Randomized controlled trial of a clinical decision support system for painful polyneuropathy

IntroductionDespite the existence of guidelines, painful neuropathy is often inappropriately treated. We sought to determine the effectiveness of a clinical decision support system on guideline‐recommended medication use.MethodsWe randomized neurology providers, stratified by subspecialty, to a best practice alert (BPA) linked to a Smartset or a BPA alone when seeing patients with neuropathy. The primary outcome was the proportion of patients with uncontrolled nerve pain prescribed a guideline‐recommended medication. Generalized estimating equations were used to assess effectiveness.ResultsSeventy‐five neurology providers (intervention 38, control 37) treated 2697 patients with neuropathy (intervention 1026, control 671). Providers did not acknowledge the BPA in 1928 (71.5%) visits. Only four of eight intervention arm neurologists who treated patients with uncontrolled nerve pain opened the Smartset. The intervention was not associated with guideline‐recommended medication use (odds ratio 0.52, 0.18‐1.48; intervention 52%, control 54.8%).DiscussionOur intervention did not improve prescribing practices for painful neuropathy. Physicians typically ignored the BPAs/Smartset; therefore, future studies should mandate their use or employ alternate strategies.See editorial on pages 552–553 in this issue.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154934/1/mus26774.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154934/2/mus26774_am.pd

Choosing Wisely: Highest‐cost tests in outpatient neurology

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Reply

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Electromyography‐related pain: Muscle selection is the key modifiable study characteristic

Introduction : The aim of this study was to estimate the effects of patient, provider, and study characteristics on electromyography (EMG)‐related pain. Methods : Patients undergoing EMG rated their EMG‐related pain after each muscle was studied on a 100‐point visual analog scale (VAS). Investigators recorded the order in which the muscles were sampled, the total time spent with the needle in each muscle, and whether electrical endplate noise was noted. Results : A total of 1781 muscles were studied in 304 patients. Eleven muscles were associated with significantly more or less pain than the others. Endplate noise was associated with more pain (5.4 mm, 95% CI 2.8–7.0). There was a small, but significant effect from needling time (0.02 mm, 95% CI 0.00–0.04). Conclusions : Among factors that electromyographers can control, muscle selection has the greatest impact on pain. Our data include an extensive list of muscle‐specific EMG‐related pain scores. Provider and other study characteristics have little or no impact on EMG‐related pain. Muscle Nerve 49:570–574, 2014Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106736/1/mus23974.pd

Bilateral nerve conduction studies in the evaluation of distal symmetric polyneuropathy

IntroductionNerve conduction studies are used to aid in the diagnosis of distal symmetric polyneuropathy (DSP). It is unclear whether bilateral lower extremity nerve conduction studies (NCS) are needed when evaluating for suspected DSP.MethodsWe retrospectively analyzed NCS from patients who presented to the University of Michigan electromyography laboratory between July 1, 2016 and December 31, 2017 with symptoms of DSP to assess agreement and correlation between left and right lower extremity NCS parameters.ResultsWe found significant agreement between abnormalities in individual nerve parameters of the left and right lower extremities of 105 patients, most notably in the sural nerve. In the 53 patients with bilateral sural, peroneal, and tibial studies, there was also significant agreement between whether the left and right met electrodiagnostic criteria for DSP (κ = 0.77).DiscussionBilateral lower extremity NCS may have limited utility in the evaluation of suspected DSP. Muscle Nerve, 2019Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151276/1/mus26616.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151276/2/mus26616_am.pd

Amyotrophic Lateral Sclerosis in a Patient with a Family History of Huntington Disease: Genetic Counseling Challenges

Amyotrophic lateral sclerosis (ALS) and Huntington disease (HD) are generally considered to be distinct and easily differentiated neurologic conditions. However, there are case reports of the co‐occurrence of ALS with HD. We present a 57‐year‐old male with a clinical diagnosis of sporadic ALS in the context of a family history of HD. This case adds to the limited literature regarding individuals with a family history of HD who present with features of ALS. There were several genetic counseling challenges in counseling this patient including the diagnostic consideration of two fatal conditions, complex risk information, the personal and familial implications, and the patient’s inability to communicate verbally or through writing due to disease progression. DNA banking effectively preserved the right of our patient and his wife not to learn his HD genetic status during a stressful time of disease progression while providing the option for family members to learn this information in the future if desired. We present lessons learned and considerations for other clinical genetics professionals who are presented with similar challenging issues.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/147074/1/jgc40725.pd

Electrodiagnostic tests are unlikely to change management in those with a known cause of typical distal symmetric polyneuropathy

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138297/1/mus25713_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/138297/2/mus25713.pd

Giving away used injection equipment: missed prevention message?

Abstract Background Our objective was to examine factors associated with distributive injection equipment sharing and how needle exchange programs (NEPs) can help reduce distributive sharing among injection drug users (IDUs). Methods 145 English speaking Canadian IDUs ages 16 years and over who had injected in the past 30 days were recruited for a cross-sectional survey. Participants were asked about their socio-demographic characteristics, HIV risk behaviours, social support, drug treatment readiness, program satisfaction, health and social service use and NEP drug use. Bivariate statistics and logistic regression were used to characterize the population and examine correlates of sharing behaviour. Results More IDUs reported distributive sharing of cookers (45%) than needles (36%) or other types of equipment (water 36%; filters 29%; swabs 8%). Regression analyses revealed the following factors associated with distributing used cookers: a history of cocaine/crack injection, an Addiction Severity Index (ASI) score indicative of a mental health problem, and older than 30 years of age. Factors associated with giving away used water included: male, injected methadone, injected other stimulants and moved 3+ times in the past 6 months. Factors associated with giving away used filters included: injected cocaine/crack or stayed overnight on the street or other public place. Factors associated with giving away swabs included: an ASI mental health score indicative of a mental health problem, and HCV negative status. Conclusions Our findings show that more IDUs give away cookers than needles or other injection equipment. While the results showed that correlates of sharing differed by piece of equipment, each point to distributive sharing by the most marginalized IDUs. Targeting prevention efforts to reduce equipment sharing in general, and cookers in particular is warranted to reduce use of contaminated equipment and viral transmission

A prescription for the Epley maneuver: www.youtube.com?

OBJECTIVES: Video-sharing Web sites are being used for information about common conditions including dizziness. The Epley maneuver (EM) is a simple and effective treatment for benign paroxysmal positional vertigo (BPPV) of the posterior canal. However, the maneuver is underused in routine care. In this study, we aimed to describe and analyze the available information about the EM on youtube.com. METHODS: A YouTube search was performed on August 31, 2011, for videos that demonstrated the entire EM. Detailed data were abstracted from each video and corresponding Web site. Videos were rated on the accuracy of the maneuver by 2 authors, with differences resolved by adjudication. Comments posted by viewers were assessed for themes regarding video use. RESULTS: Of the 3,319 videos identified, 33 demonstrated the EM. The total number of hits for all videos was 2,755,607. The video with the most hits (802,471) was produced by the American Academy of Neurology. Five of the videos accounted for 85% of all the hits. The maneuver demonstration was rated as accurate in 64% (21) of the videos. Themes derived from the 424 posted comments included patients self-treating with the maneuver after reviewing the videos, and providers using the videos as a prescribed treatment or for educational purposes. CONCLUSION: Accurate video demonstration of the Epley maneuver is available and widely viewed on YouTube. Video-sharing media may be an important way to disseminate effective interventions such as the EM. The impact of video Web sites on outcomes and costs of care is not known and warrants future study

Diabetes and obesity are the main metabolic drivers of peripheral neuropathy

ObjectiveTo determine the associations between individual metabolic syndrome (MetS) components and peripheral neuropathy in a large populationâ based cohort from Pinggu, China.MethodsA crossâ sectional, randomly selected, populationâ based survey of participants from Pinggu, China was performed. Metabolic phenotyping and neuropathy outcomes were performed by trained personnel. Glycemic status was defined according to the American Diabetes Association criteria, and the MetS using modified consensus criteria (body mass index instead of waist circumference). The primary peripheral neuropathy outcome was the Michigan Neuropathy Screening Instrument (MNSI) examination. Secondary outcomes were the MNSI questionnaire and monofilament testing. Multivariable models were used to assess for associations between individual MetS components and peripheral neuropathy. Treeâ based methods were used to construct a classifier for peripheral neuropathy using demographics and MetS components.ResultsThe mean (SD) age of the 4002 participants was 51.6 (11.8) and 51.0% were male; 37.2% of the population had normoglycemia, 44.0% prediabetes, and 18.9% diabetes. The prevalence of peripheral neuropathy increased with worsening glycemic status (3.25% in normoglycemia, 6.29% in prediabetes, and 15.12% in diabetes, P < 0.0001). Diabetes (odds ratio [OR] 2.60, 95% CI 1.77â 3.80) and weight (OR 1.09, 95% CI 1.02â 1.18) were significantly associated with peripheral neuropathy. Age, diabetes, and weight were the primary splitters in the classification tree for peripheral neuropathy.InterpretationSimilar to previous studies, diabetes and obesity are the main metabolic drivers of peripheral neuropathy. The consistency of these results reinforces the urgent need for effective interventions that target these metabolic factors to prevent and/or treat peripheral neuropathy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/143679/1/acn3531_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/143679/2/acn3531.pd