How can neurologists avoid burnout?

Over the last decade, surveys of American physicians have shown an alarming decrease in professional satisfaction and well-being accompanied by an increase in the symptoms of burnout.1 Physician burnout is a dysfunctional syndrome comprising emotional exhaustion, cynicism, depersonalization, and loss of empathy, accompanied by career dissatisfaction, from a feeling of meaninglessness of work and a sense of low personal esteem and accomplishment.2 Burnout represents a growing problem because it leads to serious harm to both physicians and patients. It produces physician impairment with poor judgment, treating patients as objects, medical errors, and poorer patient outcomes. Burned-out physicians exhibit work–life imbalance and conflicts, abandon the profession, elect premature retirement, and experience higher rates of depression, substance abuse, and suicide.3

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Editors’ Note

Editors’ Note: In WriteClick this week, referencing «Calcium supplementation and risk of dementia in women with cerebrovascular disease,» Dr. Rosenberg questions whether «the steep increase in calcium levels» after supplementation should be cited as a possible mechanism for the increased risk of dementia seen in the study, given that the absolute increase is relatively small and occurs over several hours.

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Predictors of unintended pregnancy in women with epilepsy

Objective:

To determine whether rates of unintended pregnancy in women with epilepsy (WWE) vary by contraceptive category and when stratified by antiepileptic drug (AED) category.

Methods:

These retrospective data come from the Epilepsy Birth Control Registry (EBCR) web-based survey of 1,144 WWE in the community, 18–47 years of age, who provided demographic, epilepsy, AED, contraceptive, and pregnancy data. Participants indicated whether pregnancies were intended or unintended, as well as the type of contraceptive and AED used at conception. We report failure rates relative to the frequency of use of each contraceptive category in the EBCR.

Results:

Most WWE (78.9%) reported having at least one unintended pregnancy; 65.0% of their pregnancies were unintended. Unintended pregnancy was more common among younger, racial minority, and Hispanic WWE. Among reversible contraceptive categories, the intrauterine device had the lowest failure rate. Failure rates varied greatly on systemic hormonal contraception (HC), depending on whether oral or nonoral forms were used and especially in relation to the category of AED with which HC was combined. Oral forms had greater failure rate than nonoral forms. HC combined with enzyme-inducing AEDs had a substantially greater failure rate than HC combined with no AED or any other AED category and in comparison to barrier plus any AED category. Other AED–HC combinations, in contrast, carried lower risks than barrier.

Conclusions:

Unintended pregnancy is common among WWE and may vary by contraceptive category and AED stratification. In view of the important consequences of unintended pregnancy on pregnancy outcomes, these retrospective findings warrant further prospective investigation.

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Teaching NeuroImages: Superficial siderosis due to a dural cervical arteriovenous fistula

A 58-year-old man presented to our hospital with cerebellar ataxia, pyramidal signs, dysarthria, bilateral deafness, and cognitive impairment. These symptoms were consistent with superficial siderosis (SS) of the CNS, confirmed by MRI (figure A).1 Cerebral angiography showed a dural arteriovenous fistula perispinal and pontic with venous drainage in the left foramen C1-C2, fed by meningeal branches of the vertebral artery (figure, B). The fistulous point was clipped. SS of CNS is a rare disease resulting from hemosiderin deposition on the surface of the CNS and cranial nerves.2 At diagnosis, the etiology may not be known. Finding etiology is necessary (trauma, vascular malformation).2

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Multimodal MRI profiling of focal cortical dysplasia type II

Objective:

To characterize in vivo MRI signatures of focal cortical dysplasia (FCD) type IIA and type IIB through combined analysis of morphology, intensity, microstructure, and function.

Methods:

We carried out a multimodal 3T MRI profiling of 33 histologically proven FCD type IIA (9) and IIB (24) lesions. A multisurface approach operating on manual consensus labels systematically sampled intracortical and subcortical lesional features. Geodesic distance mapping quantified the same features in the lesion perimeter. Logistic regression assessed the relationship between MRI and histology, while supervised pattern learning was used for individualized subtype prediction.

Results:

FCD type IIB was characterized by abnormal morphology, intensity, diffusivity, and function across all surfaces, while type IIA lesions presented only with increased fluid-attenuated inversion recovery signal and reduced diffusion anisotropy close to the gray–white matter interface. Similar to lesional patterns, perilesional anomalies were more marked in type IIB extending up to 16 mm. Structural MRI markers correlated with categorical histologic characteristics. A profile-based classifier predicted FCD subtypes with equal sensitivity of 85%, while maintaining a high specificity of 94% against healthy and disease controls.

Conclusions:

Image processing applied to widely available MRI contrasts has the ability to dissociate FCD subtypes at a mesoscopic level. Integrating in vivo staging of pathologic traits with automated lesion detection is likely to provide an objective definition of lesional boundary and assist emerging approaches, such as minimally invasive thermal ablation, which do not supply tissue specimen.

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Ischemic lesions, blood pressure dysregulation, and poor outcomes in intracerebral hemorrhage

Objective:

To evaluate the associations among diffusion-weighted imaging (DWI) lesions, blood pressure (BP) dysregulation, MRI markers of small vessel disease, and poor outcome in a large, prospective study of primary intracerebral hemorrhage (ICH).

Methods:

The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a multicenter, observational study of ICH among white, black, and Hispanic patients.

Results:

Of 600 patients, mean (±SD) age was 60.8 ± 13.6 years, median (interquartile range) ICH volume was 9.1 mL (3.5–20.8), and 79.6% had hypertension. Overall, 26.5% of cases had DWI lesions, and this frequency differed by race/ethnicity (black 33.8%, Hispanic 24.9%, white 20.2%, overall p = 0.006). A logistic regression model of variables associated with DWI lesions included lower age (odds ratio [OR] 0.721, p = 0.002), higher first recorded systolic BP (10-unit OR 1.12, p = 0.002), greater change in mean arterial pressure (MAP) prior to the MRI (10-unit OR 1.10, p = 0.037), microbleeds (OR 1.99, p = 0.008), and higher white matter hyperintensity (WMH) score (1-unit OR 1.16, p = 0.002) after controlling for race/ethnicity, leukocyte count, and acute in-hospital antihypertensive treatment. A second model of variables associated with poor 90-day functional outcome (modified Rankin Scale scores 4–6) included DWI lesion count (OR 1.085, p = 0.034) as well as age, ICH volume, intraventricular hemorrhage, Glasgow Coma Scale score, WMH score, race/ethnicity, acute in-hospital antihypertensive treatment, and ICH location.

Conclusions:

These results support the hypotheses that acute BP dysregulation is associated with the development of DWI lesions in primary ICH and that DWI lesions are, in turn, associated with poor outcomes.

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Dysarthria and broader motor speech deficits in Dravet syndrome

Objective:

To analyze the oral motor, speech, and language phenotype in 20 children and adults with Dravet syndrome (DS) associated with mutations in SCN1A.

Methods:

Fifteen verbal and 5 minimally verbal DS patients with SCN1A mutations (aged 15 months-28 years) underwent a tailored assessment battery.

Results:

Speech was characterized by imprecise articulation, abnormal nasal resonance, voice, and pitch, and prosody errors. Half of verbal patients had moderate to severely impaired conversational speech intelligibility. Oral motor impairment, motor planning/programming difficulties, and poor postural control were typical. Nonverbal individuals had intentional communication. Cognitive skills varied markedly, with intellectual functioning ranging from the low average range to severe intellectual disability. Language impairment was congruent with cognition.

Conclusions:

We describe a distinctive speech, language, and oral motor phenotype in children and adults with DS associated with mutations in SCN1A. Recognizing this phenotype will guide therapeutic intervention in patients with DS.

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