Neurology. Clinical practice最新文献

{"title":"Prevention of Cerebrovascular Emergencies in Spaceflight: A Review and a Proposal for Enhanced Medical Screening Guidelines.","authors":"Mark J Rosenberg, Brian F Saway, William J Tarver, James H Pavela, Jacob Hall, Sami Al Kasab, Guilherme Porto, Donna R Roberts","doi":"10.1212/CPJ.0000000000200445","DOIUrl":"10.1212/CPJ.0000000000200445","url":null,"abstract":"<p><strong>Purpose of review: </strong>A growing number of opportunities for paying customers to travel to space are becoming available. Preflight medical screening of these potential private astronauts will likely be performed by local physicians, with referral to specialists in aerospace medicine as required for more in-depth evaluation before flight qualification. Neurologic concerns contribute a portion of the potential medical risks for these private astronauts, especially with the participation of more diversified crews than traditional governmental astronauts. The objective of this article was to review the current knowledge base concerning cerebrovascular adaptation to spaceflight to inform risk factor assessment for flight-associated cerebrovascular emergencies by the neurologic community when performing initial medical screening of potential private astronauts.</p><p><strong>Recent findings: </strong>A review of published human spaceflight studies and medical guidelines regarding cerebrovascular risks for spaceflight was conducted. Most of the available literature describes cohorts of a small number of astronauts undergoing spaceflight missions of various flight profiles. While there are gaps in the literature, cerebrovascular adaptation to spaceflight occurs, which may alter the medical risk profile in susceptible individuals. The occurrence of an inflight cerebrovascular emergency could have devastating consequences; therefore, additional screening tests may be required, based on risk level and mission profile, in assessing the more diverse commercial spaceflight population expected over the next decade.</p><p><strong>Summary: </strong>With increasing interest in commercial space tourism among diverse participant populations, the stroke risk in microgravity/reduced gravity environments is unknown. Furthermore, stresses of rocket ascent/descent, abnormal fluid dynamics in microgravity, altered atmospheric conditions, and other unknown occupational hazards add additional complexity. Because inflight emergency management protocols have yet to be developed, the most effective tool to ensure spaceflight participant safety is comprehensive preflight preventative screenings. Determining neurologic risk factors is critical for developing evidence-based guidelines for preventative measures and treatment protocols in the future.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200445"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11966524/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780660","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementation of 2HELPS2B Seizure Risk Score: A Cost-Effective Approach to Seizure Detection in the Intensive Care Units.","authors":"Fazila Aseem, Emily Fink, Chuning Liu, John Whalen, Jessica Werdel, Parin Nanavati, Fei Zou, Angela Wabulya, Casey Olm-Shipman, Suzette Maria LaRoche, Clio Rubinos","doi":"10.1212/CPJ.0000000000200464","DOIUrl":"10.1212/CPJ.0000000000200464","url":null,"abstract":"<p><strong>Background and objectives: </strong>Continuous EEG (cEEG) has become a standard for monitoring critically ill patients, but it is resource-intensive with limited availability. The 2HELP2B seizure risk score can help stratify seizure risk and aid in clinical decision making to optimize duration of monitoring. This study aimed to incorporate the 2HELPS2B score to inform cEEG duration and provide cost-effective care without compromising seizure detection.</p><p><strong>Methods: </strong>We conducted a quality improvement study that targeted clinical workflow and seizure risk stratification in the intensive care units of a tertiary academic hospital. The study included adult patients who underwent cEEG between June 2020 and December 2022 (n = 552), after excluding patients undergoing cEEG for management of status epilepticus, spell characterization, intracranial pressure monitoring, and post-cardiac arrest (n = 129). We performed a retrospective chart review to establish baseline cEEG volume, seizure incidence, and monitoring duration. We then introduced the 2HELPS2B risk score through multidisciplinary education and used published recommendations to suggest optimal cEEG duration. After the intervention, we analyzed the impact of integrating the 2HELPS2B score on cEEG duration and seizure detection rates.</p><p><strong>Results: </strong>Of 552 patients, most were low risk (n = 311, 56.3%), followed by moderate risk (n = 189, 34.2%) and high risk (n = 52, 9.4%). Before the intervention, cEEG duration was similar for all risk groups. After implementation of the 2HELPSB score, there was a significant reduction in cEEG duration for low-risk and moderate-risk patients (low 36.3 vs 23.8 hours; <i>p</i> < 0.0001, moderate 36.5 vs 29.3 hours; <i>p</i> = 0.01) and no significant change for the high-risk group (41.3 vs 40.4 hours; <i>p</i> = 0.92). Seizure detection was low except for the high-risk group (1.3% vs 7.9% vs 39.1%). Reduction in cEEG duration after implementation of the 2HELPS2B score did not lead to a significant change in seizure detection (0.6% vs 9% vs 37.9%).</p><p><strong>Discussion: </strong>Most critically ill patients had low or moderate seizure risk and, accordingly, a low incidence of seizures detected during cEEG. Implementing the 2HELPS2B seizure risk score allowed customization of cEEG duration for individual patients, applying the practice of precision medicine. This approach successfully improved cEEG utilization without compromising seizure detection. In conclusion, implementing seizure risk stratification can provide cost-effective monitoring and improve cEEG access.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200464"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11962049/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictors of Health Care Utilization for Individuals With Manifest Huntington Disease.","authors":"Amy C Ogilvie, Ryan M Carnahan, Adys Mendizabal, Stephanie Gilbertson-White, Aaron T Seaman, Elizabeth A Chrischilles, Jordan L Schultz","doi":"10.1212/CPJ.0000000000200471","DOIUrl":"10.1212/CPJ.0000000000200471","url":null,"abstract":"<p><strong>Background and objectives: </strong>There is a need to understand how different factors influence health care utilization for patients with Huntington disease (HD) to maximize benefits of primary and specialty care while minimizing need for costly emergency visits or hospitalizations. The primary objective of this study was to characterize how settings where patients with HD in Northern America receive care change throughout the disease course and determine whether the likelihood of different types of service utilization is influenced by clinical, sociodemographic, and caregiver characteristics.</p><p><strong>Methods: </strong>Data from the Enroll-HD study and joinpoint regression were used to assess trends in neurology visits, general practitioner visits, emergency department visits, and inpatient stays over the disease course and as a function of total functional capacity. Generalized estimating equation models were then used to identify factors associated with use of these different services in the 6 months before their study visit.</p><p><strong>Results: </strong>Visits from 1,631 participants in the Northern America region from the Enroll-HD study were included in this study. Trends in neurology, emergency, and inpatient visits remained constant over most of the disease duration. For the general practitioner visits, there was an increasing trend in use throughout the course of disease. Clinical factors, such as psychiatric symptoms, functional ability, and comorbidities, were associated with use of multiple types of health care services. Sociodemographic and caregiver factors, such as race or ethnicity, urban or rural residence, and caregiver employment status, were also associated with use of multiple health care services.</p><p><strong>Discussion: </strong>Clinical, sociodemographic, and caregiver-related factors were all associated with outpatient, emergent, and inpatient care. This work identifies multiple avenues for future research on how to improve access to and quality of care for patients with HD, specifically relating to reducing the need for emergency visits and inpatient stays and promoting collaboration among primary and specialty clinicians.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200471"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12021023/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144025511","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"To Take or Not to Take Antiseizure Medications: Patient-Centered Decision-Making About Discontinuation After Seizure Freedom.","authors":"Wesley T Kerr, Katherine N McFarlane","doi":"10.1212/CPJ.0000000000200482","DOIUrl":"10.1212/CPJ.0000000000200482","url":null,"abstract":"","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200482"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12054742/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144020356","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Suicidal Ideation and Sleep Disturbances Among People With Huntington Disease: Evidence From the HDBOI Study.","authors":"Idaira Rodríguez Santana, Samuel A Frank, Tiago A Mestre, Astri Arnesen, Jamie L Hamilton, Hayley Hubberstey, Michaela Winkelmann, Elena Hernandez-Jimenez, Jeff Frimpter, Ricardo Dolmetsch, Talaha M Ali","doi":"10.1212/CPJ.0000000000200461","DOIUrl":"10.1212/CPJ.0000000000200461","url":null,"abstract":"<p><strong>Background and objectives: </strong>Suicidal ideation and sleep disturbances are more common among people with Huntington disease (PwHD) than otherwise healthy peers; however, the scope and magnitude of these challenges are not well understood. This study evaluated suicidal thoughts and sleep disturbances among PwHD in Europe and the United States using data from the Huntington's Disease Burden of Illness (HDBOI) study.</p><p><strong>Methods: </strong>The HDBOI study is a cross-sectional burden-of-illness study of PwHD in France, Germany, Italy, Spain, the United Kingdom, and the United States. Eligible participants were adults (18 years and older) with motor manifest Huntington disease (HD) ≥ 12 months before study recruitment. PwHD were categorized as having early-stage (ES), mid-stage (MS), or advanced-stage (AS) HD as reported by the treating physician. Data were collected by the physician, and a voluntary questionnaire was completed by the PwHD or a caregiver. All findings were analyzed descriptively. Differences were assessed using analysis of variance or χ² tests.</p><p><strong>Results: </strong>A total of 2,094 PwHD were included; 1,602 (77%) were from Europe and 492 (23%) were from the United States, with 846 (40%) with ES, 701 (33%) with MS, and 547 (26%) with AS HD. PwHD reported current (13%, n = 272) or previous (28%, n = 575) suicidal ideation, which was more common with advanced HD (ES, 11%; MS, 14%; AS, 15%; <i>p</i> < 0.05). Of 482 questionnaire respondents, 91% (n = 437) reported difficulty sleeping, which was more common with AS HD (<i>p</i> < 0.05; [<i>p</i> = 0.000]).</p><p><strong>Discussion: </strong>The HDBOI study showed a substantial burden of suicidal ideation and sleep disturbances among PwHD, which tended to worsen with disease severity.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200461"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11962051/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143772928","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality Improvement Initiative to Implement Anxiety Screening for Children and Teens With Headache and Epilepsy.","authors":"Christina Murphy, Sara E Molisani, Amanda C Riisen, Carinna M Scotti-Degnan, Dina Karvounides, Stephanie Witzman, Michael C Kaufman, Alexander K Gonzalez, Mark Ramos, Christina L Szperka, Nicholas S Abend","doi":"10.1212/CPJ.0000000000200458","DOIUrl":"10.1212/CPJ.0000000000200458","url":null,"abstract":"<p><strong>Background and objectives: </strong>We conducted a quality improvement initiative to implement standardized screening for anxiety among adolescents with headache and/or epilepsy receiving outpatient neurology care at a quaternary health care system, consistent with recommendations from the American Academy of Neurology. Our SMART (Specific, Measurable, Achievable, Relevant, and Time-Based) aim was to screen ≥90% of established patients aged 12 years or older seen by a participating health care professional using a standardized anxiety screener by February 2024.</p><p><strong>Methods: </strong>This initiative was conducted in patients seen for follow-up by 17 participating neurology health care professionals. Health care professional opinions were assessed before and after implementation of the Generalized Anxiety Disorder-7 (GAD-7), administered as a previsit questionnaire distributed using the electronic health record. The integrated workflow included a best practice advisory (BPA) alert that permitted easy access to interventions and automatic population of education materials into the after-visit summary. After 12 months of use (March 2023 to February 2024), we assessed demographic and diagnostic information, GAD-7 completion rates, anxiety symptom severity, BPA utilization, and health care professional acceptance of the intervention.</p><p><strong>Results: </strong>The GAD-7 was completed for 64% of 3,671 encounters and by 71% of 2031 unique patients. The GAD-7 was more often completed for encounters if the patient was female, younger, or White or had a headache diagnosis. Among unique patients, anxiety symptoms were minimal in 50%, mild in 24%, moderate in 17%, and severe in 10%. Severe anxiety symptoms were more often present in female patients or those with a headache diagnosis. Among patients with severe anxiety symptoms, 66% had established behavioral health care plans and, for remaining patients, referrals were made to community behavioral health care professionals (11%), or pediatric psychologists (4%) or social workers (3%) within neurology. Clinicians indicated that the approach was easy to use and improved the quality of patient care.</p><p><strong>Discussion: </strong>We implemented standardized EHR-based screening for anxiety symptoms for pediatric neurology patients, most of whom had headache or epilepsy. Screening was feasible, and approximately one-quarter of patients had moderate or severe anxiety symptoms. Future work will focus on improving completion rates of previsit questionnaires including the GAD-7 and optimizing clinician actions based on the screening data.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200458"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11962050/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143780716","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Malignancy Workup in Cryptogenic Stroke: A Survey of Canadian Stroke and Thrombosis Experts.","authors":"Laurence Poirier, Deborah M Siegal, Dominick Bossé, Jamie Brehaut, Brian Dewar, Ronda Lun, Michel Christopher Frank Shamy, Dar Dowlatshahi","doi":"10.1212/CPJ.0000000000200477","DOIUrl":"https://doi.org/10.1212/CPJ.0000000000200477","url":null,"abstract":"<p><strong>Background and objectives: </strong>The diagnostic workup for patients with cryptogenic stroke includes investigating for occult cancer, which is known to increase the risk of stroke. Current guidelines do not provide specific recommendations regarding the optimal approach for occult cancer screening after cryptogenic stroke. We surveyed Canadian stroke and thrombosis physicians to determine current workup preferences for detecting occult cancer after cryptogenic stroke.</p><p><strong>Methods: </strong>We designed and distributed an anonymous online survey targeting physicians who manage patients with cryptogenic stroke through professional memberships of the Canadian Stroke Consortium and Thrombosis Canada. Using 4 clinical scenarios representative of patients with cryptogenic stroke with different ages (younger or older than 50 years) and from both sexes, we asked respondents which tests they routinely recommend when investigating for occult cancer among a list of laboratory investigations, imaging, and procedures. Results were analyzed using descriptive statistics.</p><p><strong>Results: </strong>We received 138 responses to 5 survey questions. The most commonly recommended investigations were complete blood count (79%), creatinine (63%), and coagulation tests (56%), and the most frequently recommended imaging test was CT of the abdomen and pelvis (39%). A minority of respondents indicated they would order guideline-directed age-appropriate cancer screening. Approximately half of surveyed specialists deferred the workup of cancer to a primary care physician, and 12% did not suggest any cancer workup at all.</p><p><strong>Discussion: </strong>This survey of stroke and thrombosis experts found heterogeneity in testing for cancer screening in patients with cryptogenic stroke, with the majority either not screening at all or deferring tests to primary care providers. Our survey highlights the need for better evidence and evidence-based recommendations to guide the approach to cancer screening in this population.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200477"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12051394/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144040581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Psychosis in Neurocognitive Disorder Among Ethnoculturally Diverse Older Persons.","authors":"Estevana Isaac, Carolyn Wei Zhu, Monica Rivera Mindt, Albert L Siu, Alex Federman, Kristine Yaffe, Barbara G Vickrey, Jenifer Voeks, Parul Agarwal, Derrick Brooks, Ombolanle Ayo, Mary Sano","doi":"10.1212/CPJ.0000000000200467","DOIUrl":"10.1212/CPJ.0000000000200467","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background and objectives: &lt;/strong&gt;There is longstanding evidence that the presence of psychosis in neurocognitive disorders (NCDs) is associated with faster cognitive and functional decline. The goal of this study was to examine how clinician-diagnosed psychosis differs among ethnoracial groups with NCDs (including early onset) and to explore whether these differences exist even for those without advanced dementia.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Method: &lt;/strong&gt;This is an IRB-approved retrospective analysis. Data are from the National Alzheimer's Coordinating Center Uniform Dataset from 42 Alzheimer's Disease Research Centers. Participants aged 40-95 years as of June 2023 with mild cognitive impairment (MCI) or dementia on baseline evaluation were included. Psychosis was defined as clinician-diagnosed visual or auditory hallucinations or delusions manifesting at the time of baseline evaluation. Ethnoracial groups were self-reported. Associations between ethnoracial groups and psychosis in NCDs were estimated using adjusted multivariable logistic regression with dichotomous measures of outcomes. Covariates included age, sex, years of education, severity of cognitive impairment (Clinical Dementia Rating scale), and presence or absence of any self-reported preexisting psychiatric illness. An analysis by age younger than 65 years was also conducted. Exploratory multivariable logistic regression analyses were performed for participants with milder stages of dementia (Clinical Dementia Rating 0.5 or 1) and for the subset of participants diagnosed with MCI.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 22,854 participants were included. The mean age was 73 + 9.7 years, and 50% were women. A total of 8,352 (37%) had MCI and 14,502 (63%) had dementia. In adjusted analysis, American Indian/Alaska Native (AI/AN) (OR 2.70, 1.75-4.17, &lt;i&gt;p&lt;/i&gt; &lt; 0.0001), Black-Latino (OR 2.33, 1.25-4.35, &lt;i&gt;p&lt;/i&gt; = 0.0076), Other-Latino (OR 1.82, 1.42-2.33, &lt;i&gt;p&lt;/i&gt; &lt; 0.0001), Black, non-Latino (NL) (OR 1.66,1.47-1.87, &lt;i&gt;p&lt;/i&gt; &lt; 0.0001), and White-Latino (OR 1.42, 1.21-1.67, &lt;i&gt;p&lt;/i&gt; &lt; 0.0001) participants had greater odds of any psychotic symptom than White-NL participants. For age groups 40 to younger than 65 years, only Black-NL participants (OR 1.56, 1.13-2.14, &lt;i&gt;p&lt;/i&gt; = 0.0064) were more likely to be diagnosed with any psychotic symptoms. For milder stages of dementia, Black-Latino (OR 3.44, 1.58-7.48, &lt;i&gt;p&lt;/i&gt; = 0.0018), AI/AN (OR 2.73, 1.66-4.48, &lt;i&gt;p&lt;/i&gt; &lt; 0.0001), Other-Latino (OR 2.38, 1.72-3.30, &lt;i&gt;p&lt;/i&gt; &lt; 0.0001), Black-NL (OR 2.08,1.77-2.45, &lt;i&gt;p&lt;/i&gt; &lt; 0.0001), and White-Latino (OR 1.55, 1.23-1.95, &lt;i&gt;p&lt;/i&gt; = 0.0002) participants had greater odds of psychosis in NCDs when compared with White-NL participants. For MCI alone, there were no significant differences.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Discussion: &lt;/strong&gt;Black-NL, Latino, and AI/AN individuals were more likely to be diagnosed with psychosis in NCDs when compared with White-NL participants. More research is needed to explore s","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200467"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12048866/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143972742","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Benzodiazepine Initiation and the Risk of Falls or Fall-Related Injuries in Older Adults Following Acute Ischemic Stroke.","authors":"Shuo Sun, Victor Lomachinsky, Louisa H Smith, Joseph P Newhouse, M Brandon Westover, Deborah Lynne Blacker, Lee H Schwamm, Sebastien Haneuse, Lidia M V R Moura","doi":"10.1212/CPJ.0000000000200452","DOIUrl":"10.1212/CPJ.0000000000200452","url":null,"abstract":"<p><strong>Background and objectives: </strong>Benzodiazepine (BZD) use in older adults after acute ischemic stroke (AIS) is common. We aimed to assess the risk of falls or fall-related injuries (FRIs) in older adults after the use of BZDs during the acute poststroke recovery period.</p><p><strong>Methods: </strong>We emulated a hypothetical randomized trial of BZD use during the acute poststroke recovery period using linked data from the Get With the Guidelines Stroke Registry and Mass General Brigham's electronic health records. Our cohort included patients aged 65 years and older with an AIS admission between 2014 and 2021, no documented previous stroke, and no BZD prescriptions in the 3 months before admission. The potential for immortal time and confounding bias was addressed separately using inverse probability weighting.</p><p><strong>Results: </strong>We analyzed data from 495 patients who initiated inpatient BZDs within 3 days of admission and 2,564 who did not. After standardization, the estimate was 694 events per 1,000 (95% CI 676-709) for the BZD initiation strategy and 584 events per 1,000 (95% CI 575-595) for the noninitiation strategy. Subgroup analyses showed risk differences of 142 events per 1,000 (95% CI 111-165) and 85 events per 1,000 (95% CI 64-107) for patients aged 65-74 years and 75 years and older, respectively. Risk differences were 187 events per 1,000 (95% CI 159-206) for patients with minor (NIH Stroke Severity Scale score <math><mrow><mo>≤</mo></mrow> </math> 4) AIS and 32 events per 1,000 (95% CI 10-58) for those with moderate-to-severe AIS.</p><p><strong>Discussion: </strong>Initiating BZDs within 3 days of an AIS is associated with an elevated ten-day risk of falls or FRIs, particularly for patients aged 65-74 years and for those with mild stroke. This underscores the need for caution when initiating BZDs, especially among individuals likely to be ambulatory during the acute and subacute poststroke period.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200452"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11936338/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143720854","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient Perspectives on Antiseizure Medication Discontinuation: A Mixed-Methods Exploration of Risk Perception, Tolerance, and Counseling.","authors":"Samuel W Terman, Jordan M Silva, Max Kuster, Jasper Lee, Amanda P Brand, Kara Manuel, Navya Kalia, Micaela Dugan, Marla Reid, Katherine Mortati, Alexandra Tolmasov, Palak S Patel, James F Burke, Arthur C Grant, Chloe E Hill, Susanna S O'Kula","doi":"10.1212/CPJ.0000000000200475","DOIUrl":"10.1212/CPJ.0000000000200475","url":null,"abstract":"<p><strong>Background and objectives: </strong>Antiseizure medications (ASMs) are standard treatment for epilepsy. Yet, because ASMs can have adverse effects, guidelines suggest considering ASM withdrawal after a period of seizure freedom. We explored patients' perceived seizure risk, seizure risk tolerance, and risk counseling techniques.</p><p><strong>Methods: </strong>We interviewed adults at least one-year seizure free, seen for epilepsy across 3 academic institutions. Participants rated their own perceived seizure risks (0 \"definitely would not have another seizure\" to 10 \"definitely would\") <i>on</i> vs <i>off</i> ASMs, discussed what minimal clinically important differences would be to justify ASM continuation, rated how likely they might be to withdraw ASMs (1 \"not at all likely\" to 7 \"extremely likely\") under different hypothetical seizure risks, and recalled their previous seizure risk counseling.</p><p><strong>Results: </strong>The median age (N = 32) was 46 years (interquartile range [IQR] 33-56), with a median of 3 years since their last seizure (IQR 2-11). Participants rated their two-year chance of another seizure <i>on</i> ASMs as a median 1 (IQR 0 to 2) on a \"0-10\" scale, compared with a median 5 (IQR 4 to 7) <i>off</i> ASMs. Participants believed that their current ASMs have a median effectiveness of 9 (IQR 7-10) on a \"0-10\" scale. Participants believed that a median effectiveness of 6 (IQR 4 to 9) on a \"0-10\" scale would warrant remaining on ASMs, although 5 participants would continue their ASM if it extended the time until next seizure by any amount no matter how small. Regarding how likely they would be to withdraw ASMs under different hypothetical seizure risks, median responses on a \"1-7\" scale were 5 (IQR 1-6) when shown two-year seizure risks of 10% <i>on</i> vs 11% <i>off</i> ASMs, 1 (1-3) if 10% vs 20%, and 1 (1-2) if 25% vs 50%. No participant recalled having been presented with numerical seizure estimates regarding possible ASM withdrawal, yet 16 (50%) would like this information particularly in our presented graphical format.</p><p><strong>Discussion: </strong>Participants believed that their ASMs were highly effective and were often reluctant to withdraw. Showing hypothetical seizure risks influenced decisions, and graphical risk communication tools were generally welcomed.</p>","PeriodicalId":19136,"journal":{"name":"Neurology. Clinical practice","volume":"15 3","pages":"e200475"},"PeriodicalIF":2.3,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12054744/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144064203","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}