The practice of neurology is generally an ambulatory specialty, increasingly so since I completed my residency years ago. Nonetheless, consultation in the hospital remains an important component of most neurologists' practices and is often particularly challenging. Requests for neurologic consultation can encompass a myriad of conditions and questions; however, certain situations repeatedly generate solicitation of a neurologist' opinion. Many of these scenarios are the subjects of this issue of CONTINUUM, Neurologic Consultation in the Hospital, produced with the leadership of Dr S. Andrew Josephson.
With hospital beds increasingly occupied by acutely, and often severely, ill patients, one of the most common requests for consultation concerns a change in mental status. In their article on this subject, Dr Vanja Douglas and Dr Josephson discuss the differential diagnosis, evaluation, and management of this important condition. Delirium is not only a potentially acute life-threatening condition, but also represents a significant predictor of chronic dementia. Although the list of potential causes is extensive, the authors appropriately emphasize the importance of reviewing the patient' medications.
Although one dictionary definition of a spell is "a period of bodily or mental distress or disorder," in their article on the evaluation of the patient with spells, Drs Susannah Brock Cornes and Tina Shih principally focus on those conditions that transiently, and often recurrently, affect mental status. They discuss the discriminating features of such conditions as epileptic and nonepileptic seizures, syncope, and sleep disorders and describe a systematic evaluation that the neurologist can use in assessing the patient.
Although less frequently encountered, meningitis and encephalitis are potentially lethal conditions that require expeditious recognition and prompt initiation of appropriate therapy. Drs Karen Roos and John Greenlee ensure that you are up to speed on these serious infectious diseases.
Cardiac disease and stroke are intricately intertwined, as every neurologist knows. Thus, it is no surprise that consultation is frequently requested when stroke occurs or when information is sought about its risk in cardiac patients. In addition, a significant number of patients experience stroke as a complication of cardiac surgery procedures, especially given the huge number of these procedures currently being performed. Dr Joey English updates us on this type of neurologic consultation.
Another frequent source of consultation is a patient with generalized weakness, a subject discussed by Drs Katharina Busl and Allan Ropper. A particular focus of this article is the patient in the intensive care unit who is difficult to wean from mechanical ventilation. The authors help us better understand the entities of prolonged neuromuscular blockade, critical illness myopathy, and critical illness neuropathy, emphasizing that these are much more likely than primary neurologic disease to be responsible for weakness in the hospital setting.
In-hospital falls cause a significant degree of morbidity and constitute a substantial source of litigation. Although neurologists are very commonly consulted after a fall has occurred, it is equally important for us to recognize the potential risks for falls in patients on whom they are consulting for other purposes. Drs Ethan Cumbler and David Likosky educate us about this important matter.
Although often the province of the neurosurgeon, it clearly behooves the neurologist to understand the evaluation and management of increased intracranial pressure, discussed in this issue by Drs Kazuma Nakagawa and Wade Smith. Although invasive procedures for monitoring and alleviating increased ICP are managed by our surgical colleagues, a variety of medical strategies are available, each with its own risks and benefits. You will be more comfortable managing these options after mastering the material in this article.
Neurologists are regularly summoned to the coronary care unit, as well as elsewhere in the hospital, to provide information about the prognosis for patients who have survived hypoxic-ischemic brain injury. Family members or others concerned about the patient are understandably eager to know the expectations as soon as possible. Unfortunately, clinical examination is generally not a reliable predictor until 3 days after the cardiac arrest. In the final review article of this issue, Drs Nicole Chiota, W. David Freeman, and Kevin Barrett bring you up-to-date on the latest knowledge in this area, which is particularly important with the advent of mild hypothermia in the first 12 to 24 hours after cardiac arrest as the standard of care.
This issue of CONTINUUM, like all others, does not end with the review articles. In the Ethical Perspectives section, Dr John Hixson addresses the thorny issue of resolving conflicts when physicians disagree about patient management. Little doubt surrounds the assertion that "hand-offs" are one of the biggest potential sources of error in patient care. In her article in the Practice section, Dr Liana Dawson grapples with the broader issue of communication failures across facilities and at hospital discharge. Dr Laura Powers makes certain you understand current coding issues related to neurologic consultations, a subject of recent and ongoing dismay among neurologists in view of the Centers for Medicare & Medicaid Services's recent decision to eliminate consultation codes.
The issue concludes with a series of valuable question-and-answer opportunities that will help cement your knowledge of this subject. Drs Ronnie Bergen and Julie Hammack serve up a platter of Multiple-Choice Questions that challenge your mastery of neurologic consultation, and Dr Karen DaSilva and Dr Josephson lead you through a Patient Management Problem concerning a man presenting with weakness and fever.
I congratulate Dr Josephson and the many other contributors to this issue for selecting and elucidating a series of critically important circumstances for the neurologist who is called to perform consultations in the hospital. You will certainly be well prepared to meet these challenges after perusing this issue of CONTINUUM.
-Aaron E. Miller, MD