Faculty Bibliography

Rationale: Reducing hospital admission length of stay (LOS) has been identified as one way to improve quality and reduce healthcare costs. The epilepsy monitoring unit (EMU) poses unique challenges to reductions in LOS, given the elective nature of the admissions and the need to safely provoke seizures. Data delineating the factors that impact EMU LOS are currently very limited. In an attempt to establish benchmarks for care, we evaluated the time to first, second, and third target events (TE) in patients admitted to the EMU at a large tertiary care epilepsy center. Methods: We reviewed the medical records of 905 consecutive patients who were admitted for diagnostic scalp video-EEG monitoring at NYU's Comprehensive Epilepsy Center from January 1, 2011 to December 31, 2011. Admission reason and time to TE were assessed. Results: 40.4% of patients (366/905) experienced a first TE; mean time to first TE for pre-surgical patients was 3.4 days (D) vs. 2.5D for non-surgical patients. 31.7% (287/905) experienced a second TE; the mean time to second TE was 4.4D for pre-surgical patients vs. 2.7D for non-surgical patients. 24.7% (224/905) experienced three or more TEs; the mean time to third TE for pre-surgical patients was 4.9D vs. 2.9D for non-surgical patients. Of the patients who experienced TEs during admission, 21.5% (79/366) had only one TE during admission; of these patients, mean LOS was 7.2D for pre-surgical patients (12/79) vs. 5.1D for non-surgical patients. 17.2% (63/366) experienced only two TEs during admission; mean LOS was 8D for pre-surgical patients (14/63) vs. 5.3D for non-surgical patients. 61.2% (224/366) experienced three or more TEs during admission; mean LOS was 6.7D for pre-surgical patients (54/224) vs. 6.3D for non-surgical patients. Conclusions: Time to first TE is longer in patients admitted to the EMU for pre-surgical evaluation vs. non-surgical patients. The latter group includes patients with psychogenic non-epileptic seizures; such patients produce events more quickly i!

Rationale: Increasingly, hospitals are striving to shorten length of stay (LOS) in an effort to improve care. Beyond the impact on expense, longer stays in the hospital increase the risk of iatrogenic or other complications. The epilepsy monitoring unit (EMU) is a unique hospital setting where the admission goal focuses on capturing one or more events/seizures. Seizure provocation is performed in a controlled manner to minimize the risk of secondarily generalized convulsions and status epilepticus, and to maintain patient safety. To better establish benchmarks for care, we evaluated both the impact of admission objectives and select patient characteristics on EMU LOS. Methods: We reviewed the medical records of 905 consecutive patients who were admitted for diagnostic scalp video-EEG monitoring at NYU's Comprehensive Epilepsy Center from January 1, 2011 to December 31, 2011. Reasons for admission, number of anti-epileptic drugs on admission, and time to target events were documented. Results: Of the 905 patients included, the mean length of stay was 4.8+3.2 days. The median length of stay was 4 days. 95 subjects were admitted for pre-surgical evaluation with a mean LOS of 7.2 days, vs. 4.5 days (p<0.001) for those admitted for diagnostic evaluations. 12.8% (116/905) of patients admitted to the EMU had a previous history of epilepsy surgery and the majority of these patients were admitted for medication adjustment; patients who had undergone prior epilepsy surgery experienced longer length of stays (5.9 days) compared to those without a prior epilepsy surgical history (4.7 days) (p<0.0002). Patients admitted on three or more antiepileptic drugs (AEDs) on admission experienced longer lengths of stay (6.3 days) vs. patients on less than three concomitant AEDs (4.3 days). Patients were further stratified by reason for admission. 494/905 patients were primarily admitted for seizure characterization and these patients experienced a mean LOS of 3.9 days whereas patients who were admitted for medicatio!

Rationale: The Generalized Tonic-Clonic Convulsion (GTCC) is often associated with post-ictal electrographic slowing, and at times suppression. The mechanism of post-ictal EEG suppression is not known but may reflect involvement of bilateral subcortical networks. We examined the electrographic activity occurring after seizures with bilateral movement to determine if there are post-ictal features unique to the GTCC. Methods: We reviewed the video EEG of 100 consecutive inpatients of the NYU Comprehensive Epilepsy Center that had bilateral movement as part of their seizure semiology. Each seizure was reviewed by 2 reviewers; any records in which the patient was obscured on the video were excluded from further analysis. Any seizure with bilateral symmetric tonic, vibratory and clonic phases (defined as bilateral movement > and < 5 Hz respectively) in that order was categorized as "typical GTCC" (tGTCC). If one phase was absent, asymmetric or the progression was different, it was considered an "atypical GTCC" (aGTCC). If two phases were absent it was not a GTCC (nGTCC). All aGTCC were reviewed by at least 3 reviewers. The post-ictal EEG was categorized as: "suppression", defined as background voltage <10uV; "slowing" defined as decreased amplitude and/or frequency compared to baseline while still >10uV; or "no change from baseline." Results: 104 seizures from 100 patients were reviewed, 5 patients were excluded due to obscured video or EEG, leaving 97 seizures reviewed. 41 were tGTCC, 14 were aGTCC and 42 were nGT

Rationale: The Generalized Tonic-Clonic Convulsion (GTCC) has been described as a stereotyped seizure consisting of a symmetric tonic posture, followed by vibratory and clonic phases - defined as movements at a frequency of >5 Hz and <5 Hz respectively. We examined how frequently the classic GTCC occurs in a population and what factors, if any, contributed to deviations from this pattern. Methods: We reviewed the video EEG of 100 consecutive inpatients of the NYU Comprehensive Epilepsy Center that had bilateral limb movements as part of their seizure semiology. Each seizure was reviewed by 2 reviewers; any records in which the patient was obscured on the video were excluded from further analysis. Any seizure with bilateral symmetric tonic, vibratory and clonic phases in that order was categorized as "typical GTCC" (tGTCC), if one phase was absent, asymmetric or in the wrong order of progression it was considered "atypical GTCC" (aGTCC), if two phases were absent it was not a GTCC (nGTCC). All aGTCC were reviewed by at least 3 reviewers. Results: 104 seizures (41 from women) from 100 patients were reviewed, 2 patients were excluded due to obscured video. 45 had a tGTCC while 15 were aGTCC, and 42 were nGT

Seborrheic dermatitis is a common chronic inflammatory skin condition, characterized by scaling and poorly defined erythematous patches. It may be associated with pruritus, and it primarily affects sebum-rich areas, such as the scalp, face, upper chest, and back. Although its pathogenesis is not completely understood, some postulate that the condition results from colonization of the skin of affected individuals with species of the genus Malassezia (formerly, Pityrosporum). A variety of treatment modalities are available, including eradication of the fungus, reducing or treating the inflammatory process, and decreasing sebum production.

Hermansky-Pudlak syndrome is an autosomal recessive disorder of lysosomal storage characterized by the triad of occulocutaneous albinism, bleeding diathesis, and pulmonary fibrosis. Sarcoidosis is a disease characterized by the development of noncaseating granulomas, most commonly affecting the lungs. The pathophysiology, histological findings, clinical symptoms, and treatment of the pulmonary manifestations of Hermansky-Pudlak syndrome are distinct from those of sarcoidosis. As patients with occulocutaneous and bleeding manifestations of Hermansky-Pudlak syndrome may also develop pulmonary fibrosis, the authors present this case to illustrate that pulmonary symptoms must be carefully evaluated in those with this syndrome because in this case, the patient developed underlying pulmonary sarcoidosis. To the authors' knowledge, this is the first documented case of Hermansky-Pudlak syndrome with concomitant pulmonary sarcoidosis