Jeffrey Buchhalter - Academia.edu (original) (raw)

Papers by Jeffrey Buchhalter

Epilepsia Open, 2021

ObjectiveTo describe the development of the Pediatric Epilepsy Outcome‐Informatics Project (PEOIP... more ObjectiveTo describe the development of the Pediatric Epilepsy Outcome‐Informatics Project (PEOIP) at Alberta Children's Hospital (ACH), which was created to provide standardized, point‐of‐care data entry; near‐time data analysis; and availability of outcome dashboards as a baseline on which to pursue quality improvement.MethodsStakeholders involved in the PEOIP met weekly to determine the most important outcomes for patients diagnosed with epilepsy, create a standardized electronic note with defined fields (patient demographics, seizure and syndrome type and frequency and specific outcomes‐ seizure type and frequency, adverse effects, emergency department visits, hospitalization, and care pathways for clinical decision support. These were embedded in the electronic health record from which the fields were extracted into a data display platform that provided patient‐ and population‐level dashboards updated every 36 hours. Provider satisfaction and family experience surveys were ...

Epilepsy & Behavior, 2021

Objective: To describe the organization of the Epilepsy Learning Healthcare System (ELHS), a netw... more Objective: To describe the organization of the Epilepsy Learning Healthcare System (ELHS), a network that aims to improve care outcomes for people with epilepsy (PWE). Materials and Methods: Patients and family partners, providers, researchers, epidemiologists, and other leaders collaborated to recruit epilepsy centers and community services organizations into a novel learning network. A multidisciplinary Coordinating Committee developed ELHS governance and organizational structure, including four key planning Cores (Community, Clinical, Quality Improvement, and Data). Through Quality Improvement (QI) methodology grounded in the Institute for Healthcare Improvement (IHI) model, including iterative Plan-Do-Study-Act (PDSA) rapid learning cycles and other learning and sharing sessions, ELHS equipped epilepsy centers and community organizations with tools to standardize, measure, share, and improve key aspects of epilepsy care. The initial learning cycles addressed provider documentation of seizure frequency and type, and also screening for medication adherence barriers. Rapid learning cycles have been carried out on these initial measures in both clinical centers and community-based settings. Additional key measures have been defined for quality of life, screening, and treatment for mental health and behavioral comorbidities, transition from pediatric to adult care, counseling for women and girls living with epilepsy, referral for specialty care, and prevention and treatment of seizure clusters and status epilepticus. Results: It is feasible to adopt a learning healthcare system framework in epilepsy centers and community services organizations. Through structured collaboration between epilepsy care providers, community support organizations, PWE, and their families/caregivers we have identified new opportunities to improve outcomes that are not available in traditional care models.

Applied Clinical Informatics, 2021

Background Sudden unexpected death in epilepsy (SUDEP) is a rare but fatal risk that patients, pa... more Background Sudden unexpected death in epilepsy (SUDEP) is a rare but fatal risk that patients, parents, and professional societies clearly recommend discussing with patients and families. However, this conversation does not routinely happen. Objectives This pilot study aimed to demonstrate whether computerized decision support could increase patient communication about SUDEP. Methods A prospective before-and-after study of the effect of computerized decision support on delivery of SUDEP counseling. The intervention was a screening, alerting, education, and follow-up SUDEP module for an existing computerized decision support system (the Child Health Improvement through Computer Automation [CHICA]) in five urban pediatric primary care clinics. Families of children with epilepsy were contacted by telephone before and after implementation to assess if the clinician discussed SUDEP at their respective encounters. Results The CHICA–SUDEP module screened 7,154 children age 0 to 21 years fo...

Neurology, 2019

ObjectiveTo obtain medical records, family interviews, and death-related reports of sudden unexpe... more ObjectiveTo obtain medical records, family interviews, and death-related reports of sudden unexpected death in epilepsy (SUDEP) cases to better understand SUDEP.MethodsAll cases referred to the North American SUDEP Registry (NASR) between October 2011 and June 2018 were reviewed; cause of death was determined by consensus review. Available medical records, death scene investigation reports, autopsy reports, and next-of-kin interviews were reviewed for all cases of SUDEP. Seizure type, EEG, MRI, and SUDEP classification were adjudicated by 2 epileptologists.ResultsThere were 237 definite and probable cases of SUDEP among 530 NASR participants. SUDEP decedents had a median age of 26 (range 1–70) years at death, and 38% were female. In 143 with sufficient information, 40% had generalized and 60% had focal epilepsy. SUDEP affected the full spectrum of epilepsies, from benign epilepsy with centrotemporal spikes (n = 3, 1%) to intractable epileptic encephalopathies (n = 27, 11%). Most (93...

Neurology, 2019

The American Academy of Neurology (AAN) formed a work group to evaluate quality measures applicab... more The American Academy of Neurology (AAN) formed a work group to evaluate quality measures applicable to a general neurologist. Currently available general measurement options-such as smoking, immunization, and weight-although relevant to a wide patient population, do not, for the most part, reflect the practice of neurology. Rather than developing quality measures specific to one neurologic subspecialty, the goal of this project was to develop quality measures that are universally applicable to neurology. Quality measures use clinical practice guideline recommendation statements and research to generate a measurable action a provider may perform. Quality measures do not generate new evidence or recommendations. Quality measures are one way that guideline recommendations are operationalized for use in clinical practice. Eight quality measure groups were determined to have relevance across the practice of neurology. Falls outcome and plan of care Falls are a leading cause of death in persons aged 65 years and older. 1 In addition, multiple neurologic conditions increase the risk of falling in younger persons. In persons who do fall and who require hospitalization, the cost is approximately 39,000perpatient.2Thisqualitymeasureaddressesthepercentageofpatientswhoreportedafallduringthemeasurementandwhohadaplanofcaredocumented.ActivitycounselingforbackpainBackpainisafrequentcauseofsickdaysforthoseintheworkforceandafrequentcomplaintinneurologicpractice.3In1990,itwasreportedthatlowbackpainwasthefifthmostcommonreasontoseeaphysician.4A2002NationalHealthInterviewSurveyindicatedthatonefourthofUSadultsreportedbackpaininthelast3−monthperiod.5A2006socioeconomicstudyshowedtotalcostsattributabletolowbackpainintheUnitedStateswereestimatedat39,000 per patient. 2 This quality measure addresses the percentage of patients who reported a fall during the measurement and who had a plan of care documented. Activity counseling for back pain Back pain is a frequent cause of sick days for those in the workforce and a frequent complaint in neurologic practice. 3 In 1990, it was reported that low back pain was the fifth most common reason to see a physician. 4 A 2002 National Health Interview Survey indicated that one fourth of US adults reported back pain in the last 3-month period. 5 A 2006 socioeconomic study showed total costs attributable to low back pain in the United States were estimated at 39,000perpatient.2Thisqualitymeasureaddressesthepercentageofpatientswhoreportedafallduringthemeasurementandwhohadaplanofcaredocumented.ActivitycounselingforbackpainBackpainisafrequentcauseofsickdaysforthoseintheworkforceandafrequentcomplaintinneurologicpractice.3In1990,itwasreportedthatlowbackpainwasthefifthmostcommonreasontoseeaphysician.4A2002NationalHealthInterviewSurveyindicatedthatonefourthofUSadultsreportedbackpaininthelast3−monthperiod.5A2006socioeconomicstudyshowedtotalcostsattributabletolowbackpainintheUnitedStateswereestimatedat100 billion, two-thirds of which were indirect costs of lost wages and productivity. 6 This quality measure addresses the percentage of adults between 18 and 65 years of age with back pain who were either counseled to remain active or referred to physical therapy. Maltreatment screening and action Maltreatment is a national priority. In children, maltreatment is associated with increased medical costs, approximating 9% of all Medicaid expenditures for children. 7 It is estimated that approximately 10% of older adults experience maltreatment or abuse. 8 Maltreatment of patients is reported at a higher frequency in patients with neurologic conditions that involve functional

Pediatrics, 2017

A 20-month-old girl with a complex chromosomal disorder had first presentation of febrile status ... more A 20-month-old girl with a complex chromosomal disorder had first presentation of febrile status epilepticus and was admitted to the hospital. Two days after her initial seizure, she died suddenly and unexpectedly during a video EEG monitoring study. An advanced analysis of the physiologic changes in the hours and minutes leading up to death was undertaken. The electrocardiography over the last 19 minutes of life was reviewed, and the R-R intervals were manually measured. Heart rate variability was assessed through calculation of the SD of the R-R intervals and the root mean square of successive differences over successive 100 beat periods. Instantaneous heart rate, SD of the R-R intervals, the root mean square of successive differences, and oxygen saturation were plotted against time over the last 19 minutes of life. Diffuse cerebral suppression on EEG was observed 10 minutes before death, followed minutes later by severe bradycardia and increased heart rate variability. Although t...

Journal of Clinical Neurophysiology, 2017

Introduction-No previous population-based study has addressed the contribution of activation proc... more Introduction-No previous population-based study has addressed the contribution of activation procedures to the yield of epileptiform abnormalities on serial EEGs. We assessed yield of activation-related epileptiform abnormalities and predictors of finding an activation-related abnormality with multiple EEGs in a population-based study of newly diagnosed epilepsy. Methods-We used the resources of the Rochester Epidemiology Project to identify 449 residents of Rochester, Minnesota with a diagnosis of newly diagnosed epilepsy at age one year or older, between 1960 and 1994, who had at least one EEG. Information on all activation procedures (i.e. sleep, hyperventilation, photic activation) and seizure/epilepsy characteristics was obtained by comprehensive review of medical records. Results-At the first EEG, the yield of epileptiform abnormalities was greatest for individuals 1-19 years of age at diagnosis, for each activation procedure. The yield in patients aged 1-19 versus ≥20 years was 21.6% vs. 10.3% for sleep, 6.5% vs. 3.3% for photic stimulation, and 10.3% vs. 5% for hyperventilation. Among young people (aged 1-19 years) sleep was associated with an increased likelihood of finding an activation-related abnormality on any EEG. The likelihood of finding an activation-related abnormality on any EEG was decreased for postnatal symptomatic and for unknown etiology.

Neurology, Jan 11, 2017

See page 170 SUDEP An important cause of premature mortality in epilepsy across the life spectrum... more See page 170 SUDEP An important cause of premature mortality in epilepsy across the life spectrum From the Departments of Pediatrics and Clinical Neurosciences (J.B.

JAMA neurology, 2017

Children with benign epilepsy with centrotemporal spikes (BECTS) have traditionally been consider... more Children with benign epilepsy with centrotemporal spikes (BECTS) have traditionally been considered to have a uniformly good prognosis. However, benign may be a misnomer because BECTS is linked to cognitive deficits, a more severe phenotype with intractable seizures, and the potential for sudden unexpected death in epilepsy (SUDEP). To determine if cases of BECTS are present in the North American SUDEP Registry (NASR). The NASR is a clinical and biospecimen repository established in 2011 to promote SUDEP research. The NASR database, which includes medical records, results of electroencephalographic tests, and interviews with family members of patients with epilepsy who died suddenly without other identifiable causes of death, was queried from June 3, 2011, to June 3, 2016, for cases of BECTS. The patients with epilepsy had died suddenly without other identifiable causes of death (eg, drowning, trauma, exposure to toxic substances, or suicide); SUDEP classification was determined by ...

Neurology, Jan 25, 2017

To determine the incidence rates of sudden unexpected death in epilepsy (SUDEP) in different epil... more To determine the incidence rates of sudden unexpected death in epilepsy (SUDEP) in different epilepsy populations and address the question of whether risk factors for SUDEP have been identified. Systematic review of evidence; modified Grading Recommendations Assessment, Development, and Evaluation process for developing conclusions; recommendations developed by consensus. Findings for incidence rates based on 12 Class I studies include the following: SUDEP risk in children with epilepsy (aged 0-17 years) is 0.22/1,000 patient-years (95% confidence interval [CI] 0.16-0.31) (moderate confidence in evidence). SUDEP risk increases in adults to 1.2/1,000 patient-years (95% CI 0.64-2.32) (low confidence in evidence). The major risk factor for SUDEP is the occurrence of generalized tonic-clonic seizures (GTCS); the SUDEP risk increases in association with increasing frequency of GTCS occurrence (high confidence in evidence). Level B: Clinicians caring for young children with epilepsy shoul...

AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 2014

When attempting to identify a specific epilepsy syndrome, physicians are often unable to make or ... more When attempting to identify a specific epilepsy syndrome, physicians are often unable to make or agree upon a diagnosis. This is further complicated by the fact that the current classification and diagnosis of epilepsy requires specialized training and the use of resources not typically available to the average clinician, such as training to recognize specific seizure types and electroencephalography (EEG)1-4. Even when training and resources are available, expert epileptologists often find it challenging to identify seizure types and to distinguish between specific epilepsy syndromes5. Information relevant to the diagnosis is present in narrative form in the medical record across several visits for an individual patient. Our ultimate goal is to create a system that will assist physicians in the diagnosis of epilepsy. This paper explores, as a baseline, text classification methods that attempt to correlate the narrative text features to the diagnosis of West syndrome (Infantile Spas...

Epilepsy & Behavior, 2015

Epilepsia, 2014

The yield of epileptiform abnormalities in serial electroencephalography (EEG) studies has not be... more The yield of epileptiform abnormalities in serial electroencephalography (EEG) studies has not been addressed in a population-based setting for subjects with incident epilepsy or a single unprovoked seizure, raising the possibility of methodologic limitations such as selection bias. Our aim was to address these limitations by assessing the yield and predictors of epileptiform abnormalities for the first and subsequent EEG recording in a study of incident epilepsy or single unprovoked seizure in Rochester, Minnesota. We used the resources of the Rochester Epidemiology Project to identify all 619 residents of Rochester, Minnesota, born in 1920 or later with a diagnosis of incident epilepsy (n = 478) or single unprovoked seizure (n = 141) between 1960 and 1994, who had at least one EEG study. Information on all EEG studies and their results was obtained by comprehensive review of medical records. Among subjects with epilepsy, the cumulative yield of epileptiform abnormalities was 53% a...

Epilepsy currents / American Epilepsy Society, 2013

Epilepsy currents / American Epilepsy Society, 2012

Epilepsy currents / American Epilepsy Society, 2012

* This means money that your institution received for your efforts on this study. ** Use this sec... more * This means money that your institution received for your efforts on this study. ** Use this section to provide any needed explanation. * This means money that your institution received for your efforts. ** For example, if you report a consultancy above there is no need to report travel related to that consultancy on this line. Section #4 Other relationships Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? No other relationships/conditions/circumstances that present a potential conflict of interest. Yes, the following relationships/conditions/circumstances are present: Thank you for your assistance. Epilepsy Currents Editorial Board

Epilepsy currents / American Epilepsy Society, 2011

In Clinical Science Commentary Status epilepticus (SE), whether in a child or adult, convulsive o... more In Clinical Science Commentary Status epilepticus (SE), whether in a child or adult, convulsive or nonconvulsive is considered a life-threatening emergency that requires prompt evaluation and treatment. There are several critical issues in accomplishing the former, so that the latter may be pursued. The first is the identification of the condition, status epilepticus. Although it would seem that this should be straightforward, the diagnosis of SE, particularly in the setting of a new-onset seizure can be challenging. The answer to the crucial question "when did this begin" is frequently not known with precision. Unless the family happens to look at a watch or clock, the time of onset may not be known accurately. In addition, children can be found seizing by a parent who hears something unusual or is just checking their child at night. Whether the real duration of the seizure is known or just estimated, the next challenge is to define when the event becomes SE. The duration suggested by the International League Against Epilepsy guideline (1) has been 30 minutes. This duration was selected based primarily on animal studies indicating that this is the critical time after which neurologic damage occurs. However, more recent literature questions the wisdom of putting off more aggressive diagnostic and thera

Epilepsy Currents, 2012

In Clinical Science Commentary Two of the most fundamental aspects of caring for children with ep... more In Clinical Science Commentary Two of the most fundamental aspects of caring for children with epilepsy is knowledge of seizure type and frequency of seizures. The recent report by Sadleir calls for a reassessment of each. What is an absence seizure? The 1981 International League Against Epilepsy (ILAE) classification system of seizures described the features of an "absence attack" to include its "sudden onset, interruption of ongoing activities, a blank stare ... usually the patient will be unresponsive when spoken to" (1). The five types of absence seizures listed include: absence with impairment of consciousness only, absence with clonic components (eyelids and mouth specifically noted), absence with atonic components, absence with tonic components, and absence with automatisms. Embedded in this definition is the assumption of an electrical correlate to complete the electroclinical seizure definition. In the case of absence, it is a generalized spike or polyspike-slow wave (GSW) discharge of >2.5 Hz. This raises the ongoing discussion of a semiological classification of seizures (2) versus one in which the EEG correlate is part of the definition. Without knowing the interictal or ictal EEG, it is not certain that the description above would correctly classify a seizure of generalized versus focal onset. This is reflected in the ILAE Glossary of Descriptive for Ictal Semiology in which the word "absence" is not to be found (3). Rather, the EEG neutral term "dyscognitive" is used to describe those "… events in which disturbance of cognition is the predominant or most apparent feature and ... " specific features of cognition are impaired such as perception, attention, memory, and executive function. This discussion is most relevant to the child or adult at the initial evaluation for an event of impaired consciousness indicating that prior knowledge of the patient's evaluation shapes how we define and quantify ongoing events.

Epilepsia, 2010

SummaryThe International League Against Epilepsy (ILAE) Commission on Classification and Terminol... more SummaryThe International League Against Epilepsy (ILAE) Commission on Classification and Terminology has revised concepts, terminology, and approaches for classifying seizures and forms of epilepsy. Generalized and focal are redefined for seizures as occurring in and rapidly engaging bilaterally distributed networks (generalized) and within networks limited to one hemisphere and either discretely localized or more widely distributed (focal). Classification of generalized seizures is simplified. No natural classification for focal seizures exists; focal seizures should be described according to their manifestations (e.g., dyscognitive, focal motor). The concepts of generalized and focal do not apply to electroclinical syndromes. Genetic, structural–metabolic, and unknown represent modified concepts to replace idiopathic, symptomatic, and cryptogenic. Not all epilepsies are recognized as electroclinical syndromes. Organization of forms of epilepsy is first by specificity: electroclini...

Epilepsia Open, 2021

ObjectiveTo describe the development of the Pediatric Epilepsy Outcome‐Informatics Project (PEOIP... more ObjectiveTo describe the development of the Pediatric Epilepsy Outcome‐Informatics Project (PEOIP) at Alberta Children's Hospital (ACH), which was created to provide standardized, point‐of‐care data entry; near‐time data analysis; and availability of outcome dashboards as a baseline on which to pursue quality improvement.MethodsStakeholders involved in the PEOIP met weekly to determine the most important outcomes for patients diagnosed with epilepsy, create a standardized electronic note with defined fields (patient demographics, seizure and syndrome type and frequency and specific outcomes‐ seizure type and frequency, adverse effects, emergency department visits, hospitalization, and care pathways for clinical decision support. These were embedded in the electronic health record from which the fields were extracted into a data display platform that provided patient‐ and population‐level dashboards updated every 36 hours. Provider satisfaction and family experience surveys were ...

Epilepsy & Behavior, 2021

Objective: To describe the organization of the Epilepsy Learning Healthcare System (ELHS), a netw... more Objective: To describe the organization of the Epilepsy Learning Healthcare System (ELHS), a network that aims to improve care outcomes for people with epilepsy (PWE). Materials and Methods: Patients and family partners, providers, researchers, epidemiologists, and other leaders collaborated to recruit epilepsy centers and community services organizations into a novel learning network. A multidisciplinary Coordinating Committee developed ELHS governance and organizational structure, including four key planning Cores (Community, Clinical, Quality Improvement, and Data). Through Quality Improvement (QI) methodology grounded in the Institute for Healthcare Improvement (IHI) model, including iterative Plan-Do-Study-Act (PDSA) rapid learning cycles and other learning and sharing sessions, ELHS equipped epilepsy centers and community organizations with tools to standardize, measure, share, and improve key aspects of epilepsy care. The initial learning cycles addressed provider documentation of seizure frequency and type, and also screening for medication adherence barriers. Rapid learning cycles have been carried out on these initial measures in both clinical centers and community-based settings. Additional key measures have been defined for quality of life, screening, and treatment for mental health and behavioral comorbidities, transition from pediatric to adult care, counseling for women and girls living with epilepsy, referral for specialty care, and prevention and treatment of seizure clusters and status epilepticus. Results: It is feasible to adopt a learning healthcare system framework in epilepsy centers and community services organizations. Through structured collaboration between epilepsy care providers, community support organizations, PWE, and their families/caregivers we have identified new opportunities to improve outcomes that are not available in traditional care models.

Applied Clinical Informatics, 2021

Background Sudden unexpected death in epilepsy (SUDEP) is a rare but fatal risk that patients, pa... more Background Sudden unexpected death in epilepsy (SUDEP) is a rare but fatal risk that patients, parents, and professional societies clearly recommend discussing with patients and families. However, this conversation does not routinely happen. Objectives This pilot study aimed to demonstrate whether computerized decision support could increase patient communication about SUDEP. Methods A prospective before-and-after study of the effect of computerized decision support on delivery of SUDEP counseling. The intervention was a screening, alerting, education, and follow-up SUDEP module for an existing computerized decision support system (the Child Health Improvement through Computer Automation [CHICA]) in five urban pediatric primary care clinics. Families of children with epilepsy were contacted by telephone before and after implementation to assess if the clinician discussed SUDEP at their respective encounters. Results The CHICA–SUDEP module screened 7,154 children age 0 to 21 years fo...

Neurology, 2019

ObjectiveTo obtain medical records, family interviews, and death-related reports of sudden unexpe... more ObjectiveTo obtain medical records, family interviews, and death-related reports of sudden unexpected death in epilepsy (SUDEP) cases to better understand SUDEP.MethodsAll cases referred to the North American SUDEP Registry (NASR) between October 2011 and June 2018 were reviewed; cause of death was determined by consensus review. Available medical records, death scene investigation reports, autopsy reports, and next-of-kin interviews were reviewed for all cases of SUDEP. Seizure type, EEG, MRI, and SUDEP classification were adjudicated by 2 epileptologists.ResultsThere were 237 definite and probable cases of SUDEP among 530 NASR participants. SUDEP decedents had a median age of 26 (range 1–70) years at death, and 38% were female. In 143 with sufficient information, 40% had generalized and 60% had focal epilepsy. SUDEP affected the full spectrum of epilepsies, from benign epilepsy with centrotemporal spikes (n = 3, 1%) to intractable epileptic encephalopathies (n = 27, 11%). Most (93...

Neurology, 2019

The American Academy of Neurology (AAN) formed a work group to evaluate quality measures applicab... more The American Academy of Neurology (AAN) formed a work group to evaluate quality measures applicable to a general neurologist. Currently available general measurement options-such as smoking, immunization, and weight-although relevant to a wide patient population, do not, for the most part, reflect the practice of neurology. Rather than developing quality measures specific to one neurologic subspecialty, the goal of this project was to develop quality measures that are universally applicable to neurology. Quality measures use clinical practice guideline recommendation statements and research to generate a measurable action a provider may perform. Quality measures do not generate new evidence or recommendations. Quality measures are one way that guideline recommendations are operationalized for use in clinical practice. Eight quality measure groups were determined to have relevance across the practice of neurology. Falls outcome and plan of care Falls are a leading cause of death in persons aged 65 years and older. 1 In addition, multiple neurologic conditions increase the risk of falling in younger persons. In persons who do fall and who require hospitalization, the cost is approximately 39,000perpatient.2Thisqualitymeasureaddressesthepercentageofpatientswhoreportedafallduringthemeasurementandwhohadaplanofcaredocumented.ActivitycounselingforbackpainBackpainisafrequentcauseofsickdaysforthoseintheworkforceandafrequentcomplaintinneurologicpractice.3In1990,itwasreportedthatlowbackpainwasthefifthmostcommonreasontoseeaphysician.4A2002NationalHealthInterviewSurveyindicatedthatonefourthofUSadultsreportedbackpaininthelast3−monthperiod.5A2006socioeconomicstudyshowedtotalcostsattributabletolowbackpainintheUnitedStateswereestimatedat39,000 per patient. 2 This quality measure addresses the percentage of patients who reported a fall during the measurement and who had a plan of care documented. Activity counseling for back pain Back pain is a frequent cause of sick days for those in the workforce and a frequent complaint in neurologic practice. 3 In 1990, it was reported that low back pain was the fifth most common reason to see a physician. 4 A 2002 National Health Interview Survey indicated that one fourth of US adults reported back pain in the last 3-month period. 5 A 2006 socioeconomic study showed total costs attributable to low back pain in the United States were estimated at 39,000perpatient.2Thisqualitymeasureaddressesthepercentageofpatientswhoreportedafallduringthemeasurementandwhohadaplanofcaredocumented.ActivitycounselingforbackpainBackpainisafrequentcauseofsickdaysforthoseintheworkforceandafrequentcomplaintinneurologicpractice.3In1990,itwasreportedthatlowbackpainwasthefifthmostcommonreasontoseeaphysician.4A2002NationalHealthInterviewSurveyindicatedthatonefourthofUSadultsreportedbackpaininthelast3−monthperiod.5A2006socioeconomicstudyshowedtotalcostsattributabletolowbackpainintheUnitedStateswereestimatedat100 billion, two-thirds of which were indirect costs of lost wages and productivity. 6 This quality measure addresses the percentage of adults between 18 and 65 years of age with back pain who were either counseled to remain active or referred to physical therapy. Maltreatment screening and action Maltreatment is a national priority. In children, maltreatment is associated with increased medical costs, approximating 9% of all Medicaid expenditures for children. 7 It is estimated that approximately 10% of older adults experience maltreatment or abuse. 8 Maltreatment of patients is reported at a higher frequency in patients with neurologic conditions that involve functional

Pediatrics, 2017

A 20-month-old girl with a complex chromosomal disorder had first presentation of febrile status ... more A 20-month-old girl with a complex chromosomal disorder had first presentation of febrile status epilepticus and was admitted to the hospital. Two days after her initial seizure, she died suddenly and unexpectedly during a video EEG monitoring study. An advanced analysis of the physiologic changes in the hours and minutes leading up to death was undertaken. The electrocardiography over the last 19 minutes of life was reviewed, and the R-R intervals were manually measured. Heart rate variability was assessed through calculation of the SD of the R-R intervals and the root mean square of successive differences over successive 100 beat periods. Instantaneous heart rate, SD of the R-R intervals, the root mean square of successive differences, and oxygen saturation were plotted against time over the last 19 minutes of life. Diffuse cerebral suppression on EEG was observed 10 minutes before death, followed minutes later by severe bradycardia and increased heart rate variability. Although t...

Journal of Clinical Neurophysiology, 2017

Introduction-No previous population-based study has addressed the contribution of activation proc... more Introduction-No previous population-based study has addressed the contribution of activation procedures to the yield of epileptiform abnormalities on serial EEGs. We assessed yield of activation-related epileptiform abnormalities and predictors of finding an activation-related abnormality with multiple EEGs in a population-based study of newly diagnosed epilepsy. Methods-We used the resources of the Rochester Epidemiology Project to identify 449 residents of Rochester, Minnesota with a diagnosis of newly diagnosed epilepsy at age one year or older, between 1960 and 1994, who had at least one EEG. Information on all activation procedures (i.e. sleep, hyperventilation, photic activation) and seizure/epilepsy characteristics was obtained by comprehensive review of medical records. Results-At the first EEG, the yield of epileptiform abnormalities was greatest for individuals 1-19 years of age at diagnosis, for each activation procedure. The yield in patients aged 1-19 versus ≥20 years was 21.6% vs. 10.3% for sleep, 6.5% vs. 3.3% for photic stimulation, and 10.3% vs. 5% for hyperventilation. Among young people (aged 1-19 years) sleep was associated with an increased likelihood of finding an activation-related abnormality on any EEG. The likelihood of finding an activation-related abnormality on any EEG was decreased for postnatal symptomatic and for unknown etiology.

Neurology, Jan 11, 2017

See page 170 SUDEP An important cause of premature mortality in epilepsy across the life spectrum... more See page 170 SUDEP An important cause of premature mortality in epilepsy across the life spectrum From the Departments of Pediatrics and Clinical Neurosciences (J.B.

JAMA neurology, 2017

Children with benign epilepsy with centrotemporal spikes (BECTS) have traditionally been consider... more Children with benign epilepsy with centrotemporal spikes (BECTS) have traditionally been considered to have a uniformly good prognosis. However, benign may be a misnomer because BECTS is linked to cognitive deficits, a more severe phenotype with intractable seizures, and the potential for sudden unexpected death in epilepsy (SUDEP). To determine if cases of BECTS are present in the North American SUDEP Registry (NASR). The NASR is a clinical and biospecimen repository established in 2011 to promote SUDEP research. The NASR database, which includes medical records, results of electroencephalographic tests, and interviews with family members of patients with epilepsy who died suddenly without other identifiable causes of death, was queried from June 3, 2011, to June 3, 2016, for cases of BECTS. The patients with epilepsy had died suddenly without other identifiable causes of death (eg, drowning, trauma, exposure to toxic substances, or suicide); SUDEP classification was determined by ...

Neurology, Jan 25, 2017

To determine the incidence rates of sudden unexpected death in epilepsy (SUDEP) in different epil... more To determine the incidence rates of sudden unexpected death in epilepsy (SUDEP) in different epilepsy populations and address the question of whether risk factors for SUDEP have been identified. Systematic review of evidence; modified Grading Recommendations Assessment, Development, and Evaluation process for developing conclusions; recommendations developed by consensus. Findings for incidence rates based on 12 Class I studies include the following: SUDEP risk in children with epilepsy (aged 0-17 years) is 0.22/1,000 patient-years (95% confidence interval [CI] 0.16-0.31) (moderate confidence in evidence). SUDEP risk increases in adults to 1.2/1,000 patient-years (95% CI 0.64-2.32) (low confidence in evidence). The major risk factor for SUDEP is the occurrence of generalized tonic-clonic seizures (GTCS); the SUDEP risk increases in association with increasing frequency of GTCS occurrence (high confidence in evidence). Level B: Clinicians caring for young children with epilepsy shoul...

AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 2014

When attempting to identify a specific epilepsy syndrome, physicians are often unable to make or ... more When attempting to identify a specific epilepsy syndrome, physicians are often unable to make or agree upon a diagnosis. This is further complicated by the fact that the current classification and diagnosis of epilepsy requires specialized training and the use of resources not typically available to the average clinician, such as training to recognize specific seizure types and electroencephalography (EEG)1-4. Even when training and resources are available, expert epileptologists often find it challenging to identify seizure types and to distinguish between specific epilepsy syndromes5. Information relevant to the diagnosis is present in narrative form in the medical record across several visits for an individual patient. Our ultimate goal is to create a system that will assist physicians in the diagnosis of epilepsy. This paper explores, as a baseline, text classification methods that attempt to correlate the narrative text features to the diagnosis of West syndrome (Infantile Spas...

Epilepsy & Behavior, 2015

Epilepsia, 2014

The yield of epileptiform abnormalities in serial electroencephalography (EEG) studies has not be... more The yield of epileptiform abnormalities in serial electroencephalography (EEG) studies has not been addressed in a population-based setting for subjects with incident epilepsy or a single unprovoked seizure, raising the possibility of methodologic limitations such as selection bias. Our aim was to address these limitations by assessing the yield and predictors of epileptiform abnormalities for the first and subsequent EEG recording in a study of incident epilepsy or single unprovoked seizure in Rochester, Minnesota. We used the resources of the Rochester Epidemiology Project to identify all 619 residents of Rochester, Minnesota, born in 1920 or later with a diagnosis of incident epilepsy (n = 478) or single unprovoked seizure (n = 141) between 1960 and 1994, who had at least one EEG study. Information on all EEG studies and their results was obtained by comprehensive review of medical records. Among subjects with epilepsy, the cumulative yield of epileptiform abnormalities was 53% a...

Epilepsy currents / American Epilepsy Society, 2013

Epilepsy currents / American Epilepsy Society, 2012

Epilepsy currents / American Epilepsy Society, 2012

* This means money that your institution received for your efforts on this study. ** Use this sec... more * This means money that your institution received for your efforts on this study. ** Use this section to provide any needed explanation. * This means money that your institution received for your efforts. ** For example, if you report a consultancy above there is no need to report travel related to that consultancy on this line. Section #4 Other relationships Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work? No other relationships/conditions/circumstances that present a potential conflict of interest. Yes, the following relationships/conditions/circumstances are present: Thank you for your assistance. Epilepsy Currents Editorial Board

Epilepsy currents / American Epilepsy Society, 2011

In Clinical Science Commentary Status epilepticus (SE), whether in a child or adult, convulsive o... more In Clinical Science Commentary Status epilepticus (SE), whether in a child or adult, convulsive or nonconvulsive is considered a life-threatening emergency that requires prompt evaluation and treatment. There are several critical issues in accomplishing the former, so that the latter may be pursued. The first is the identification of the condition, status epilepticus. Although it would seem that this should be straightforward, the diagnosis of SE, particularly in the setting of a new-onset seizure can be challenging. The answer to the crucial question "when did this begin" is frequently not known with precision. Unless the family happens to look at a watch or clock, the time of onset may not be known accurately. In addition, children can be found seizing by a parent who hears something unusual or is just checking their child at night. Whether the real duration of the seizure is known or just estimated, the next challenge is to define when the event becomes SE. The duration suggested by the International League Against Epilepsy guideline (1) has been 30 minutes. This duration was selected based primarily on animal studies indicating that this is the critical time after which neurologic damage occurs. However, more recent literature questions the wisdom of putting off more aggressive diagnostic and thera

Epilepsy Currents, 2012

In Clinical Science Commentary Two of the most fundamental aspects of caring for children with ep... more In Clinical Science Commentary Two of the most fundamental aspects of caring for children with epilepsy is knowledge of seizure type and frequency of seizures. The recent report by Sadleir calls for a reassessment of each. What is an absence seizure? The 1981 International League Against Epilepsy (ILAE) classification system of seizures described the features of an "absence attack" to include its "sudden onset, interruption of ongoing activities, a blank stare ... usually the patient will be unresponsive when spoken to" (1). The five types of absence seizures listed include: absence with impairment of consciousness only, absence with clonic components (eyelids and mouth specifically noted), absence with atonic components, absence with tonic components, and absence with automatisms. Embedded in this definition is the assumption of an electrical correlate to complete the electroclinical seizure definition. In the case of absence, it is a generalized spike or polyspike-slow wave (GSW) discharge of >2.5 Hz. This raises the ongoing discussion of a semiological classification of seizures (2) versus one in which the EEG correlate is part of the definition. Without knowing the interictal or ictal EEG, it is not certain that the description above would correctly classify a seizure of generalized versus focal onset. This is reflected in the ILAE Glossary of Descriptive for Ictal Semiology in which the word "absence" is not to be found (3). Rather, the EEG neutral term "dyscognitive" is used to describe those "… events in which disturbance of cognition is the predominant or most apparent feature and ... " specific features of cognition are impaired such as perception, attention, memory, and executive function. This discussion is most relevant to the child or adult at the initial evaluation for an event of impaired consciousness indicating that prior knowledge of the patient's evaluation shapes how we define and quantify ongoing events.

Epilepsia, 2010

SummaryThe International League Against Epilepsy (ILAE) Commission on Classification and Terminol... more SummaryThe International League Against Epilepsy (ILAE) Commission on Classification and Terminology has revised concepts, terminology, and approaches for classifying seizures and forms of epilepsy. Generalized and focal are redefined for seizures as occurring in and rapidly engaging bilaterally distributed networks (generalized) and within networks limited to one hemisphere and either discretely localized or more widely distributed (focal). Classification of generalized seizures is simplified. No natural classification for focal seizures exists; focal seizures should be described according to their manifestations (e.g., dyscognitive, focal motor). The concepts of generalized and focal do not apply to electroclinical syndromes. Genetic, structural–metabolic, and unknown represent modified concepts to replace idiopathic, symptomatic, and cryptogenic. Not all epilepsies are recognized as electroclinical syndromes. Organization of forms of epilepsy is first by specificity: electroclini...