptic seizures and generalized tonic-clonic seizures.

Distinguishing between generalized tonic-clonic seizures (GTCSs) and convulsive psychogenic nonepileptic seizures (PNESs) can be difficult at the bedside, and this distinction has important implications for patient care. This study used a fully blinded method to examine postictal breathing parameters to identify features distinguishing between generalized tonic-clonic seizures (GTCSs) and convulsive psychogenic nonepileptic seizures (PNESs). Three blinded readers examined edited video recordings of the postictal phase of 72 convulsive seizure episodes recorded from 56 patients. There were 59 GTCS episodes and 13 PNES episodes. Postictal breathing after a PNES episode was more rapid than after a GTCS episode and, thereafter, normalized more rapidly. Postictal breathing after a GTCS episode was more likely to be characterized by stertorous respirations. Postictal breathing after a PNES episode was very unlikely to be characterized by stertorous respirations. Postictal respiratory pattern can assist in discriminating between GTCS and convulsive PNES.

Using the Internet to recruit patients for epilepsy trials: results of a New Zealand pilot study.

PURPOSE: We created a database that could be accessed via the Internet by any neurologist or pediatric neurologist in New Zealand. The database was designed to facilitate recruitment of patients for investigator-driven drug trials. METHODS: We established an epilepsy database, and invited neurologists and pediatric neurologists throughout New Zealand to register patients via the Internet when they were uncertain of the optimal management. Details regarding seizure type and frequency, epilepsy syndrome, etiology, drug history, and investigations were collected. We produced an algorithm to select patients who had failed to respond to a single antiepileptic drug (AED). These patients were randomized immediately via the Internet to receive a different drug. Participants were not reimbursed. RESULTS: The pilot study recruited patients from mid-June to December 2007. Sixteen neurologists participated; neurologists were based in eight different cities. One hundred thirty-seven patients were registered, of whom 113 were considered suitable for drug trials. Thirty-five patients who had used a single antiepileptic drug AED were enrolled, and 14 of these were successfully randomized online to a different drug. Follow-up information was entered via the Internet for all 108 patients who were seen again during the following year. DISCUSSION: We have demonstrated that patients can be recruited for trials and randomized from routine clinics via the Internet. Trials could compare AEDs or look at other aspects of epilepsy management. An international pilot study is planned. Neurologists are invited to enroll patients with epilepsy, who would be suitable for randomized controlled trials, into a Web-based register.

EpiNet as a way of involving more physicians and patients in epilepsy research: Validation study and accreditation process.

OBJECTIVE: EpiNet was established to encourage epilepsy research. EpiNet is used for multicenter cohort studies and investigator-led trials. Physicians must be accredited to recruit patients into trials. Here, we describe the accreditation process for the EpiNet-First trials. METHODS: Physicians with an interest in epilepsy were invited to assess 30 case scenarios to determine the following: whether patients have epilepsy; the nature of the seizures (generalized, focal); and the etiology. Information was presented in two steps for 23 cases. The EpiNet steering committee determined that 21 cases had epilepsy. The steering committee determined by consensus which responses were acceptable for each case. We chose a subset of 18 cases to accredit investigators for the EpiNet-First trials. We initially focused on 12 cases; to be accredited, investigators could not diagnose epilepsy in any case that the steering committee determined did not have epilepsy. If investigators were not accredited after assessing 12 cases, 6 further cases were considered. When assessing the 18 cases, investigators could be accredited if they diagnosed one of six nonepilepsy patients as having possible epilepsy but could make no other false-positive errors and could make only one error regarding seizure classification. RESULTS: Between December 2013 and December 2014, 189 physicians assessed the 30 cases. Agreement with the steering committee regarding the diagnosis at step 1 ranged from 47% to 100%, and improved when information regarding tests was provided at step 2. One hundred five of the 189 physicians (55%) were accredited for the EpiNet-First trials. The kappa value for diagnosis of epilepsy across all 30 cases for accredited physicians was 0.70. SIGNIFICANCE: We have established criteria for accrediting physicians using EpiNet. New investigators can be accredited by assessing 18 case scenarios. We encourage physicians with an interest in epilepsy to become EpiNet-accredited and to participate in these investigator-led clinical trials.

Thoracic Myelopathy Due to Gnathostomiasis Acquired in New Zealand.

Gnathostomiasis is a zoonotic disease endemic in Asia. It most commonly manifests as gastrointestinal and cutaneous disease. Central nervous system involvement is a rare but feared complication, often leaving patients with permanent neurologic deficits. Clinicians outside of Asia and Latin America may have little experience with this illness, causing delays in diagnosis and treatment. We describe a 40-year-old woman who developed a progressive myelopathy over 18 months. She had never traveled outside of New Zealand. Cerebrospinal fluid (CSF) showed marked eosinophilia and Gnathostoma serology was positive in both serum and CSF. This is the first report of gnathostomiasis acquired in New Zealand, and the first case of neurognathostomiasis reported outside Asia. Clinicians should include neurognathostomiasis in the differential diagnosis of myelopathy and CSF eosinophilia, even if there is no history of travel to endemic areas.

Leprosy in a backpacker.

Leprosy is the most common cause of peripheral neuropathy in the developing world. It is not expected to be acquired by visitors traveling through these countries. We present a backpacker who contracted leprosy during brief stays in endemic countries.

New Zealand's neurologist workforce: a pragmatic analysis of demand, supply and future projections.

AIMS: To estimate current and future specialist neurologist demand and supply to assist with health sector planning. METHODS: Current demand for the neurology workforce in New Zealand was assessed using neuroepidemiological data. To assess current supply, all New Zealand neurology departments were surveyed to determine current workforce and estimate average neurologist productivity. Projections were made based on current neurologists anticipated retirement rates and addition of new neurologists based on current training positions. We explored several models to address the supply-demand gap. RESULTS: The current supply of neurologists in New Zealand is 36 full-time equivalents (FTE), insufficient to meet current demand of 74 FTE. Demand will grow over time and if status quo is maintained the gap will widen. CONCLUSIONS: Pressures on healthcare dollars are ever increasing and we cannot expect to address the identified service gap by immediately doubling the number of neurologists. Instead we propose a 12-year strategic approach with investments to enhance service productivity, strengthen collaborative efforts between specialists and general service providers, moderately increase the number of neurologists and neurology training positions, and develop highly skilled non-specialists including trained.

Asymmetric oro-facial angioedema following alteplase for acute ischaemic stroke.

We present a patient with asymmetric oro-facial angioedema following thrombolysis for acute ischaemic stroke with serial photographs of this phenomenon. We discuss the mechanism for the development of asymmetric oro-facial oedema following thrombolysis and suggest a management plan.

Reversible cerebral vasoconstriction following carotid endarterectomy.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by the triad of severe "thunderclap" headaches, neurological symptoms and transient segmental cerebral arterial vasoconstriction. We report a patient with RCVS following carotid endarterectomy and review the literature on RCVS following carotid revascularisation.

Nitrous oxide use in first-year students at Auckland University.

In a recent Lancet Case report, a patient presented with subacute combined degeneration of the spinal cord after recreational use of nitrous oxide (N2O). There is very little information about use of this substance as a recreational drug. In a questionnaire-based study, we surveyed 1782 students in their first year at the University of Auckland, New Zealand. 1360 (76%) questionnaires were completed and consistent. 780 (57%) students were aware of recreational use of N2O, 158 (12%) used the substance recreationally, and 39 (3%) inhaled it at least monthly. Users were most likely to be white and to be men. Our results show a high frequency of recreational N2O use in first-year students at Auckland University. Although this study does not accurately reflect use of this substance in the wider community, the high prevalence suggests that presentations of subacute myelopathy in an otherwise fit young person should prompt an enquiry about use of N2O.