Neishay Ayub

ObjectivesBurnout can impair clinical judgment and is prevalent across all medical subspecialties. Neurology, in particular, is associated with high rates of burnout and low satisfaction with work-...

Objective: Ceribell Inc.'s point‐of‐care electroencephalographic (EEG) system and artificial intelligence‐based Automated Seizure Burden Estimator (ASBE; ClarityPro) have US Food and Drug Administration clearance for diagnosing electrographic status epilepticus (ESE). The AccuRASE study using ASBE version 6 (V6) showed high negative predictive value (NPV) but limited sensitivity and positive predictive value (PPV) at certain thresholds. Version 8 (V8) is the updated algorithm trained with additional EEG samples. Methods: We tested V8 on the previously used rapid‐response EEG test dataset (not used to train V8). Sensitivity, specificity, PPV, and NPV were compared against blinded expert annotations. ESE, ESE and possible ESE (ESE/pESE), electrographic seizures (ESz), and Esz with highly epileptiform patterns (Esz/HEPs) at burden thresholds of >1%, >10%, >20%, >50%, and >90% were analyzed. Additionally, we evaluated the built‐in ESE and ESE/pESE alerts (≥90% over 5 min, ≥20% over 1 h, or ≥10 continuous minutes of seizure). Results: V8 showed 100% sensitivity at lower thresholds (>10%–20%) for ESE (V6 .86), without a specificity loss (V8 .9 vs. V6 .85), and retained NPV (V8 1.0 vs. V6 .99). Sensitivity at 50% threshold was .86 for ESE (V6 .71), and specificity was .94 (V6 .91); PPV for ESE was 30% for ESE and 80% for ESE/pESE. The specificity for ESE remained high for 90% burden (V8 .96, V6 .97) but the sensitivity dropped (.29 vs. V6 .43). Sensitivity was lower for ESz/HEPs (.54 → .44 at >10% threshold), although the algorithm is not designed to detect HEPs. Built‐in alert analysis showed significantly improved sensitivity for ESE (.57 → .86); specificity and NPV remained high (>.94). Significance: ASBE V8 showed meaningful improvements in sensitivity, continued excellent NPV, and improved built‐in alert accuracy for ESE and ESE/pESE. The best seizure burden threshold for ruling out ESE now is 20% (vs. 10% with V6) and that for ruling in ESE/pESE with reasonable certainty is 50% (vs. 90% with V6).

With increasing efforts to ensure a racially and ethnically diverse physician workforce, it is unclear whether the improved diversity changes in medical schools have been reflected among neurology residents. We aimed to examine the demographic changes of neurology residency applicants and matriculants relative to their medical school graduate counterparts. This was a population-based repeated cross-sectional study of Association of American Medical Colleges data on self-reported race, ethnicity, and gender of US medical school graduates, neurology residency applicants, and neurology residency matriculants from 2007 to 2020. The representation quotient (RQ) for each applicant and matriculant cohort was calculated from the ratio of the percentage of a racial, ethnic, and gender group in the population to that of those graduating medical school. Median RQs greater than 1 indicated that a cohort is overrepresented compared with their medical school graduate counterparts, whereas RQs less than 1 indicated underrepresentation. Mann-Whitney U tests were used to assess statistical changes in representation between applicants and matriculants within each racial and gender identity. Yearly changes in RQ were assessed using linear regressions for each race by gender. Asian men (RQ_app = 1.20 [interquartile range (IQR) 1.13–1.28]), Black men (RQ_app = 1.23 [IQR 0.94–1.39]), and Hispanic men (RQ_app = 1.16 [IQR 0.89–1.29]) were overrepresented as applicants. RQ_app for Asian men remained stagnant while all other applicants trended toward increased representation. Hispanic men were the only group to have a significant increase in RQ_mat during the study period. Asian women (RQ_app = 0.98 vs RQ_mat = 1.12; p = 0.006) and White women (RQ_app = 0.40 vs RQ_mat = 0.79; p < 0.001) experienced increases in representation when transitioning to matriculants. Black men (RQ_app = 1.23 vs RQ_mat = 0.64; p < 0.001) experienced the largest reduction in representation, when comparing applicants with matriculants, among all groups. Black women (RQ_app = 0.58 vs RQ_mat = 0.59; p = 0.49) were underrepresented throughout application. Racially minoritized women were underrepresented among neurology applicants, and most did not show significant increases in representation as matriculants. Black men experienced the largest magnitude reduction in RQ when transitioning from applicants to matriculants. There is a need for greater professional support for applicants from historically underrepresented backgrounds to ensure their equitable recruitment into neurology.

With more women entering the medical workforce, caregiving challenges and family-work conflicts are of growing importance to today's neurologists. The aim of this study was to assess the impact of caregiver (CG) status on academic achievements in neurology, analyze the division of labor and time devoted to domestic responsibilities, and measure family-work conflict in US academic neurology faculty. A total of 19 US neurology departments completed a survey on baseline demographics, academic achievements, CG status, division of domestic time and labor, and responses on a FWC scale. Variables were assessed using independent samples t tests (or Mann-Whitney U for non-normally distributed data) and X² analyses as appropriate, with CGs vs noncaregivers (N-CGs) serving as the independent groups. Women were twice as likely as men to categorize themselves as caregivers (p = 0.005). There were no significant differences in academic achievements between the CG and N-CG groups. However, CG men had a statistically significantly higher number of leadership positions (p = 0.022), number of publications as first or last author (p = 0.020), and number of awards (p = 0.004) when compared with CG women. The percentage of CG women faculty who reported spending more than 22 hours per week on child care was significantly higher than that of CG men (p = 0.003). Caregiver women also reported doing more work at home; taking care of children when they are sick; taking days off work when children are sick; handling more chores related to child care (e.g., managing activities/schedules); and doing laundry, cooking, and cleaning related to child care. Finally, the CG group experienced a higher level of FWC, as evidenced by responses on the FWC scale (p < 0.001). This finding was same for CG women compared with CG men (p = 0.034). Although the caregiving burden did not directly affect academic productivity, it significantly increased FWC in US academic neurology faculty surveyed. Female CG faculty disproportionately shouldered domestic and household responsibilities. Beyond recognizing CG challenges, advocating for a change in paradigm and providing solutions to these pervasive issues could be instrumental in preventing further attrition of professionals from our field, particularly women with caregiving roles.

This position statement serves to establish the American Academy of Neurology (AAN)'s stance on neurology care team's needs for safe prescribing of opioids and research for nonopioid pain alternatives so that the AAN can continue to advocate effectively for its members. While considerable improvements have been made in prescribing practices to address patient pain, opioids remain the most misused prescription medication in the United States. Neurology care teams often care for patients with chronic, complex conditions that include pain disorders such as migraine, peripheral neuropathy, traumatic brain injury, multiple sclerosis, and low back pain and are the 14th most frequent group to prescribe opioids. The AAN is dedicated to upstream approaches to prevent opioid misuse through research aimed at finding alternative therapies for chronic pain, reducing opioid addiction and misuse, and using tools such as electronic prescribing of controlled substances and state prescription monitoring programs to improve the safety of opioid prescribing when opioid treatment is necessary.

Burnout is a context-dependent, global issue among physicians in the medical field who often face job-related stressors, high workloads, and limited or lack of social support or autonomy. Within medicine, neurology is a specialty with high levels of burnout and low levels of work-life satisfaction. We, therefore, conducted this study to evaluate burnout rates among neurologists globally and identify the tools used to evaluate it. Among the 14 articles analyzed, the mean burnout prevalence rate among neurologists ranged from 18.1% to 94% (N = 8,735) across 6 countries (the United States, China, Philippines, Spain, Greece, and Brazil). Assessment of burnout using the Maslach Burnout Inventory (MBI) revealed that almost two-thirds (65.9%) of neurologists (N = 7,816) report experiencing burnout. Ten studies (71.4%) assessed burnout by using the MBI; the other 4 studies used the Copenhagen Burnout Inventory, a survey questionnaire generated by the American Academy of Neurology Stroke Practice Resources Workgroup, the Mini-Z survey, and a single question from the Physician Work Life Study. Among the 5 studies that used the same tool for measuring burnout (22-item MBI) and burnout criteria cutoff (emotional exhaustion [EE] ≥ 27 and/or depersonalization (DP) ≥ 10 subscale), the mean burnout rate ranged from 45% to 67% (p < 0.05, N = 7,816) across 3 countries (China, the United States, and Brazil). Of the studies that used the MBI and reported the 3 subscales of EE, DP, and personal accomplishment (PA), only the mean EE score was statistically different between studies. There were no significant differences detected in burnout rates among residents, among attending physicians, or residents compared with attendings. This meta-analysis of burnout among practicing neurologists reveals that available published data span different levels of training, different sample sizes, and different survey tools with different cutoffs used for burnout within the same tool. Although burnout rates among neurologists were found to differ by country, it is evident from this systematic review that a great deal of neurology physicians are experiencing burnout across the globe. This systematic review may inform future approaches to reduce burnout among neurologists.

The use of rapid response EEG (rr-EEG) has recently expanded in limited-resource settings and as a supplement to conventional EEG to rapidly detect and treat nonconvulsive status epilepticus. The study objective was to test the accuracy of an rr-EEG's automated seizure burden estimator (ASBE). This is a retrospective observational study using multiple blinded reviewers. All consecutive clinical rr-EEG procedures performed between November 2019 and February 2021 at Yale New Haven Hospital, one affiliated community hospital, and one affiliated inner-city regional hospital were included. Three reviewers blindly reviewed each EEG. The reference standard was 2/3 agreement. The co-primary outcome measures were the negative predictive value (NPV) of the ASBE for the detection of electrographic status epilepticus (ESE) or possible ESE (ESE/pESE) (to be used as a screening method to exclude ESE without the need for urgent expert review) and the positive predictive value (PPV, to be used for immediate treatment without requiring urgent expert review). These were assessed using a variety of seizure burden cutoffs determined by the algorithm (>1%, >10%, >20%, >50%, and >90%). In the first 2 hours, a >10% burden cutoff detected 86% (95% CI 42%-100%) of studies with ESE alone and 88% (68%-97%) with ESE/pESE; this >10% cutoff had a NPV of 99% (97%-100%) for ESE and 98% (95%-100%) for ESE/pESE. The specificity at this threshold was 79% (73%-84%) for ESE and 84% (79%-89%) for ESE/pESE, but the PPV was low at 11% (4%-23%) for ESE and 39% (26%-53%) for ESE/pESE. A >90% burden cutoff was 97% (94%-99%) specific for detecting ESE (PPV 33% [7%-70%]) and 99% (97%-100%) specific for detecting ESE/pESE [PPV 78% (40%-97%)], although the sensitivity dropped significantly to 29% (13%-51%) for ESE/pESE and 43% (10%-82%) for ESE at the >90% threshold. The ASBE has high specificity at >90% seizure burden threshold for detecting ESE and ESE/pESE, with good PPV for ESE/pESE, though with only low-to-moderate sensitivity; at this threshold, it can be used to help triage patients for immediate treatment/transfer, urgent expert review, and additional CEEG. A >10% threshold has a high sensitivity, detecting approximately 85% of patients with ESE; at this lower cutoff, it can be used as a screening tool to exclude ESE with >95% NPV. This study provides Class II evidence that ASBE software can reliably exclude ESE (98% negative predictive value using a <10% burden cutoff) without expert review in most patients requiring rapid response EEG.

Most acute symptomatic seizure (ASyS) patients stay on antiseizure medications (ASM) long-term, despite low epilepsy development risk. The Post-Acute Symptomatic Seizure (PASS) clinic is a transition of care model for ASyS patients who individualize ASM management with the goal of a safe deprescription. We evaluated patients discharged on ASMs after a witnessed or suspected ASyS to analyze their PASS clinic visit attendance and its predictors. A single-center, retrospective cohort study of adults without epilepsy who were discharged from January 1, 2019, to September 30, 2019, on first-time ASMs due to witnessed or suspected ASyS (PASS clinic-eligible). We fit a cause-specific Cox proportional hazards model to analyze factors associated with PASS clinic attendance, which depends on survival in this patient population that has a high early postdischarge mortality (a competing risk). We checked for multicollinearity and the assumption of proportional hazards. Among 307 PASS clinic-eligible patients, 95 (30.9%) attended the clinic and 136 (44.3%) died during a median follow-up of 14 months (interquartile range = 2-34). ASyS occurred in 60.2% (convulsive 47%; electrographic 26.7%) of patients. ASMs were continued in the absence of ASyS or epileptiform abnormalities (EAs) in 27% of patients. Multivariable analysis revealed that the presence of EAs (HR = 1.69, 95% CI 1.10-2.59), PASS clinic appointments provided before discharge (HR = 3.39, 95% CI 2.15-5.33), and less frequently noted ASyS etiologies such as autoimmune encephalitis (HR = 2.03, 95% CI 1.07-3.86) were associated with an increased clinic attendance rate. Medicare/Medicaid insurance (HR = 0.43, 95% CI 0.24-0.78, p = 0.005) and the presence of progressive brain injury (i.e., tumors; HR = 0.55, 95% CI 0.32-0.95, p = 0.032) were associated with reduced rate of PASS clinic attendance. Our real-world data highlight the need for appropriate postdischarge follow-up of ASyS patients, which can be fulfilled by the PASS clinic model. Modest PASS clinic attendance can be significantly improved by adhering to a structured discharge planning process whereby appointments are provided before discharge. Future research comparing patient outcomes, specifically safe ASM discontinuation in a PASS clinic model to routine clinical care, is needed.

Ictal asystole is a rare condition associated primarily with temporal lobe epilepsy that can cause syncope, falls and head trauma. It is also associated with increased rates of sudden unexplained death in epilepsy (SUDEP). We present a case of a 33-year-old woman with a history of childhood epilepsy who presented with 3 years of recurrent syncope. Video-EEG revealed temporal lobe seizures with ictal asystole. EKG showed stepwise progression of bradycardia, asystole, and tachycardia. MRI showed focal cortical thickening at the right insular cortex with blurring of the grey-white matter interface, consistent with insular focal cortical dysplasia. The patient was transitioned from lacosamide to clobazam due to concern for PR interval prolongation and was referred to cardiology for pacemaker placement. Ictal asystole should be considered as a rare but serious cause of unexplained recurrent syncope, particularly in patients with a history of seizures. Management includes antiepileptic drug regimen optimization, consideration of epilepsy surgery, and referral for cardiac pacing when asystole lasts greater than 6 seconds.