Samson, Kurt

doi: 10.1097/01.NT.0000521707.42281.48

Features

A retrospective, population-based study found that 11 adverse events (AEs) occurred for every 100 admissions for neurological conditions in hospitals in Canada. Outside experts pointed to system errors and problems with communication especially in handing off patients to other doctors as likely causes of problems.

Nearly 50 percent of adverse events that occur in hospitals are preventable, experts in patient safety told Neurology Today, which is why new data from a Canadian study showing that patients with neurological conditions had significantly more complications that those in the general hospital population are disturbing. The report, they said, speaks to the need for evidence-based best practices that better promote hospital safety.

Published in the June 14 online edition of Neurology, the retrospective, population-based study looked at discharge data for 177,612 pediatric and adult patients with neurological conditions from 115 Alberta health care facilities from 2009 to 2015. The report found 11 adverse events (AEs) occurred for every 100 admissions for neurological conditions this, compared with an earlier (2004) Canadian Adverse Events Study that found 7.5 AEs per 100 patients admitted for any condition at a representative sample of Canadian hospitals. [For more detailed findings, see Data on Adverse Events in Neurological Conditions.]

In the new study, AEs occurred most often in patients with spinal cord injury, stroke, Alzheimer disease and related dementia (ADRD), and traumatic brain injury (TBI). Infections and respiratory complications were the most common AEs except in brain tumor and spinal cord injury patients. Patients with spinal cord injury had 5.4 times greater odds of an AE compared to those with other neurological conditions. Adverse events were also more common in older patients and in those with higher comorbidity scores.

Neurological patients with AEs had 2.4 times the odds of dying compared to those without AEs, said lead author Nathalie Jett, MD, professor of neurology and community health sciences at the University of Calgary Cumming School of Medicine and Canada Research Chair in Neurological Health Services Research at the Hotchkiss Brain Institute & O'Brien Institute for Public Health.

Our findings support previous reports that hospitalized patients are at great risk for AEs, with higher estimates reported in this neurological population compared to the prior Canadian study in the general hospital population.

She noted that a number other international studies have reported that around 37 percent to 51 percent of AEs in hospital patients are preventable.

There are several of steps that can be taken to minimize the risk of AEs in neurological patients such as determining fall risk on admission, avoiding sedating medications, assessing swallowing function early, implementing deep venous thrombosis prophylaxis when necessary and doing careful medication reconciliation so patients do not miss any critical drugs on admission, noted Dr. Jett.

The time is right to carefully explore the reasons for these AEs and to develop and implement standardized clinical care pathways to reduce the rates of AEs for hospitalized neurological patients, she said.

The study authors assessed adverse events from discharge data for patients with one of nine neurological conditions: ADRD, brain tumor, epilepsy, motor neuron disease, multiple sclerosis, parkinsonism/Parkinson disease, spinal cord injury, traumatic brain injury, and stroke.

The researchers included 15 AEs in 18 categories: infections; ulcers; endocrinological AEs; venous thromboembolic; cardiac; respiratory; hemorrhagic; drug-related; fluid-related; obstetrical; fetal; surgical; traumatic; anesthetic; delirium-related; other CNS issues; gastrointestinal; and falls.

Among spinal cord patients, AEs occurred in 39.4 out of every 100 admissions, and among these patients, surgery-related AEs accounted for the highest proportion of AEs followed by infections and respiratory-related AEs (24.4 percent, 23.9 percent, and 16.7 percent, respectively).

The reason for the high proportion of AEs in those with a spinal cord injury is likely multifactorial, Dr. Jett told Neurology Today. Spinal cord patients were more likely to have a surgical AE, she noted, adding that these patients have more procedures and interventions in the hospital.

Commenting on the study, Don B. Smith, MD, FAAN, clinical professor of neurology and director of the Colorado Neurological Institute at the University of Colorado Health Sciences Center, said: The adverse events reported here are clinically significant. Neurologists will rightly be concerned that this paper supports previous reports that neurological patients are more frequently affected by AEs than are non-neurological patients.

The paper is a valuable contribution to the patient safety movement by offering insights into the frequency and types of AEs that affect neurological patients, he said. If confirmed by other studies, the findings may help to stratify and specify the types of AE risks across different types of neurological patients, and such information could be valuable in predicting and preventing adverse events.

Dr. Smith cautioned, however, that the paper was a retrospective, observational study that used ICD-10-CA codes to identify both neurological diagnoses and adverse events. The latter is something that has not yet been validated, and the sensitivity and specificity of administrative data in identifying AEs are not precisely known, he told Neurology Today. It is unfortunate that the researchers were not able to determine which of these adverse events were preventable, he added.

There are many strategies to mitigate the risk of adverse events in hospitals, but limited evidence of their effectiveness, Dr. Smith noted. Preventable harm is usually due to a system failure rather than the actions of individual health care providers. One of the most important root causes is a failure in communication, something that is particularly prone to occur during transitions of care. As a starting point for exploring this issue, I would recommend the AAN's NeuroLearn courses on patient safety.

Janis Miyasaki, MD, FAAN, professor and director of the Movement Disorders Program at the University of Alberta, in Edmonton, noted that throughout Canada the nursing ratios vary across hospitals, regions, and provinces.

In addition, she said, registered nurses have increasingly been replaced by licensed practical nurses.In some hospitals neurology patients are deemed to be lighter care than other groups of patients.

She told Neurology Today that access to neurologists and neurosurgeons could be relevant as a trend, as well.

There are approximately 775 neurologists in Canada compared to [approximately] 14,000 in the US, and the Canadian population is approximately a 9:1 ratio to US, so the neurology workforce is certainly an issue throughout North America.

The findings are pretty generalizable to hospitals in the United States, and are not surprising, said Eric J. Thomas, MD, MPH, professor and director of the University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety. Certainly, these results are reason for more focus on improvement, he said.

Although there are evidence-based guidelines that, if followed consistently, might prevent many of these AEs, especially for stroke, best practices are lacking, he told Neurology Today.

Dr. Thomas noted that the study did not address the effect of long MD trainee hours spent on the ward or transitions of care from one shift to another. He said these factors might play a role in higher AEs in patients, adding that other studies have found that increased numbers of shifts, with concurrent increases in handoffs, increase the risk for adverse events.

The solution is not necessarily to make clinicians work longer and thereby reduce handoffs, but rather to improve the way handoffs are conducted and to improve the information in electronic health records, he said.

An important first step is to recognize that AEs among neurological patients are most often the product of multiple failures at various levels within the system of care, rather than at one person or level, said John C. Probasco, MD, assistant professor and medical director of the Inpatient General Neurology Service at Johns Hopkins Hospital in Baltimore.

With that in mind, he said, it is most important to engage all members of the care team in monitoring and reporting events, as well as having a system in place for making such reports. Reporting should include everything from near-misses to the most harmful events. A system for report review is also needed to address the specific event as well as to help identify areas for improvement to prevent future events.

In addition, care team members should be engaged in developing, implementing, and monitoring the impact of any AE interventions.

Finally, it is important to provide feedback to care team members that their report has been noted and steps are being taken to address opportunities or challenges they have identified, ideally with their involvement. This model can be applied not only at the hospital or health system level but at the level of care units and provider teams.

Dr. Probasco agreed with Dr. Thomas that shift length and frequency put both neurologists in training and in practice at risk for cognitive and emotional fatigue, a set-up for AEs to occur.

Sound and consistent sign-out practices are one demonstrated and practical way to reduce communication failures at the point of care transition, he said. Overall, a balance must be struck between the risks posed by shift length and frequency with those posed by care transitions.

* Infections were highest among brain tumor patients (23.6 percent), while surgery-related AEs accounted for a higher proportion of AEs than did respiratory-related AEs (20.0 percent vs 12.1 percent).

* Hemorrhagic issues accounted for 13.5 percent more than respiratory problems.

* Patients under 18 years old with a spinal cord injury or a traumatic brain injury had fewer AEs than those who were 18 or older, while younger patients with a stroke or motor neuron disease had more AEs than those who were older.

* Admissions with ADRD had the greatest proportion of comorbidities, closely followed by stroke and brain tumor. The co-occurrence of neurological conditions was 7 percent, with the highest proportion in patients with PD (32.5 percent) and the lowest in those with multiple sclerosis (8.1 percent).

* The median length of stay was eight days and was highest for spinal cord injuries, ADRD, and parkinsonism/Parkinson disease, while the overall mortality was 9.1 per 100 admissions, and was highest among those with motor neuron disease at 18 per 100 admissions.

* Those with ADRD represented the higher proportion of admitted patients (37 percent), followed by stroke (24.4 percent) and epilepsy (12.9 percent), and of all admissions, 6.9 percent were re-admissions. Readmissions were higher in patients with motor neuron disease, brain tumor, and ADRD.

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Adverse Events Reported to Be Higher for Neurological In-Patients in Canadian Study: What Can Be Done? - LWW Journals

Talan, Jamie

doi: 10.1097/01.NT.0000521711.65152.03

Features

Called the mother of autism, Isabelle Rapin, MD, died in June at the age of 89. Neurologists she trained with share the role she had in shaping their views and careers in pediatric neurology.

Swiss-born child neurologist Isabelle Rapin, MD, who arrived at work to Albert Einstein College of Medicine almost every day for more than six decades, died in June at the age of 89.

Formidable in ways that changed the world for children with autism and their parents, her work helped debunk major misconceived notions about the disorder that it was a single disease, that it was a psychiatric syndrome caused by so-called refrigerator (emotionally cold) mothers, and that it could be caused by vaccinations.

She delivered more than 550 presentations and invited lectures, as visiting professor, symposium organizer or participant, at universities and hospitals around the world. Her research, lectures, and publications were amplified by the thousands of doctors from around the globe that she taught and mentored during the course of her career.

Dr. Rapin was a behavioral neurologist before the term was coined. And her science of autism would become the foundation for the field. She published a paper parsing the contributors to the autism epidemic in Neurology just a month before her death from bacterial pneumonia. Her family is working to publish her next manuscript on why congenital blindness might cause autism, and what this implies about brain development and organization.

Dr. Rapin met and married her soul-mate, Harold Oaklander, during her first year at Einstein. Together they brought four children into the world in the space of five years while she was building her career. The concept that professional women could have it all would not emerge for another half century. She was the first female faculty member at Einstein, and she was its longest-living member. She had no interest in working anywhere else.

Her interest in the human brain was so profound that she arranged an academic autopsy after the death of her brother, a mathematics professor in Switzerland, and brought his brain to the Bronx where she supervised Einstein pathologists to study its delicate tissues. From this, they published the first known neuropathological study of Asperger syndrome. She so enjoyed accompanying her daughter Anne Louise Oaklander, MD, FAAN, a neurologist at Massachusetts General Hospital (and a member of Neurology Today's editorial advisory board), to their renowned brain cutting conference, that she left instructions that her own brain and spinal cord be studied there as well.

Isabelle Rapin was born and raised in Lausanne, Switzerland. Her father was a university professor of English literature. With his wife, an American who graduated from Vassar before her married life in Switzerland, they raised their three children as dual citizens who were fully bilingual in English and French. All would go on to graduate degrees in science and math. Summers with her mother's Connecticut family encouraged Isabelle to seek professional opportunities in the United States after she completed medical school at the University of Lausanne.

Her pediatric internship at Bellevue Hospital and neurology residency at Columbia exposed her to two legends in American neurology: Fred Plum, MD, and Houston Merritt, MD. It was a time when residents lived in the hospital as house officers and took calls every other night. The only female neurology resident, she was judged as sub-par and told she would need to repeat her arduous first year to remain in the residency. She did so, and for the rest of her life told this story to encourage the young people she mentored, including her children: Persevere when times are hard, especially when people say you are not good enough. Have faith in yourself. Put your head down and just keep working.

In 1958, Albert Einstein was a newly-minted medical school in New York, and the dean wanted to create a pediatric neurology specialty. Dr. Rapin, well trained in both specialties, was the obvious appointment. She was interested in communication disorders, particularly the congenital deafness caused by in utero exposure to rubella, and she pushed the then-radical idea that early diagnosis and intensive education could prevent or ameliorate the mental retardation and disability that were felt to be inevitable at that time. Her insights took hold and helped to end the routine practice of institutionalizing and segregating the deaf. For years, she treated children and taught at St. Joseph's School for the Deaf to help deaf children acquire language by other means, including sign language, which improved their brain development and their futures. Her protg, Oliver Sacks, credited her with developing his interest in the senses and later dedicated his book The Mind's Eye to her.

She then began to study how inherited disorders of metabolism caused brain damage, and to explore autism. She believed that this was a common final pathway for many problems in the brain's language systems. She emphasized that autism was a syndrome with many causes, and not a disease. Although known as demanding to her residents, she was known to kick off her shoes and get down on the ground to play with her young patients. She also knew how important it was to support the families. She loved children, knew how to interact with them, and always emphasized the potential each child has, said Dr. Oaklander. It was a treat to watch her play with her grandchildren, while delighting in the normalcy of their own milestones.

Her deep caring, intellect and thinking about patients and their issues is what made her such a force in the field, said Daniel Geschwind, MD, PhD, endowed professor of neurology, psychiatry and human genetics at University of California, Los Angeles. She is one of the last of a generation of great clinician-scientists. Dr. Geschwind and his colleagues started a bi-annual course on autism at Cold Spring Harbor Laboratory and asked Dr. Rapin to give an introduction to the history of autism.

Dr. Geschwind said that she appeared intimidating but it was because of her desire to get at the truth. She would come across crusty but that was like a coating for delicious chocolate candy. She was actually very warm, delightful, compassionate and funny.

Roberto F. Tuchman, MD, FAAN, met Isabelle Rapin in 1986 when he was considering Einstein's child neurology program, and she went on to become his mentor there and lifelong friend. He loved rounding with her. She would discuss a case and rattle off a differential diagnosis and a possible pathology and link everything she was saying back to the behavior and clinical symptoms. She was beautifully descriptive. Dr. Tuchman created a database of all of the autistic patients she had seen at Einstein. I would read her notes and I could almost see the patient before me, he said. This database, and the videos Dr. Rapin would take of the children, led to many insights about the road to autism.

It all started with her need to understand the substrate of language and communication disorders, said Solomon (Nico) Moshe, MD, professor of neurology at Albert Einstein College of Medicine and another of her former fellows. She was an amazing neurologist. She always said: Every patient can teach you something. You just have to listen.

Mark F. Mahler, MD, FAAN, the Saul K. Korey professor and chair of neurology at Albert Einstein College of Medicine, agreed. She was a European intellect, he said. They used to close the library together at midnight. Her humility, her breadth of knowledge and her unique perspective on these disorders was inspiring.

Dr. Rapin was known for keeping long hours, and Dr. Oaklander said that their mother delivered several of her children while she was at work. Sorry, she would say politely. I can't help you finish. I have to walk over to the maternity ward. Despite this, her rich life outside of her Einstein world was rather surprising for those who met her professionally. She was the family's main cook and gardener. They lived in a large apartment in Manhattan and enjoyed their weekend and vacation retreat, Klinkenberg, a pre-revolutionary war Dutch stone house on the Hudson River that they restored and still own. She loved reading. And she especially loved her husband Harold. She was a fabulous person, he said. She had a great mind.

They had many prominent visitors at Klinkenberg, including her close friend Oliver Sacks, MD.

In addition to her commitments to patients and her family, she found time for organizational and administrative leadership. The first director of pediatric neurology at Einstein, she helped launch the International Child Neurology Association. She served on study sections of the National Institutes of Health, and then as a member of their National Advisory Council, a position now held by Dr. Oaklander. The AAN celebrated her achievements with the President's Award in 2010. She became the first vice president of the American Neurological Association in 1981. She had won the International Society for Research in Autism Lifetime achievement award.

A decade ago, Dr. Tuchman saw his mentor at the International Society for Autism Research. You know, Dr. Rapin told her friend, I am the oldest person presenting a poster here. Indeed, she was almost 80. (Her husband, almost 96, still teaches a program on unemployment that he founded at Cornell University while in his 80's.) Dr. Rapin would officially retire in 2012 at the age of 84, but she never stopped working. For the past several years, scoliosis was the only thing that kept her down. I became her wheelchair without wheels, said her husband.

In an autobiography published in the Journal of Child Neurology in 2001, Dr. Rapin wrote: Consider every patient a potential source of new knowledge, describe what you see, pursue your interests vigorously, and learn to cut corners and prioritize. Find a good mentor, enjoy what you do, and be lucky.

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Leading Child Neurologist and Autism Expert Isabelle Rapin, MD, Dies - LWW Journals

Moran, Mark

doi: 10.1097/01.NT.0000521712.72776.d2

Features

An international group of researchers delivered high frequencies of electrical stimulation through electrodes placed outside the brain of a mouse, to selectively target neurons in the hippocampus without an incision and without affecting the overlying cortex. The method has potential for translation to humans, but as the authors and independent experts report, much more work is needed.

An innovative method of delivering noninvasive deep brain stimulation appears to activate brain areas resulting in motor changes in a mouse model that could, potentially, prove relevant to treatment of Parkinson's disease and other movement and psychiatric disorders in humans, according to a report published in the June 1 issue of Cell.

Using a novel method known as temporal interference, an international group of researchers delivered high frequencies of electrical stimulation through electrodes placed outside the brain, to selectively target neurons in the hippocampus without an incision and without affecting the overlying cortex.

Human application is unlikely very soon, but the report has stirred interest among experts in movement disorders as a possible answer to a problem: how to deliver deep brain stimulation known to be effective in neuropsychiatric disorders without the risks associated with the traditionally invasive procedure.

Traditional deep brain stimulation requires opening the skull and implanting an electrode, which can have complications, and only a small number of people can do this kind of neurosurgery, the senior study author Edward Boyden, PhD, associate professor of biological engineering and brain and cognitive sciences at MIT, told Neurology Today. Our technology could be useful, should human trials prove effective, as a wearable device that could be worn by patients with severe conditions. Conceivably it could help with conditions where occasional stimulationfor instance, for half an hourresults in plasticity that helps relieve symptoms. The strategy could also be useful to researchers in mapping parts of the brain involved with neurological disorders so that better DBS positioning may become possible.

Dr. Boyden is quick to point out the hurdles that must be overcome before the strategy could be employed in humans. We haven't yet done any peer-reviewed studies on the human brain, although we have begun studies, he said. Our technology is not as focal as traditional DBS, and for conditions where stimulation must be constant, a standard implant might be more secure and easier to maintain.

The temporal interference strategy he and colleagues used involves the manipulation of high-frequency electrical currents delivered via electrodes placed outside the mouse scalp. The currents are too fast to drive neurons, but they interfere with one another in such a way that where they intersect, deep in the brain, a small region of low-frequency current is generated inside neurons. This low-frequency current can be used to drive neurons' electrical activity, while the high-frequency current passes through surrounding tissue with no effect.

By tuning the frequency of these currents and changing the location of the electrodes, the researchers can control the location of the brain tissue that receives the low-frequency stimulation. You can go for deep targets and spare the overlying neurons, although the spatial resolution is not yet as good as that of deep brain stimulation, Dr. Boyden said.

Moreover, by shifting the site of stimulation, Dr. Boyden and colleagues could activate different parts of the motor cortex and prompt the mice to move their limbs, ears, or whiskers.

The strategy appears to be safe, based on this study. We found that TI [temporal interference] stimulation at amplitudes sufficient to recruit deep brain structures, such as the hippocampus, did not alter the neuronal and synaptic integrity of the underlying tissue 24 hours after stimulation, Dr. Boyden and colleagues wrote. Additional time points other than 24-hours post stimulation may provide in the future a more detailed picture of the safety of TI stimulation.

Commenting on the report, Michele Tagliati, MD, FAAN, director of the Movement Disorders Program at Cedars Sinai, Los Angeles, said: This is extremely exciting. The practice of brain stimulation is limited by one fundamental problem you have to stick a wire electrode in the brain. That is a limitation to the willingness of physicians to recommend the surgery and of patients to undergo it.

Finding a noninvasive way to stimulate the brain has been a holy grail in this field, Dr. Tagliati said. In my opinion, this is a credible strategy that can really advance the field by providing something that we have been trying to do for a long time noninvasive stimulation of key parts of the brain that can benefit patients with movement disorders. There is an enormous amount of work yet to do refining this strategy, and I would not expect to see this in the clinic anytime soon. However, I would not be surprised if it advances to phase 2 safety trials very soon.

Joseph Jankovic, MD FAAN, professor of neurology, Distinguished Chair in Movement Disorders, and director of the Parkinson's Disease Center and Movement Disorders Clinic at Baylor College of Medicine, was somewhat more circumspect. The study provides a proof of principle that relatively non-invasive electrical stimulation of deep brain structures is feasible, he told Neurology Today. This should be added to a growing list of techniques, such as optogenetic manipulation of neuronal networks, that require a great deal of animal work before it can be applied clinically. While I agree with the authors that the prospects for noninvasive DBS using electricity are potentially exciting, I am very skeptical that it might be rapidly deployable in human clinical trials.

There are many unanswered questions before this technique can be applied for movement disorders, epilepsy or psychiatric disorders, Dr. Jankovic said. One question is whether the electrical stimulation can be delivered continuously in the target nucleus without untoward effects. Another question is related to the method of delivery. Would the patients require wearing a helmet device that would deliver electricity in a way to make the treatment portable?

Finally, I think there are serious safety concerns about the effect of chronic electricity on various brain structures, he said.

Nevertheless, he said, the strategy is a breakthrough. This is an important study conducted by a highly-regarded group of researchers, Dr. Jankovic said. It addresses a hugely unmet need, namely the ability to normalize abnormal brain circuitry in patients with dysfunction in the cortico-striatal-thalamic pathway in patients with Parkinson's disease, dystonia, Tourette syndrome and other hyperkinetic movement disorders, without invading the brain by either implanting stimulating electrodes or creating a lesion via focused ultrasound.

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A Noninvasive Novel Method of Deep Brain Stimulation in Animal Model - LWW Journals