Low-Cost Robotic Assessment of Visuo-Motor Deficits in Alzheimer's Disease.

A low-cost robotic interface was used to assess the visuo-motor performance of patients with Alzheimer's disease (AD). Twenty AD patients and twenty age-matched controls participated in this work. The battery of tests included simple reaction times, position tracking, and stabilization tasks performed with both hands. The regularity, velocity, visual and haptic feedback were manipulated to vary movement complexity. Reaction times and movement tracking error were analyzed. Results show a marked group effect on a subset of conditions, in particular when the patients could not rely on the visual feedback of hand movement. The visuo-motor performance correlated with the measures of global cognitive functioning and with different memory-related abilities. Our results support the hypothesis that the ability to recall and use visuo-spatial associations might underlie the impairment in complex motor behavior that has been reported in AD patients. Importantly, the patients had preserved learning effects across sessions, which might relate to visuo-motor deficits being less evident in every-day life and clinical assessments. This robotic assessment, lasting less than 1 h, provides detailed information about the integrity of visuo-motor abilities. The data can aid the understanding of the complex pattern of deficits that characterizes this pervasive disease.

Cost of Unnecessary Testing in the Evaluation of Pediatric Syncope.

Syncope is a common and a typically benign clinical problem in children and adolescents. The majority of tests ordered in otherwise healthy pediatric patients presenting with syncope have low diagnostic yield. This study quantifies testing and corresponding patient charges in a group of pediatric patients presenting for outpatient evaluation for syncope. Patients seen between 3/2011 and 4/2013 in the multi-disciplinary Syncope Clinic at Cincinnati Children's Hospital Medical Center were enrolled in a registry which was reviewed for patient information. The electronic medical record was used to determine which syncope patients underwent cardiac (electrocardiogram, echocardiogram, or exercise testing) or neurologic (head CT/MRI or electroencephalogram) testing within the interval from 3 months before to 3 months after the Syncope Clinic visit. Testing charges were obtained through hospital billing records. 442 patients were included for analysis; 91% were Caucasian; 65.6% were female; median age was 15.1 years (8.1-21.2 years). Cardiac and neurologic testing was common in this population. While some testing was performed during the Syncope Clinic visit, 46% of the testing occurred before or after the visit. A total of $1.1 million was charged to payers for cardiac and neurological testing with an average total charge of $2488 per patient. Despite the typically benign etiology of pediatric syncope, patients often have expensive and unnecessary cardiac and/or neurologic testing. Reducing or eliminating this unnecessary testing could have a significant impact on healthcare costs, especially as the economics of healthcare shift to more capitated systems.

Availability, accessibility, and affordability of neurodiagnostic tests in 37 countries.

OBJECTIVE: To determine the availability, accessibility, and affordability of EEG, EMG, CSF analysis, head CT, and brain MRI for neurologic disorders across countries. METHODS: An online, 60-question survey was distributed to neurology practitioners in 2014 to assess the presence, wait time, and cost of each test in private and public health sectors. Data were stratified by World Bank country income group. Affordability was calculated with reference to the World Health Organization's definition of catastrophic health expenditure as health-related out-of-pocket expenditure of >40% of disposable household income, and assessment of providers' perceptions of affordability to the patient. RESULTS: Availability of EEG and EMG is correlated with higher World Bank income group (correlation coefficient 0.38, test for trend p = 0.046; 0.376, p = 0.043); CSF, CT, and MRI did not show statistically significant associations with income groups. Patients in public systems wait longer for neurodiagnostic tests, especially MRI, EEG, and urgent CT (p < 0.0001). The mean cost per test, across all tests, was lower in the public vs private sector (US $55.25 vs $214.62, p < 0.001). Each drop in World Bank income group is associated with a 29% decrease in the estimated share of the population who can afford a given test (95% confidence interval -33.4, 25.2; p < 0.001). In most low-income countries surveyed, only the top 10% or 20% of the population was able to afford tests below catastrophic levels. In surveyed lower-middle-income countries, >40% of the population, on average, could not afford neurodiagnostic tests. CONCLUSIONS: Neurodiagnostic tests are least affordable in the lowest income settings. Closing this "diagnostic gap" for countries with the lowest incomes is essential.

ViibraTip for Testing Vibration Perception to Detect Diabetic Peripheral Neuropathy: A NICE Medical Technology Guidance.

VibraTip™ was selected by the Medical Technologies Advisory Committee (MTAC) to undergo evaluation through the National Institute for Health and Care Excellence (NICE). VibraTip™ provides a vibratory stimulus for the purpose of detecting diabetic peripheral neuropathy (DPN) in patients with type 1 or 2 diabetes mellitus, and is intended to replace the current practice of using the 128 Hz tuning fork or 10 g monofilament (comparators). The sponsor (McCallan Medical) provided clinical and economic submissions which were evaluated by an External Assessment Centre (EAC). Of six diagnostic studies identified, the EAC considered that only one was directly relevant to the assessment. This study indicated VibraTip™ had a sensitivity of 0.79 (95 % CI 0.69-0.90) and specificity of 0.82 (95 % CI 0.74-0.90) for DPN using a neurothesiometer at 25 V as a reference standard. This was non-inferior to the comparators, but the sample size (n = 141) was too small to draw unequivocal conclusions and it is unclear how generalisable results were to clinical practice. The sponsor presented a de facto cost-minimisation model that in the base case showed minimal cost savings and, in sensitivity analysis which assumed diagnostic superiority of VibraTip™, showed large savings. The EAC appraised this model and concluded it was flawed as it was not evidence based and costs were likely to be unrealistic. The MTAC considered that the technology showed promise but decided the case for adoption was not proven, and therefore made a research recommendation as is reflected in NICE Medical Technology Guidance 22.

Kathleen Mears Memorial Lecture: personal accountability: your key to survival in health care reform.

Over the past thirty years the rising cost of healthcare has produced changes in reimbursement strategies. Continually, pressures are placed on the practitioners to reduce the length of the patient hospital stay and provide services in a high quality, risk free, cost effective manner. Following the implementation of diagnostic related groups (DRGs) in the 1980s and Managed Care in the 1990s we are now faced with embracing and surviving the Affordable Health Care Act-H.R.3590 (HHS 2013) that is linking reimbursement to quality outcomes. In short, financial constraints in the funding of health care will once more alter the patterns of delivery and challenge the practitioners to maintain superior care. As Neurodiagnostic Professionals this new reform offers another opportunity to review our process of care and the Neurodiagnostic labs role in the delivery of healthcare. For success, close examination of routine workflows, recognizing and solving existing delivery limitations, developing team care coordination, and increasing the neurodiagnostic professionals profile within the work environment will be required. Embracing your role in this overall process will most likely demand more paperwork, changing protocols, learning and implementing new policies, accepting new work schedules, implementing new quality standards, and pursuing additional education or credentials. Unlike never before more emphasis will be placed on measuring and reporting on the quality of the care we deliver in our labs, intensive care units, and operating rooms.

Diagnosis, costs, and utilization for psychogenic non-epileptic seizures in a US health care setting.

BACKGROUND: Psychogenic non-epileptic seizures (PNES) pose a substantial burden to patients and the health care system, due to long diagnostic and treatment delays. METHODS: This study used medical chart notes from 103 patients to shed light on the diagnostic process. Electronic medical records and cost data from a US health system were also used to investigate costs and utilization for the 12-months before and after PNES diagnosis. RESULTS: The results show that accurate diagnosis was typically achieved via the use of multiple medical tests, including vEEG, magnetic resonance imaging (MRI), and computed tomography (CT) scans, as well as historical diagnostic and clinical information. In the year following PNES diagnosis, a decline in average visits (-1.45) and costs (-$1784) were observed. The largest cost savings were seen in neurology care and inpatient stays. CONCLUSIONS: This study has implications for timely and accurate diagnosis of PNES, which may decrease the overall health care burden for individuals and the health care system.

A low-cost body inertial-sensing network for practical gait discrimination of hemiplegia patients.

Gait analysis is widely used in detecting human walking disorders. Current gait analysis methods like video- or optical-based systems are expensive and cause invasion of human privacy. This article presents a self-developed low-cost body inertial-sensing network, which contains a base station, three wearable inertial measurement nodes, and the affiliated wireless communication protocol, for practical gait discrimination between hemiplegia patients and asymptomatic subjects. Every sensing node contains one three-axis accelerometer, one three-axis magnetometer, and one three-axis gyroscope. Seven hemiplegia patients (all were abnormal on the right side) and 7 asymptomatic subjects were examined. The three measurement nodes were attached on the thigh, the shank, and the dorsum of the foot, respectively (all on the right side of the body). A new method, which does not need to obtain accurate positions of the sensors, was used to calculate angles of knee flexion/extension and foot in the gait cycle. The angle amplitudes of initial contact, toe off, and knee flexion/extension were extracted. The results showed that there were significant differences between the two groups in the three angle amplitudes examined (-0.52±0.98° versus 6.94±2.63°, 28.33±11.66° versus 47.34±7.90°, and 26.85±8.6° versus 50.91±6.60°, respectively). It was concluded that the body inertial-sensing network platform provided a practical approach for wearable biomotion acquisition and was effective for discriminating gait symptoms between hemiplegia and asymptomatic subjects.

A novel animal model of closed-head concussive-induced mild traumatic brain injury: development, implementation, and characterization.

Closed-head concussive injury is one of the most common causes of traumatic brain injury (TBI). While single concussions result in short-term neurologic dysfunction, multiple concussions can result in cumulative damage and increased risk for neurodegenerative disease. Despite the prevalence of concussion, knowledge about what occurs in the brain following this injury is limited, in part due to the limited number of appropriate animal research models. To study clinically relevant concussion we recently developed a simple, non-invasive rodent model of closed-head projectile concussive impact (PCI) TBI. For this purpose, anesthetized rats were placed on a platform positioned above a torque-sealed microcentrifuge tube packed with fixed amounts of dry ice. Upon heating, rapid sublimation of the dry ice produced a build-up of compressed CO(2) that triggered an eruptive force causing the cap to launch as an intact projectile, resulting in a targeted PCI head injury. A stainless steel helmet was implemented to protect the head from bruising, yet allowing the brain to sustain a mild PCI event. Depending on the injury location and the application of the helmet, PCI-induced injuries ranged from severe (i.e., head injury with subdural hematomas, intracranial hemorrhage, and brain tissue damage), to mild (no head injury, intracranial hemorrhage, or gross morphological pathology). Although no gross pathology was evident in mild PCI-induced injury, the following protein changes and behavioral abnormalities were detected between 1 and 24 h after PCI injury: (1) upregulation of glial fibrillary acidic protein (GFAP) in hippocampal regions; (2) upregulation of ubiquitin carboxyl-terminal hydrolase L1 (UCHL-1) in cortical tissue; and (3) significant sensorimotor abnormalities. Overall, these results indicated that this PCI model was capable of replicating salient pathologies of a clinical concussion, and could generate reproducible and quantifiable outcome measures.

Validation of rapid neurodevelopmental assessment instrument for under-two-year-old children in Bangladesh.

OBJECTIVE: The objective of this study was to determine the reliability and validity of a comprehensive assessment procedure for ascertaining neurodevelopmental status of children aged 0 to 24 months for use by multidisciplinary professionals in a developing country. METHODS: We developed the Rapid Neurodevelopmental Assessment (RNDA) to determine functional status in the following domains: primitive reflexes, gross motor, fine motor, vision, hearing, speech, cognition, behavior, and seizures. Reliability was determined for 50 children who were aged <3 months and 30 children who were aged > or =3 to 24 months and were administered the RNDA by 8 different professionals (3 physicians, 4 therapists, and 1 special teacher). Validity was determined on 34 children aged <3 months in hospital and 81 children aged > or =3 to 24 months in urban (n = 47) and rural (n = 34) community-based populations by any 1 of the 8 professionals, with simultaneous administration of the adapted Bayley Scales of Infant Development II by a psychologist as the gold standard. RESULTS: Mean kappa coefficients of agreement among professionals in overall and individual domains in the 2 age groups ranged from good to excellent. For both younger and older children, there was good concurrent validity (ie, significantly lower mean Mental Development Index and Psychomotor Development Index scores) for children with > or =1 neurodevelopmental impairment and for children with impairments in most functional domains, compared with children with no impairments. Significantly more impairments were found in children from disadvantaged compared with socioeconomically more advantaged communities, indicating good discriminant validity. CONCLUSIONS: The RNDA can be used by professionals from a range of backgrounds with high reliability and validity for determining functional status of children who are younger than 2 years. The study findings have important practical implications for early identification and intervention to mitigate neurodevelopmental impairments in large populations that live in developing countries where professional expertise is sparse.

[Toward establishment of an economical basis for neurological care in Japan: appropriate assessment of techniques for diagnosis and treatments].

Appropriate assessments for medical techniques of clinical diagnostic examination have been one of long-standing issues in social insurance system in Japan. Assessments of those in the surgical fields in which the most of assessments are evaluated by surgical operations including related materials as well as surgeons' techniques, is rather easy to evaluate quantitatively. Comparing with this, medical fields including neurology, quantitative assessments of medical techniques either diagnostic or treatment is not so easy. In order to evaluate the burden in each technique in the medical fields, several research and surveillance have been performed. In terms of 'duration' of the medical techniques, there have been several date in favor of long duration techniques are evaluated as to be worth to cost higher. However, these data were criticized for the reasons of ignorance of patients' opinion such as satisfaction to the diagnosis and treatments. However, in neurological fields, "the neurological examination techniques" which has a consensus of taking long duration in each patient, was able to be evaluated as an independent item in medical social insurance system in 2008, albeit it is not as technique but as laboratory examination. Towards establishment of the economical basis for medical care, Japanese Neurological Association should have another identity of artisans' union as well as academic union.

[Economical basis for neurologic services and the system for health insurance: diagnosis procedure combinations and insurance scores of neurophysiological tests].

The Social Insurance Union of Societies Related to Internal Medicine and the Social Insurance Union of Societies Related to Surgical Medicine have pushed for revisions of the medical service fee against the Medical Economics Division of Insurance Department, Ministry of Health, Labor and Welfare. About neurological diseases, Japanese Society of Neurology, Japanese Society of Neurological Therapeutics, Japanese Society of Clinical Neurolphysiology, and Japanese Society of Child Neurology are involved in this movement. The examination fee of the electrical encephalography and the nerve conduction study was accepted. I review the process of the comprehensive medicine, and the revision of DPC (Diagnosis Procedure Combination) and medical service fee.

Clinical decision rules for the use of liquor diagnostics in hospitalized neurology patients reduced costs without affecting clinical outcomes.

OBJECTIVES: Excessive use of laboratory diagnostics has been common. This study aimed to evaluate whether clinical decision rules for the use of liquor diagnostics would enable cost containment without affecting medical care. METHODS: This was a single-center, retrospective, cost-minimization study based on the records of all 16,319 patients hospitalized and discharged at a Neurology Clinic in Austria between 2004 and 2006. Cost of liquor diagnostics, discharge diagnosis, duration of hospital stay, and mortality were compared along the line before, during, and after implementation of decision rules in mid-2005. RESULTS: There were no significant changes in patient characteristics over time, not in the diagnoses at discharge, nor in the percentage of patients undergoing liquor diagnostics. The average number of tests per patient significantly decreased. Standard tests largely replaced serological tests for infections, regardless of diagnosis. Annual costs for liquor diagnostics decreased by 32.9 percent. Overall, the duration of hospital stay and mortality significantly decreased as well; however, differences were not significant for any single diagnosis-related group. CONCLUSIONS: Diagnostic algorithms may allow cost containment without affecting medical care.

Cost assessment of headache in childhood and adolescence: preliminary data.

Headache, and in particular migraine, is a common disturbance in childhood and adolescence. The disabling nature of headache, evident in the adult, together with its effects on family life and reduction in performance of scholastic activity, make it a disease with an elevated social economic impact. We present preliminary results of a prospective study conducted over 6 months on a population of headache sufferers in childhood and adolescence who referred to our Juvenile Neuropsychiatry Centre of the Hospital of Perugia. Our objective was to quantify the direct and indirect costs associated with juvenile headache.

The role of neuroimaging in dementia.

Potential new therapies for the treatment of Alzheimer's disease demand early and accurate diagnosis. Although clinical evaluation is generally sufficient when the disease is well established, neuroimaging tools are helpful to detect the earliest changes of Alzheimer's disease or differentiate Alzheimer's disease from the other forms of dementia. This article reviews the basic concepts of brain imaging and clinical application. It concludes with a brief discussion of future directions in neuroimaging for the diagnosis and longitudinal follow-up of Alzheimer's disease.

How often does routine pediatric EEG have an important unexpected result?

BACKGROUND: Electroencephalogram recordings are requested for the assessment of many childhood disorders. To assess the utility of the EEG in children, we studied how often routine EEG results can be correctly predicted from the EEG requisition. METHOD: Five hundred consecutive initial EEG requests from the IWK Grace Health Centre from two time epochs were examined. All EEGs were 16 channel (10-20 electrode system). Based only on the requisition (patient demographics, referring physician, and reason for EEG), we coded our prediction of the result and then the actual result. When results were discordant from prediction, a judgment was made about the potential importance of the result. RESULTS: Overall, EEG results were correctly predicted in 81%. Prediction for all nonepilepsy reasons was accurate in 91% (n=320) and 96% for paroxysmal nonepileptic events (n=158) but only 59% for epileptic disorders (n=141) (p<0.0001). Neurologists ordered 45% of EEGs, pediatricians 32%, and GP's 17%. Predictions were least accurate for neurologists' requests (p<0.006) however, neurologists were more likely to request EEG for epileptic disorders (p<0.0001). Age of the child and urban versus rural address did not affect the accuracy of prediction. CONCLUSION: Results of routine pediatric EEG for most nonepilepsy reasons appear highly predictable and therefore, possibly of little value to an experienced clinician. When requested for epilepsy, this "ancient" test remains full of surprises.

Dementia diagnostic guidelines: methodologies, results, and implementation costs.

OBJECTIVE: To facilitate the diagnostic process for dementia. Five guidelines and four consensus statements on specific diagnostic recommendations, specialist referral recommendations, and costs of recommended diagnostic procedures were compared and summarized. DATA SOURCES AND SELECTION: A MEDLINE search from 1984 to 1999 and queries to experts yielded 14 guidelines and consensus statements that addressed the diagnosis of dementia. Only nine documents which had national or international scopes were reviewed. METHODS: Comparisons were made on the specific diagnostic criteria for patient history, clinical examination, functional assessment, laboratory tests, neuroimaging, and other diagnostic tests, as well as specialist referral recommendations and costs for the recommended diagnostic procedures. The first three authors reviewed independently each document and completed a table on specific recommendations in each document. To settle disagreements about specific recommendations, they discussed them until they reached a consensus. To interpret the intent of vague statements, they used their best judgment. RESULTS: The documents differed in content, recommendations, and development methodology. They were based on either expert opinion or scientific evidence, or both. Although the nine documents were nearly unanimous in several recommendations, including assessing the presenting problem, taking a medical history, conducting physical and neurological examinations, and assessing the patient's mental and cognitive status, considerable differences in recommendations were common. Such differences led to large differentials in the estimated costs (range, $190 to $2,001) for recommended diagnostic assessments. CONCLUSIONS: A systematic approach to diagnostic recommendations for dementia may induce greater consistency among guidelines and consensus statements. The current approach leads to considerable variability in recommendations and estimated costs.