Practice Issues

This collection contains Practice Issues articles published in Continuum. In addition to the lifelong learning of new clinical and scientific knowledge, neurologists must understand the constantly evolving environment in which they practice. Changes occur rapidly in reimbursement and regulatory areas, in the integration of evidence-based medicine, and in the implementation of patient safety measures into clinical practice. Each article, written by neurologists with particular experience in systems-based practice and practice-based learning and improvement, present case-based examples of one of these issues as it relates to the clinical topic of the issue in which it was published.

Contains: 59 Items
2020 August Volume 26, 1075-1081
Optimizing Behavioral Sleep Strategies

Ong, Jason C.; Gamaldo, Charlene

Audio Interview
Patients are increasingly looking to optimize sleep as a health and wellness strategy. Sleep health is often individualized based on three elements that correspond to overall physical and mental well-being: (1) sleep quality, which refers to the continuity and depth of sleep as well as a feeling of restoration upon awakening; (2) sleep quantity, which refers to the duration of sleep that is appropriate for a given age group; and (3) timing of the sleep window, which refers to the positioning of sleep that is aligned with an individual’s circadian rhythm for sleep or an ideal circadian zone. In the past, prescribing hypnotic medications was considered the primary approach for improving sleep. However, there has ...
2020 April Volume 26, 506-512
Innovations in Prehospital Stroke Management Utilizing Mobile Stroke Units

Alexandrov, Anne W.; Alexandrov, Andrei V.

Audio Interview
Using a representative case, this article discusses prehospital innovations for patients with acute large vessel occlusion ischemic stroke, including mobile stroke unit care supported by advanced field imaging.
2019 June Volume 25, 845-849
Incorporating Clinical Practice Guidelines and Quality Measures Into High-Quality Cost-Effective Care for Patients With Multiple Sclerosis

Rae-Grant, Alexander D.

Audio Interview
This article presents a hypothetical case of a patient with multiple sclerosis (MS), reviewing the use of clinical practice guidelines and incorporation of quality measures into practice. Appropriate diagnosis of MS is important to avoid the cost and consequences of a misdiagnosis. Ensuring that treatment discussion occurs when a patient with MS is receptive is good clinical practice and a guideline recommendation from the American Academy of Neurology. Continuing dialogue about disease-modifying therapy and ongoing monitoring are important for patient care and improved outcomes. Ultimately, cost-effective care in MS relates to using appropriate medicines in patients with active MS, ensuring adherence, and care...
2019 April Volume 25, 543-549
Tips and Resources for Medication Reconciliation

Shenoy, Anant M.; Bennett, Amy; Segal, Alan Z.

Audio Interview
Medication errors occur despite best intentions and are often the result of medication discrepancies. Medication reconciliation reduces the likelihood of errors by addressing medication discrepancies that result from multiple points of care, transitions in care, or patient report. Providers and practices may feel overwhelmed by new record systems and regulatory requirements, but multiple resources are available to assist providers to perform medication reconciliation with their patients. Providers and practices should implement medication reconciliation strategies, such as adoption of a multidisciplinary approach, engagement of patients to track medications, and identification of patients who are at high risk f...
2018 December Volume 24, 1794-1799
End-of-life Considerations and Shared Decision Making in Neurocritical Care

Lazaridis, Christos

Audio Interview
The goal of shared decision making in the neurocritical care setting is to form plans of care that are consistent with best medical practice and are respectful of the patient’s values. Close cooperation and meaningful interaction must be achieved with family members so that the patient’s “person can emerge” through discussions. This article highlights several caveats that can subvert this complex process, including the cognitive biases that affect both clinicians and surrogates. Impact, optimism, and gain-framing biases may be particularly relevant when considering patients who are receiving neurocritical care. Practitioners need to be cognizant of the distorting influences of these biases and make attempts to ...
2017 October Volume 23, 1458-1466
The Implication of Diagnostic Errors

Govindarajan, Raghav

Audio Interview
Diagnostic errors are mistakes in the diagnostic process that lead to a misdiagnosis, a missed diagnosis, or a delayed diagnosis. While the past decade’s impetus to improve patient safety has focused on medication errors, health care–associated infections, and postsurgical complications, diagnostic errors have received comparatively less attention. Diagnostic errors will continue to play a major role in the patient safety and quality improvement movement because of their burden on care and their financial burden. Developing a patient-partnered diagnostic approach with self-reflection and awareness of cognitive biases is the key to minimizing the impact of diagnostic errors.
2017 August Volume 23, 1156-1161
Driving Safety and Fitness to Drive in Sleep Disorders

Tippin, Jon; Dyken, Mark Eric

Audio Interview
Driving an automobile while sleepy increases the risk of crash-related injury and death. Neurologists see patients with sleepiness due to obstructive sleep apnea, narcolepsy, and a wide variety of neurologic disorders. When addressing fitness to drive, the physician must weigh patient and societal health risks and regional legal mandates. The Driver Fitness Medical Guidelines published by the National Highway Traffic Safety Administration (NHTSA) and the American Association of Motor Vehicle Administrators (AAMVA) provide assistance to clinicians. Drivers with obstructive sleep apnea may continue to drive if they have no excessive daytime sleepiness and their apnea-hypopnea index is less than 20 per hour. Those...
2017 June Volume 23, 877-881
Safety Considerations During Transitions of Care From Inpatient to Outpatient Settings

Ponce de Leon, Marcus; Hohler, Anna D.

Audio Interview
Hospital admissions are times of intense change. New medications are started, treatment regimens are modified, and care plans that will continue in the outpatient setting are initiated. After discharge, most patients receive care from different providers than those seen in the hospital. This situation will increase as inpatient-based practice patterns, such as neurohospitalist practices, become more prevalent. Communication failures during the transition from hospital to clinic increase the risk of adverse events. Providers must realize that successful transition can impact the patient’s health as significantly as treatment of the admitting diagnosis. The transition should be carefully planned and standardized....
2017 April Volume 23, 557-562
Practical Considerations in Addressing Physician Burnout

Deb, Anindita

Audio Interview
Physician burnout is an epidemic impacting patient care, career satisfaction, and physician health and well-being. Symptoms may result in potentially damaging consequences for physicians’ professional and personal lives. Neurologists are experiencing burnout at higher rates than most medical and surgical specialties. Empowering physicians to identify symptoms of burnout and engage with their organization to reduce triggers will lead to healthier physician-organization and physician-patient relationships. It is imperative that the medical community continue to raise awareness, recognize symptoms early, and provide techniques and resources to address physician burnout.
2017 February Volume 23, 259-267
Remote Evaluation of the Patient With Acute Stroke

Demaerschalk, Bart M.

This article describes advances related to the successful remote evaluation of the patient with acute stroke. Telestroke is a connected care approach that brings expert stroke care to remote, neurologically underserved urban or rural locations. Recent findings reveal strong evidence showing that telestroke is equivalent to in-person care. Time is critical in treating patients with acute stroke, and telestroke networks must assure that technology improves—not delays—delivery of care. The stroke center and the spoke site must work collaboratively to develop and institute protocols and policies to ensure that eligible patients are identified, assessed, and treated swiftly. Adverse outcomes, such as intracranial he...
2016 December Volume 22, 2012-2014
Registry Participation in Neuromuscular Disease

Shenoy, Anant M.

Patient registries are a resource to better study neurologic disease and may facilitate the development of future treatments. Clinicians should become comfortable with the strengths and limitations of patient registries and be able to discuss them with their patients. This article discusses the use of patient registries through the example of registries for patients with neuromuscular disease.
2016 October Volume 22, 1691-1695
Safety Considerations in Magnetic Resonance Imaging of Patients With Implanted Medical Devices

Ponce de Leon, Marcus

Audio Interview
MRI is a valuable tool in the evaluation of patients with neurologic disease. It offers ease of use and widespread availability; however, MRI can pose significant health hazards to patients with implantable devices. Accordingly, the US Food and Drug Administration (FDA) has changed the safety labeling of implantable devices. This article increases provider awareness by detailing the potential safety risks MRI poses to patients with implantable devices and reviews the most recent FDA device labeling.
2016 June Volume 22, 947-950
Health Literacy and Outcomes in Multiple Sclerosis

Henson, Lily Jung

Audio Interview
Health literacy is an important consideration when managing patients with multiple sclerosis. Literacy impacts comprehension about patient condition, participation in medical decision making, and compliance with treatment plans. Awareness of health literacy allows clinicians to tailor their approach to individual patients and improve the overall care of patients.
2016 April Volume 22, 619-625
Caregiver Stress and the Patient With Dementia

Sanders, Amy E.

Audio Interview
Informal caregivers (often, but not exclusively, family members) are essential to the clinical care of a patient with dementia. Most caregivers are untrained and unpaid. As a result, caregivers often experience stress caused by the caregiving experience; they are the “invisible second patients” in dementia care. Clinicians can help caregivers by supporting them in their role and by referring them to additional resources for support.
2016 February Volume 22, 266-269
Cultural Barriers to Medication Adherence in Epilepsy

Montouris, Georgia; Hohler, Anna D.

Audio Interview
Antiepileptic drugs can prevent seizures in most patients; however, nonadherence is frequently reported. Nonadherence is associated with a higher incidence of emergency department visits, increased hospital admissions, and an increased risk of mortality. Misconceptions about epilepsy, level of education, and language barriers are contributors to nonadherence. Misconceptions about epilepsy and antiepileptic drugs are prevalent among economically disadvantaged predominantly minority persons with epilepsy. Educational interventions may improve adherence.
2015 December Volume 21, 1751-1756
Prevention and Management of Health Care–Associated Infections

Govindarajan, Raghav

Audio Interview
Health care–associated infections (formerly called hospital-acquired infections or nosocomial infections) are a major public health concern. They place an enormous burden on the health care system, prolong hospitalization, and increase health care costs. Neurologists act as primary providers in the hospital or the clinic for patients with multiple comorbidities. We must be aware of the burden of health care–associated infections, their common types, risk factors, and various prevention strategies. Common strategies can be applied in day-to-day practice to help prevent health care–associated infections.
2015 October Volume 21, 1451-1454
Advanced Practice Provider Utilization in the Neurocritical Care Unit

Lee, Jessica D.

Audio Interview
This article discusses the role of advanced practice providers (APPs) in the interprofessional team management of patients with critical neurologic illnesses and how this role has evolved through the years. There is increasing demand for these types of practitioners, formerly termed midlevel providers. Furthermore, the use of APPs appears to have a positive impact on patient satisfaction, reduced costs, and reduced length of stays.
2015 August Volume 21, 1150-1156
Screening Patients With Headaches for Abuse

Schulman, Elliott A.; Franchek-Roa, Kathleen

Audio Interview
Nearly 6 in 10 patients with migraine have experienced childhood maltreatment. Asking about childhood or ongoing abuse is essential in developing optimal treatment plans. By using the Adverse Childhood Experiences Study questionnaire, neurologists can capture information about childhood adversity. Childhood adversity is associated with chronic migraine, but can also lead to psychiatric comorbidity. Knowing how to address previous adversity can improve health outcomes.
2015 June Volume 21, 838-843
Managing Outpatients With Suicidal or Homicidal Ideation

Poa, Edward; Kass, Joseph S.

Regardless of their specialty, physicians encounter various potential clinical emergencies in their outpatients that may require referring patients for the appropriate level and urgency of care. One such situation is the outpatient who presents with suicidal or homicidal ideation. In this circumstance, the physician is faced with performing a rapid evaluation of the symptoms, determining the acuity of the situation, and safely referring the patient to an appropriate level of care. Using case vignettes, this article reviews some of the immediate critical factors to consider in evaluating and managing the outpatient who expresses thoughts of suicide or homicide.
2015 April Volume 21, 480-486
Practical Considerations in Opioid Use for Brain Neoplasm

Perloff, Michael D.

Audio Interview
Neurologists are often on the front lines of diagnosis for primary and metastatic brain tumors. Patients with brain tumors typically have multiple comorbidities and pain generators beyond headache, necessitating opioid therapy. Opioid-based pain relief and safety in the medically ill patient are complex. While using the lowest-potency opioid with adjunct medications is always prudent, patients with brain tumors frequently require dose escalation. Opioid selection and use is based on the patient’s respiratory and cardiac function as well as drug clearance capability. Specific opioid combinations, employing long-acting and short-acting drugs, have greater efficacy in specific patient profiles and make adverse dru...
2015 February Volume 21, 206-210
Teamwork Approach to Prevention and Treatment of Skin Breakdown in Spinal Cord Patients

Ponce de Leon, Marcus

Audio Interview
Pressure ulcers, which are localized injuries to skin and underlying tissue resulting from prolonged pressure, are a significant complication among patients with spinal cord injury. They threaten patients’ quality of life, prolong stays at health care facilities, and pose a burden on the overall health care system through increased costs. Familiarity with the risk factors for developing pressure ulcers and the methods used to treat them is paramount to decreasing their occurrence and lessening the negative impact from both a human and economic standpoint.
2014 December Volume 20, 1688-1691
Legal Issues of Return to Play After a Concussion

Malhotra, Raman K.

It is increasingly important for neurologists to recognize the legal implications of assessing and treating an athlete who sustained a concussion, then returning the athlete back to play. Poor initial identification of the concussion or failure to recognize persistent symptoms may lead to premature return to play and unnecessary long-term neurologic consequences. Becoming familiar with recent guidelines and practice parameters on concussion management is of paramount importance. Clear documentation of neurologic signs and symptoms of the patient and discussion of short- and long-term risks of concussion is also crucial. It is also important to learn about state legislation regarding concussion education and ret...
2014 October Volume 20, 1430-1434
Do All Neuropathy Patients Need an EMG at Least Once?

Smith, A. Gordon

EMG, which consists of nerve conduction studies and needle electromyography, is an essential diagnostic tool in the evaluation of patients with suspected peripheral neuropathy. Many neurologists order an EMG for all patients with suspected peripheral neuropathy. Not surprisingly, evidence now exists that shows EMG is a major driver of health care costs associated with neuropathy diagnoses. As neurologic practice evolves from fee for service to value-based compensation, neurologists will need to justify the diagnostic utility of EMG (outcome) relative to its cost. While carefully performed studies of diagnostic utility in many patient populations are lacking, a robust literature provides guidance regarding the p...
2014 August Volume 20, 1067-1074
The Importance of Visual Field Testing in Idiopathic Intracranial Hypertension

Wall, Michael

Audio Interview
Idiopathic intracranial hypertension (IIH) is a disease of unknown cause typically affecting obese women in the childbearing years. Although headache is the most common symptom, the major morbidity of IIH is visual loss, with 5% to 10% of patients progressing to blindness. While about 95% of patients with IIH have visual loss documented by perimetry, only about one-third notice their visual loss because most loss occurs in the peripheral visual field. Since treatment decisions in IIH are made primarily by changes in visual field function, serial perimetry is the most critical test to obtain when following patients with IIH. This article describes the role of visual field testing in the monitoring of IIH patient...
2014 June Volume 20, 686-689
Communication Challenges in Complex Medical Environments

Lee, Jessica D.; Hohler, Anna

Audio Interview
The provision of health care is becoming increasingly complex and can involve multiple providers and care setting transitions, particularly as the population is living longer, and often with chronic disease. The Electronic Health Record (EHR) was intended to provide a comprehensive documentation of a patient’s health-related information; however, health care systems often function in isolation with EHRs that are unique only to that system. The EHR may also limit face-to-face communication between treating physicians within the same system. It is only with diligent effort that changes in medical management plans are conveyed among providers. When multiple providers are involved in a patient’s care, physician-to-...
2014 April Volume 20, 436-440
Cost and Utility in the Diagnostic Evaluation of Stroke

Burke, James F.

Audio Interview
The diagnostic evaluation in a patient presenting with acute stroke has several purposes depending on the clinical circumstances. These include identifying stroke mimics, differentiating ischemic stroke from intracerebral hemorrhage in the acute setting, clarifying stroke localization, and determining the stroke mechanism to guide secondary prevention. The neurologist needs to be aware of the cost implications of different approaches to the diagnostic evaluation.
2014 February Volume 20, 181-185
Epilepsy and Pregnancy: A Practical Approach to Mitigating Legal Risk

Kass, Joseph S.

Audio Interview
Women with epilepsy are at increased risk of obstetric complications and poorer cognitive outcomes for their offspring. This article aims to provide neurologists with a practical framework for understanding, identifying, and managing legal risk when treating pregnant women with epilepsy.
2013 December Volume 19, 1703-1708
Administration of Glucocorticoids in Boys With Duchenne Muscular Dystrophy

Gutierrez, Amparo; England, John D.

Duchenne muscular dystrophy (DMD) is the most common neuromuscular disease affecting boys. Advances in their care can delay the progression of DMD-related disability and prolong survival. The administration of glucocorticoids is among these advances. Glucocorticoid therapy, however, is associated with a myriad of potential adverse effects, and treating physicians as well as patients and their family members must understand the benefit/risk ratio of glucocorticoid therapy. Although current best evidence supports the use of glucocorticoids in patients with DMD, many are not offered the option. Considerable variability in practice also exists regarding when and how these drugs should be administered.
2013 October Volume 19, 1401-1405
Video Recording in Movement Disorders: Practical issues

Duker, Andrew P.

Video recording can provide a valuable and unique record of the physical examinations of patients with a movement disorder, capturing nuances of movement and supplementing the written medical record. In addition, video is an indispensable tool for education and research in movement disorders. Digital file recording and storage has largely replaced analog tape recording, increasing the ease of editing and storing video records. Practical issues to consider include hardware and software configurations, video format, the security and longevity of file storage, patient consent, and video protocols.
2008 December Volume 14, 141-144

Wechsler, Lawrence R.; Zaidi, Syed

2009 February Volume 15, 165-169

Lewis, Steven L.; Stamatakos, Alyssa

2009 April Volume 15, 191-194

Pennell, Page B.

2009 October Volume 15, 173-177

Collins, Timothy A.

2009 December Volume 15, 207-210

Mantovani, John F.

2010 February Volume 16, 170-174

Donofrio, Peter D.

2010 June Volume 16, 246-249
2010 August Volume 16, 170-174
2010 October Volume 16, 238-242

Desai, Troy; Bever, Christopher T. Jr

2010 December Volume 16, 166-170
2011 February Volume 17, 152-158
An Approach to Preoperative Neurologic Consultation for Non-neurologic Surgery

Lewis, Steven L.

Neurologists are commonly asked to provide outpatient or inpatient consultation prior to non-neurologic surgery in patients with an underlying neurologic disorder; however, a paucity of neurologic literature and no evidence-based guidelines exist regarding how to approach this common clinical problem. Extrapolating on the literature regarding the process of preoperative consultation by internists and internal medicine subspecialists, this article attempts to provide a general framework for the neurologist who is asked to evaluate a patient preoperatively. The importance of timely and effective communication, including discussion and clarification with the referring surgeon regarding the neurologist's role in ea...
2011 April Volume 17, 347-352
Interpretation of Genetic Testing: Variants of Unknown Significance

Fogel, Brent L.

As the number of genes available for commercial sequencing increases and the promise of clinical whole-genome sequencing becomes a reality, the interpretation of the results of these tests becomes more challenging for the practicing neurologist as these studies have the potential to detect novel genetic variants. Such reports are becoming more frequent in general practice, and neurologists are often left to puzzle over the relevance of these "variants of unknown significance," as such genetic changes are often described, and how to communicate this information to the patients and their families. This article will briefly illustrate how clinicians can use such results in the care of their patients. Only genetic ...
2011 June Volume 17, 630-634
The Review of Systems in Spinal Cord Injury and Dysfunction

Gorman, Peter H.

Individuals with spinal cord injury or dysfunction represent unique diagnostic challenges when they present with symptoms of generalized malaise or "feeling lousy." Those individuals with injury or dysfunction at or above the T6 level are specifically at risk for the phenomenon known as autonomic dysreflexia, which is a medical emergency. The underlying cause of autonomic dysreflexia as well as other secondary complications in the patient with a spinal cord injury can best be uncovered through a comprehensive review of systems, which encompasses constitutional, head, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, respiratory, skin, neurologic, psychiatric, endocrinologic, hematologic, and imm...
2011 June Volume 17, 617-629
Management of Acute Neurorehabilitation Programs

Vogl, Susan M.

Outcome management, performance improvement, evidence-based practice, and policy payment mechanisms are critical operational drivers at every level of health care delivery. It is essential that all health care providers involved in patient care have a working knowledge of health care operations, including the policies and reimbursement mechanisms that drive their particular clinical practice. Providing excellent patient care includes understanding health care policies, regulations, and outcomes that have a historical and current impact on health care delivery. Some of these factors include patient access, patient safety, and information measurement and management. Inpatient acute neurorehabilitation programs ha...
2011 August Volume 17, 877-881
Motor Vehicle Operation in the Setting of Multiple Sclerosis With Myelopathy: Assessment, Adaptive Equipment, Counseling, and Cessation of Driving

Niewoehner, Patricia M.; Thomas, Florian P.

Many individuals with multiple sclerosis are safe drivers; others self-regulate their driving or cease driving altogether because of their own safety concerns. When patients are unsafe to drive and have poor insight into their condition, they may ignore a provider's repeated communication to stop driving. Addressing this issue when a person is initially diagnosed with multiple sclerosis and continuing the discussion over time when assessing other activities of daily living may ease the process of driving cessation. Referral for a driving evaluation may be appropriate, in conjunction with referrals to a social worker for mobility counseling and to a psychologist for grief and loss issues associated with driving ...
2011 October Volume 17, 1124-1128
Communication Failures Across Facilities and at Hospital Discharge

Dawson, Liana E.

Inadequate communication has been identified as a significant factor in paid medical claims and is highlighted as one of the fundamental causes of patient adverse events. This article recounts an actual community hospital case illustrating both interfacility and physician-to-physician communication failures and their effect on patient care. Strategies for improving communication lie in optimizing facility transfer recordkeeping requirements and in improving discharge records by sharing accountability among all providers associated with a patient's hospitalization.
2011 December Volume 17, 1340-1343
Cryptogenic Stroke and Patent Foramen Ovale

Jaigobin, Cheryl

In patients with cryptogenic stroke and patent foramen ovale, options for stroke prevention include medical therapy (antiplatelet therapy or anticoagulation) and percutaneous device closure. In the only completed randomized controlled trial comparing medical therapy and percutaneous device closure, there was no difference in outcome between the two forms of treatment, and both are viable options for stroke prevention. The choice of therapy is made after careful weighing of potential risks and benefits associated with each form of therapy based on the limited evidence to date and the anticipated patient adherence with the planned treatment. Participation in a clinical trial is a third option for these patients.
2012 October Volume 18, 1172-1176
Guidelines in Practice: Therapies for Benign Paroxysmal Positional Vertigo

Shenoy, Anant M.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. This article describes the presentation and physical examination of a patient with BPPV. The case is then used to explore various features of the diagnosis, examination, and management of BPPV, with a focus on the 2008 AAN practice parameter on therapies for BPPV.
2012 February Volume 18, 192-198
Guidelines in Practice: Treatment of Painful Diabetic Neuropathy

Shenoy, Anant M.

This article describes a patient with a painful diabetic peripheral neuropathy. Features of his history, examination, and diagnostic workup are presented. His treatment course is described as guided by the AAN’s evidence-based guideline on the treatment of painful diabetic neuropathy. Lastly, features of coding for diabetic peripheral neuropathy are reviewed.
2012 February Volume 18, 181-184
Difficult Decisions: Managing Chronic Neuropathic Pain With Opioids

England, John D.; Franklin, Gary M.

The decision to use opioids to treat chronic neuropathic pain is complex and somewhat controversial. Although opioid therapy may be appropriate for some patients with chronic neuropathic pain, physicians must implement strategies to reduce opioid abuse, addiction, and diversion. The decision to use chronic opioids should be made proactively with institution of best practices to ensure safe and effective use. As with all aspects of chronic pain management, better education of both health care providers and patients is necessary. Fortunately, specific recommendations for the safe and effective use of opioids are now available in several recently published guidelines. The best practices embodied in these guideline...
2012 April Volume 18, 421-425
Helping Patients Make the Best Decision Regarding Duration of Temozolomide Chemotherapy Treatment

Groves, Morris D. Jr; Plummer, Ava B.

Outcomes for patients with glioblastoma have improved with the addition of temozolomide (TMZ) chemotherapy to radiation therapy followed by adjuvant TMZ for up to 1 year. Patients often wish to continue chemotherapy after the standard 1-year course. Whether to continue or to stop TMZ is a complex and stressful decision for the patient and family, and the decision should be based on a discussion of the known risks and benefits of each choice.
2012 June Volume 18, 659-668
Brain Death Dilemmas and the Use of Ancillary Testing

Webb, Adam; Samuels, Owen

Audio Interview
The Uniform Determination of Death Act indicates that “an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead,” with brain death being determined based on “accepted medical standards.” The AAN has published practice guidelines providing medical standards for the determination of brain death.1,2 The most recent AAN guideline update notes that “because of the deficiencies in the evidence base, clinicians must exercise considerable judgment when applying the criteria in specific circumstances” and that “ancillary tests can be used when uncertainty exists about t...
2012 August Volume 18, 900-904
Migraine and Disability Rights

Shapiro, Robert E.

Audio Interview
Patients with migraine often have substantial disabilities. US federal law provides protections for disabled Americans. This discussion provides information regarding the disability rights of patients with transformed migraine.
2012 October Volume 18, 1163-1166
Anxiety in a Dizzy Patient: The Importance of Communication in Improving Outcome

Fife, Terry D.

Audio Interview
Most patients with dizziness have a benign self-limited condition, often of labyrinthine origin; however, some develop a more intractable form of dizziness that can be challenging to evaluate. In many of these patients, brain imaging, vestibular testing, and clinical examination are normal, but the patient is significantly impaired. Many such patients have coexisting anxiety, which can make it difficult to determine whether the anxiety is a reaction to the dizziness or its primary cause. A careful history, including an assessment of the impact of symptoms on quality-of-life, social, and work-related issues is critical, and effective patient communication is essential. The following case exemplifies how a high-f...
2012 December Volume 18, 1474-1481
2013 February Volume 19, 204-222
Sleep and Fatigue Countermeasures for the Neurology Resident and Physician

Avidan, Alon Y.

Audio Interview
Purpose of Review: Fragmented sleep, prolonged work hours, misalignment of sleep-wake cycles, and an expectation to make medical decisions when alertness levels are reduced are pervasive in neurology residency training. Sleep loss in residency training can lead to cognitive and psychosocial impairment and accidents, compromise patient care, and reduce the trainee’s quality of life. Neurology residents experience levels of hypersomnolence similar to residents in surgical specialties and have comparable subjective levels of sleepiness as persons with pathologic sleep disorders such as narcolepsy and obstructive sleep apnea. Over the past 2 decades, work-hour limitations were established to alleviate fatigue and s...
2013 February Volume 19, 223-228
In-Home Testing for Obstructive Sleep Apnea

Kirsch, Douglas B.

The landscape of sleep medicine practice is actively evolving out of the laboratory, driven primarily by the improvement of home testing technology and the implementation of utilization management by insurance companies. This article will review a case of a patient with possible obstructive sleep apnea and discuss the history of home sleep testing and the reasons that home sleep testing will have an increasingly large role in the practices of physicians who evaluate patients with sleep disorders. Neurologists with an interest in sleep medicine should educate themselves on the use of home testing in clinical practice.
2013 April Volume 19, 475-479
Genetic Testing for Early-Onset Alzheimer Disease

Tsao, Jack W.

The availability of testing for identified risk genes for Alzheimer disease (AD) in patients with clinically probable AD or their at-risk family members raises important questions for the neurologist. Because the potential benefits and risks of testing vary for each patient, physicians need to evaluate whether it is appropriate on a case-by-case basis. This article outlines the testing decision process and serves as a guide to assist clinicians with associated counseling and result disclosure. Because genetic testing is relatively new and preventive and therapeutic options for AD remain limited, it is important to remain sensitive to and understand the specific challenges associated with obtaining these tests i...
2013 June Volume 19, 801-805
Monitoring and Antiepileptic Drug Safety

Willmore, L. James

Audio Interview
Treatment of patients with epilepsy strives for complete seizure control without intolerable drug side effects. Independent of blood drug levels, toxic effects allow titration to efficacy; however, allergic reactions, metabolically or genetically determined drug-induced illnesses, and idiosyncratic effects of drugs, while rare, may be life-threatening. Monitoring is an attempt to detect serious systemic toxic reactions of antiepileptic drugs in time to intervene and protect patients. The process begins with the disclosure to patients and family members of all information required for an informed decision delivered within the framework of risks and benefits. This review provides guidance regarding designing a m...
2013 August Volume 19, 1092-1099
Multiple Sclerosis Treatment: Risk Mitigation

Ontaneda, Daniel; Fox, Robert J.

The growing number of disease-modifying medications approved for multiple sclerosis (MS) treatment is a significant step forward and provides new options for our patients. These medications, however, have differing efficacy and risk profiles. Although accurate predictors of efficacy are not available, treatment choices can be guided by patient-specific risk stratification. The use of risk mitigation strategies can help clinicians tailor MS treatment recommendations for individual patients.