Brian Mathew

Consensus‐based recommendations (CBRs) are essential for health care decision‐making when evidence is limited or conflicting. They can be developed using established methodologies such as the Delphi technique, the nominal group technique (NGT), and the RAND Corporation/University of California Los Angeles (UCLA) Appropriateness Method (RAM). This review explores the advantages and disadvantages of these methods and their applications in epilepsy. A narrative review using PubMed (November 22, 2017 to November 22, 2022) was undertaken examining publications describing Delphi, NGT, and RAM. The frequency of use of each method and their applications in epilepsy care were also reviewed (1966 to October 31, 2023). Sixteen articles were included describing the different consensus‐based methods. The advantages and disadvantages of each method varied widely. The Delphi technique, the most widely used method, emerged as adaptable for instances with limited evidence or impracticality of face‐to‐face interactions. Although NGT favors prompt consensus in single‐session formats, the RAM offers a balanced approach with its hybrid structure. We identified 64 epilepsy studies that used consensus methods, with 58 utilizing the most widely used technique, the Delphi. The Delphi guided consensus mostly for management including for individuals with rare conditions such as myoclonic–atonic seizures or in those with epilepsy and pregnancy. The NGT guided expert consensus on the use of cannabidiol for Dravet and Lennox–Gastaut syndromes and facilitated decision‐making among pharmacy students addressing ethical issues related to patients with epilepsy who drive. The RAM was applied in four studies for its combined individual and group evaluative approach. It was used to develop recommendations or imaging, create quality‐of‐care indicators for infantile spasms, and establish a web‐based tool for assessing surgical candidacy. Consensus methodologies are crucial to inform robust CBR for epilepsy management where clinical practice guidelines are not possible due to limited evidence. The best method depends on the study goal and available resources.

Status epilepticus (SE) is a common, life‐threatening neurologic emergency. Understanding population‐level outcomes after SE requires a validated case definition, yet International Classification of Diseases, 10th Revision, Clinical Modification (ICD‐10‐CM) codes of SE have not been well‐validated in US populations since adoption in 2015. We aimed to determine whether the ICD‐10‐CM code‐based definitions accurately identify SE in the in‐hospital setting. The population included all ages (excluding neonates) admitted to a Mount Sinai Health System (MSHS) intensive care unit (ICU) in 2019. A data collection form was developed, tested, and used by trained reviewers. Every admission in a random month (November) was reviewed to determine whether all SE cases had at least one code for epilepsy, seizure, or convulsion followed by all charts with an ICD‐10‐CM diagnosis code for seizure/epilepsy/convulsion in 2019. Chart review data were linked to MSHS electronic medical record data. Sensitivity (Sn), specificity (Sp), negative predictive value (NPV), and positive predictive value (PPV) with 95% confidence intervals (CIs) and Youden index were calculated for ICD‐10 coding of SE (G40.xx1 or G40.xx3, as G41 was not adopted in the United States). MSHS had 13 694 ICU admissions in 2019, for which 1851 charts were reviewed and of which 173 were admissions with definite SE. The ICD‐10‐CM case definition (G40.xx1) has an Sn of 68.7% (95% CI = 61.5–75.8) and Sp of 92.6% (95% CI = 91.4–93.8). PPV was 47.4% (95% CI = 41–53.8), and NPV was 96.8% (95% CI = 95.9–97.6). Youden index was 61.3%. ICD‐10‐CM coding for SE has high specificity but limited sensitivity. These findings align with SE prevalence studies showing a decrease in prevalence with the change from ICD‐9‐CM to ICD‐10‐CM, which may be related to the United States' unique adoption of ICD‐10‐CM, which did not include the standalone SE code (G41). Our findings emphasize the importance of revision and improvement of coding practices to best represent the prevalence of SE, and of consideration when planning for the next iteration of ICD coding.

Objective To describe the frequency of neuropsychiatric complications among hospitalized patients with coronavirus disease 2019 (COVID-19) and their association with pre-existing comorbidities and clinical outcomes. Methods We retrospectively identified all patients hospitalized with COVID-19 within a large multicenter New York City health system between March 15, 2020 and May 17, 2021 and randomly selected a representative cohort for detailed chart review. Clinical data, including the occurrence of neuropsychiatric complications (categorized as either altered mental status [AMS] or other neuropsychiatric complications) and in-hospital mortality, were extracted using an electronic medical record database and individual chart review. Associations between neuropsychiatric complications, comorbidities, laboratory findings, and in-hospital mortality were assessed using multivariate logistic regression. Results Our study cohort consisted of 974 patients, the majority were admitted during the first wave of the pandemic. Patients were treated with anticoagulation (88.4%), glucocorticoids (24.8%), and remdesivir (10.5%); 18.6% experienced severe COVID-19 pneumonia (evidenced by ventilator requirement). Neuropsychiatric complications occurred in 58.8% of patients; 39.8% experienced AMS; and 19.0% experienced at least one other complication (seizures in 1.4%, ischemic stroke in 1.6%, hemorrhagic stroke in 1.0%) or symptom (headache in 11.4%, anxiety in 6.8%, ataxia in 6.3%). Higher odds of mortality, which occurred in 22.0%, were associated with AMS, ventilator support, increasing age, and higher serum inflammatory marker levels. Anticoagulant therapy was associated with lower odds of mortality and AMS. Conclusion Neuropsychiatric complications of COVID-19, especially AMS, were common, varied, and associated with in-hospital mortality in a diverse multicenter cohort at an epicenter of the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) is associated with mortality in persons with comorbidities. The aim of this study was to evaluate in-hospital outcomes in patients with COVID-19 with and without epilepsy. We conducted a retrospective study of patients with COVID-19 admitted to a multicenter health system between March 15, 2020, and May 17, 2021. Patients with epilepsy were identified using a validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)/ICD-10-CM case definition. Logistic regression models and Kaplan-Meier analyses were conducted for mortality and non-routine discharges (i.e., not discharged home). An ordinary least-squares regression model was fitted for length of stay (LOS). We identified 9833 people with COVID-19 including 334 with epilepsy. On univariate analysis, people with epilepsy had significantly higher ventilator use (37.70% vs 14.30%, p < .001), intensive care unit (ICU) admissions (39.20% vs 17.70%, p < .001) mortality rate (29.60% vs 19.90%, p < .001), and longer LOS (12 days vs 7 days, p < .001). and fewer were discharged home (29.64% vs 57.37%, p < .001). On multivariate analysis, only non-routine discharge (adjusted odds ratio [aOR] 2.70, 95% confidence interval [CI] 2.00-3.70; p < .001) and LOS (32.50% longer, 95% CI 22.20%-43.60%; p < .001) were significantly different. Factors associated with higher odds of mortality in epilepsy were older age (aOR 1.05, 95% CI 1.03-1.08; p < .001), ventilator support (aOR 7.18, 95% CI 3.12-16.48; p < .001), and higher Charlson comorbidity index (CCI) (aOR 1.18, 95% CI 1.04-1.34; p = .010). In epilepsy, admissions between August and December 2020 or January and May 2021 were associated with a lower odds of non-routine discharge and decreased LOS compared to admissions between March and July 2020, but this difference was not statistically significant. People with COVID-19 who had epilepsy had a higher odds of non-routine discharge and longer LOS but not higher mortality. Older age (≥65), ventilator use, and higher CCI were associated with COVID-19 mortality in epilepsy. This suggests that older adults with epilepsy and multimorbidity are more vulnerable than those without and should be monitored closely in the setting of COVID-19.