Brian Callaghan

Background and ObjectiveFollowing the outbreak of viral infections from the severe acute respiratory syndrome coronavirus 2 virus in 2019 (coronavirus disease 2019 [COVID-19]), reports emerged of long-term neurologic sequelae in survivors. To better understand the burden of neurologic health care and incident neurologic diagnoses in the year after COVID-19 vs influenza, we performed an analysis of patient-level data from a large collection of electronic health records (EMR).MethodsWe acquired deidentified data from TriNetX, a global health research network providing access to EMR data. We included individuals aged 18 years or older during index event, defined as hospital-based care for COVID-19 (from April 1, 2020, until November 15, 2021) or influenza (from 2016 to 2019). The study outcomes were subsequent health care encounters over the following year for 6 neurologic diagnoses including …

Objective To assess the adequacy of telehealth evaluation as compared to in-person evaluation in neurologic clinic visits. Background The Covid-19 pandemic offers an opportunity to evaluate telehealth visits to inform future care delivery. Design/Methods The full study will be a multi-institutional retrospective analysis of neurologic care at six academic health centers; this abstract reports data from one institution, the University of Michigan. We compared neurologic patients with a telehealth new patient visit (cases) to patients with an in-person new patient visit (controls) from September 2020–December 2021. The primary interest was adequacy of telehealth evaluation, thus the primary outcome was a follow-up neurologic clinic visit within 90 days (likely faster than standard follow-up). Emergency room (ER) visits and hospitalizations for neurologic diagnoses following the initial clinic visit were also assessed …

One response to high health care costs is prior authorization—the process wherein physicians or other qualified health care professionals seek approval from an insurance entity before providing certain tests, medications, services, or procedures. 1-4 Although designed to improve quality and control cost, prior authorization may decrease access, 2, 5 delay care, 2-5 decrease patient satisfaction and outcomes, 2, 4, 5 and increase clinician burnout. 5, 6 These challenges need to be addressed. Manypayers, policymakers, andregulatorsviewprior authorization as a means to promote health care value. 1, 2 Payers can control costs, ensuring patients receive treatments or medications that are supported by evidencebased guidelines and are cost-effective. For example, prior authorization for migraine treatments often requires use of cost-effective, guideline-concordant medications, such as topiramate, β-blockers …

Peer review serves 2 primary objectives. First, it helps editors decide which papers to publish. Second, and just as importantly, peer review improves the quality of the manuscripts that we publish in Neurology®(and, we hope, of the manuscripts that we do not accept and are published elsewhere).Because of the complex and increasingly sophisticated clinical, diagnostic, research, and analytical methods used in our field, we must rely on the expertise of hundreds of colleagues who spend hours reviewing the papers submitted to the journal. As subject matter and methods experts, peer reviewers evaluate the novelty and relevance of the research question addressed by the study, the suitability and robustness of the data source, and the methods used to answer the research question. They also help editors contextualize the research findings. Peer reviews are the cornerstone on which we base editorial decisions …

We performed a cross‐sectional study to determine associations between cognition and MRI‐derived brain outcomes, with obesity, diabetes duration, and metabolic risk factors in 51 Pima American Indians with longstanding type 2 diabetes (T2d) (mean [SD] age: 48.4 [11.3] years, T2d duration: 20.1 [9.1] years). Participants had similar cognition (NIH Toolbox Cognition Battery composite: 45.3 [9.8], p = 0.64, n = 51) compared to normative data. T2d duration, but not other metabolic risk factors, associated with decreased cortical thickness (Point Estimate (PE): −0.0061, 95%CI: −0.0113, −0.0009, n = 45), gray matter volume (PE: −830.39, 95%CI: −1503.14, −157.64, n = 45), and increased white matter hyperintensity volume (PE: 0.0389, 95%CI: 0.0049, 0.0729, n = 45).

Neuropathy, headache, and low back pain (LBP) are common conditions requiring pain management. Yet little is known regarding whether access to specialists impacts opioid prescribing. We aimed to identify factors associated with opioid initiation among opioid-naïve older adults and evaluate how access to particular specialists impacts prescribing. This retrospective cohort study used a 20% Medicare sample from 2010 to 2017. Opioid initiation was defined as a first opioid prescription filled within 12 months after a diagnosis encounter. Disease-related opioid initiation was defined as a first opioid prescription filled within 7 days following a disease-specific claim. Logistic regression using generalized estimating equations was used to determine the association of patient demographics, provider types, and regional physician specialty density with disease-related opioid initiation, accounting for within-region …

BackgroundThe clinical evaluation of a new diagnosis of MS typically includes serologic testing to evaluate for its many mimics, yet there is little data to guide approaches to such testing.ObjectiveTo evaluate for the frequency and clinical significance of serologic testing for MS diagnostic evaluations.MethodsIn a single MS subspeciality center retrospective study, new patient evaluations for MS over the course of a year were identified, and the results of serologic testing and diagnostic evaluation extracted. Retrospective longitudinal diagnostic assessment was performed to confirm the accuracy of initial serological testing assessments.Results150 patients had 823 serologic tests. 40 (5%) tests were positive, and resulted in 117 additional serologic tests, 10 radiographs, and 2 biopsies. 77 (51%) patients were diagnosed with a non-demyelinating disorder. Serologic testing results did not change any diagnosis, yet in …

Diabetic peripheral neuropathy (DPN) manifests with many different patterns of nerve injury. Distal symmetric polyneuropathy (DSP) is the most common patterns of injury, but diabetic autonomic neuropathy (DAN), mononeuropathies, and radiculopathy also occur along with less common nerve injury patterns. The clinical features and risk factors for DPN are similar for those with type 1 and type 2 diabetes, but we highlight some of the nuanced differences that have been reported. While metabolic syndrome components have been demonstrated to be risk factors for both types of diabetes, patients with type 2 diabetes are more likely to have these comorbidities. Clinical trials have demonstrated that glycemic control lowers the incidence of DPN in those with type 1 diabetes, but the effect is much less pronounced in those with type 2 diabetes. Weight loss is a promising intervention in those with type 2 diabetes that are …

We are grateful for the response to this guideline summary. 1 Dr. Argoff makes the important point that many patients with painful diabetic neuropathy continue to experience pain despite using the recommended medications. This highlights the need for new therapies for this common and highly morbid condition. He also points to two recent papers, both examining the same trial at different time points, that evaluated the efficacy of 10 kHz spinal cord stimulation (SCS) for patients with painful diabetic neuropathy. 2, 3 This AAN guideline was focused on oral and topical medications; therefore, devices such as SCS were not included. 4 However, it should be pointed out that the recent studies of 10kHz SCS were not blinded, which is extremely important when rating the evidence for clinical trials with pain outcomes. As a result, future studies with appropriate sham controls are needed before including these interventions …

We thank Drs. Gregory and Graber for their insightful correspondence on our recent manuscript. 1 We agree that neurologists are unevenly distributed in the US geographically, and often clustered near academic centers in urban areas. Though we did not investigate neurology sub-specialists in our study, we believe that the distribution of sub-specialists, such as neuro-oncologists, would be even more imbalanced. Therefore, many patients may need to travel long distance to seek care. As you suggested, telemedicine may improve patient access to care, but insurance coverage and providing care across state-lines remains challenging. Due to the pandemic, the Centers for Medicare and Medicaid Services (CMS) and many private health plans lifted telemedicine restrictions and expanded coverage. Some of these changes are expected to remain after the pandemic. We should all closely monitor this situation to …

We appreciate and agree with the critical points raised by Calixte et al. regarding racial disparities in access to neurological care. Our findings 1 that Black patients travel shorter distances does not mean that Black patients have better access to neurologic care compared to White patients. Transportation insecurity is one potential reason that travel distance might have been lower for Black patients. Further, we focused on travel distance, but other measures of access such as seeing an outpatient neurologist and referrals to subspecialists care were not studied and are also important. Addressing these disparities in access to neurologic care requires a multifaceted approach. Efforts to increase diversity in the healthcare workforce, reduce transportation barriers, improve outreach and education, and promote culturally sensitive care are essential to build trust between healthcare professionals and patients from different …

Introduction/aims In vasculitic neuropathy (VN), a 50% side‐to‐side difference in the amplitude of compound muscle action potentials and sensory nerve action potentials is considered meaningful, but unequivocal evidence is lacking. The aim of this study is to characterize electrodiagnostic features that best distinguish VN from other axonal polyneuropathies. Methods We conducted a case–control study between January 2000 and April 2021. We reviewed the records of patients with VN who had bilateral nerve conduction studies (NCS) and evaluated different electrodiagnostic models to help distinguish VN from non‐inflammatory axonal polyneuropathies. Results We identified 82 cases, and 174 controls with non‐inflammatory axonal neuropathies. The amplitude percent difference Z‐score model showed the best discriminatory capability between cases and controls (area under the curve [AUC] 0.87; 95 …

We agree in part with Drs. Johnston and Sartwelle's comment on our article;[1] the evidence base underlying headache guidelines is limited. It is not clear, though, that current guidelines recommend too little imaging. For example, little is known about the harms of headache neuroimaging (eg via incidental findings). Thus, the assertion that guideline-based care results in worse outcomes than universal imaging is itself non-evidence based.Drs. Johnston and Sartwelle's argument that more imaging is needed because misdiagnosis of headache is" the most common diagnostic error" leading to neurology lawsuits is unfounded. Neurologists see 10 million headache visits per year and approximately 0.0005% result in lawsuits.[2-4] Misdiagnoses in headache patients are common causes of lawsuits because headache is ubiquitous and even the best medicine is imperfect, not because neurologists fail to image. If all …

OBJECTIVE Metabolic syndrome components may cumulatively increase the risk of diabetic polyneuropathy (DPN) in type 2 diabetes mellitus (T2DM) patients, driven by insulin resistance and hyperinsulinemia. We investigated the prevalence of DPN in three T2DM subgroups based on indices of β-cell function and insulin sensitivity. RESEARCH DESIGN AND METHODS We estimated β-cell function (HOMA2-B) and insulin sensitivity (HOMA2-S) in 4,388 Danish patients with newly diagnosed T2DM. Patients were categorized into subgroups of hyperinsulinemic (high HOMA2-B, low HOMA2-S), classical (low HOMA2-B, low HOMA2-S), and insulinopenic (low HOMA2-B, high HOMA2-S) T2DM. After a median follow-up of 3 years, patients filled the Michigan Neuropathy Screening Instrument questionnaire (MNSIq) to identify DPN (score ≥ 4). We used Poisson regression to calculate …

Tree-based methods have become one of the most flexible, intuitive, and powerful analytic tools for exploring complex data structures. The best documented, and arguably most popular uses of tree-based methods are in biomedical research, where multivariate outcomes occur commonly (e.g. diastolic and systolic blood pressure and nerve conduction measures in studies of neuropathy). Existing tree-based methods for multivariate outcomes do not appropriately take into account the correlation that exists in such data. In this paper, we develop goodness-of-split measures for building multivariate regression trees for continuous multivariate outcomes. We propose two general approaches: minimizing within-node homogeneity and maximizing between-node separation. Within-node homogeneity is measured using the average Mahalanobis distance and the determinant of the variance-covariance matrix. Between …

Aims Describe and compare healthcare costs and utilization for insured persons with type 1 diabetes (T1D), type 2 diabetes (T2D), and without diabetes in the United States. Methods Using a nationally representative healthcare claims database, we identified matched persons with T1D, T2D, and without diabetes using a propensity score quasi-randomization technique. In each year between 2009 and 2018, we report costs (total and out-of-pocket) and utilization for all healthcare services and those specific to medications, diabetes-related supplies, visits to providers, hospitalizations, and emergency department visits. Results In 2018, we found out-of-pocket costs and total costs were highest for persons with T1D (out-of-pocket: $2,037.2, total: $25,652.0), followed by T2D (out-of-pocket: $1,543.3, total: $22,408.1), and without diabetes (out-of-pocket: $1,122.7, total: $14,220.6). From 2009 to 2018, out-of-pocket costs …

Brier et al. make a great point that even great tests fail when performed in low prevalence populations. This is the biggest problem with current paraneoplastic testing as indication creep has occurred with neurologists sending this test in very low clinical scenarios. Fixing this issue should be a high priority to improve current practice. However, the current panel also includes several antibodies in 1 panel, including those that are for central and those that are for peripheral conditions. The lumping of tests that should rarely—if ever—all be performed on the same patient, increases the likelihood of false positive results. In addition to optimizing the patient population that receives these tests, we also need to create optimal bundles of antibodies that are more specific to the clinical presentation.

The Mayo Clinic laboratory group should be commended for developing a powerful tool to improve diagnosis of rare and potentially treatable neurologic conditions. Similarly, their efforts to develop scoring systems to improve paraneoplastic test ordering and for including predictive information for different antibody cutoffs should be lauded. These efforts have the potential to mitigate the problem that data from our paper demonstrates: a high level of false positive results. 1 However, our data suggest that this is a highly prevalent problem, with false positives outnumbering true positives by 2.5: 1. 1 To effectively improve current practice, 3 related, ongoing, and important issues need to be addressed:(1) optimizing condition specific panels;(2) limiting panel use to patients with a reasonable pretest probability of a given target condition;(3) evaluating the real world performance of panels.The Mayo Clinic laboratory group …

The application of any test, in any context, requires consideration of how often it leads to false positives, true positives, and the benefits and harms of each. If imaging studies never led to harm, universal imaging would be warranted; everybody would have an MRI of the brain and a full-body MRI too. It is dangerous to assume that the risks of false-positive results after imaging in patients with migraine is zero. While, undoubtedly, many false positive MRIs in patients with migraine do not lead to harm, it is a major leap of faith to assume that this is universally the case. When true positives are exceedingly rare and false positives vastly outnumber them, the theoretical benefits of imaging rapidly evaporate if even a small fraction of false positives lead to harm. If our goal is to first do no harm, then it's hard to argue that wider use of neuroimaging in migraine is warranted without high-quality evidence regarding the potential …

To BackgroundObesity is a global epidemic and is associated with cognitive impairment and dementia. It remains unknown whether weight loss interventions, such as bariatric surgery, can mitigate cognitive impairment.ObjectivesWe aimed to determine the effect of surgical weight loss on cognition in individuals with class II/III obesity.DesignWe performed a prospective cohort study of participants who underwent bariatric surgery. At baseline and two years following surgery, participants completed metabolic risk factor and neuropsychological assessments.SettingParticipants were enrolled from an academic suburban bariatric surgery clinic.ParticipantsThere were 113 participants who completed baseline assessments and 87 completed two-year follow-up assessments (66 in-person and 21 virtual) after bariatric surgery. The mean (SD) age was 46.8 (12.5) years and 64 (73.6%) were female.InterventionBariatric …