Faculty Bibliography

IMPORTANCE/UNASSIGNED:Antibiotic prescribing varies across primary care physicians (PCPs) and disproportionately harms older adults, yet whether residency training is a factor in this variation is unknown. OBJECTIVE/UNASSIGNED:To evaluate whether PCPs' Accreditation Council for Graduate Medical Education (ACGME) competency ratings toward the end of residency are associated with their early-career pattern of antibiotic prescribing to older adults. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cohort study involved graduates of US ACGME-accredited internal medicine and family medicine residency programs between January 1, 2015, and December 31, 2020, who were in their first 5 years of primary care practice. Their ACGME Milestone ratings (hereafter competency ratings) were linked to Medicare Parts B and D public claims from January 1, 2015, to December 31, 2022. Data analysis was conducted between March 2024 and May 2026. EXPOSURE/UNASSIGNED:Overall competency rating in the middle of the final year of residency. Ratings for 22 subcompetencies (5-point developmental scale) were averaged within 6 core competency domains (patient care, medical knowledge, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement), averaged across domains, and then standardized at the residency program level. MAIN OUTCOME AND MEASURE/UNASSIGNED:Annual antibiotic prescription rate. This primary outcome was expressed as an incidence rate ratio (IRR) adjusted for physician, residency program, practice location, and patient-panel factors. Residency training program was examined as a secondary factor. RESULTS/UNASSIGNED:The analysis included 31 800 PCPs (mean [SD] age on practice entry, 32.8 [4.2] years; 15 990 females [50%]) who graduated from 1090 residency programs, representing 129 225 physician-years of prescribing data. Among these physicians, 58% graduated from a US medical school, 90% earned an MD degree, and 51% specialized in internal medicine and 49% specialized in family medicine. Each physician panel had a mean (SD) of 169 (144) Medicare beneficiaries per year (mean [SD] age, 70.3 [3.5] years; 59% female patients). Physicians prescribed a mean (SD) of 54.1 (52.2) antibiotics per year, and the full cohort wrote 7 664 372 antibiotic prescriptions across the study period. In unadjusted analyses, graduates from internal medicine and family medicine residency programs with highest vs lowest quintile prescribing rates prescribed a difference of 14.9 (95% CI, 13.8-15.9; P < .001) and 18.8 (95% CI, 17.9-19.7; P < .001) additional antibiotics per 100 beneficiaries per year, respectively. In adjusted analysis, each 1-SD increase in overall competency rating was associated with 0.7 (95% CI, 0.5-0.9) fewer antibiotic prescriptions per 100 beneficiaries per year (adjusted IRR, 0.98; 95% CI, 0.97-0.99; P < .001). Each year of experience was associated with higher antibiotic prescribing (IRR, 1.01; 95% CI, 1.01-1.02; P < .001), even accounting for the reduction in prescribing that occurred across study years. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This study found that higher assessed competence near the end of residency was associated with lower antibiotic prescribing in early primary care practice. Competency assessments may inform prescribing variation-focused efforts during training and early practice.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Despite extensive investigation, no proven neuroprotective therapy exists for traumatic brain injury. Although this translational gap has been widely discussed, it has not been objectively characterized through systematic analysis. We hypothesized that this deficit reflects not only biological intractability but also constraints within the research ecosystem that impede translational progress. METHODS:Web of Science, PubMed, and Scopus were searched without date or document type restrictions. A natural language processing pipeline screened results and classified study designs, topical areas, geographic affiliations, and funding sources. All analyses and visualizations were performed using open-source Python libraries. RESULTS:94 399 publications spanning 1829 to 2026 comprised the corpus. Research output was geographically concentrated. Thematic network analysis revealed 4 discrete research domains (preclinical, acute clinical, chronic/rehabilitation, and sports-related), with the preclinical domain spatially isolated from all 3 clinical clusters. Randomized controlled trials comprised 1.5% of publications, while reviews exceeded 20% of annual output throughout the 21st century. Preclinical research share peaked near 23% of annual publications around 2000 and subsequently declined without a commensurate rise in clinical trial activity (Chow test, P < .001). Diagnostic biomarker research comprised 3.8% of publications but remained poorly integrated with prospective trial designs. Postacute pharmacotherapy research represented 0.8% of publications and the smallest trial-integrated fraction of any area examined. Citation concentration was substantial (Gini 0.725), with nearly one-fifth of publications uncited. Journal-level analysis revealed a sustained decline in neurosurgery-specific journal representation from 1980 to 2025; in 1993, neurology and neuroscience journals surpassed neurosurgery journals in proportional share of annual publications and have maintained that lead since. National Institutes of Health-funded research, the largest funder by a factor of 5, produced randomized controlled trial rates indistinguishable from those of unfunded literature (1.6%). CONCLUSION/CONCLUSIONS:Traumatic brain injury literature has grown substantially without commensurate advances in high-evidence research, reflecting identifiable inefficiencies in infrastructure and funding strategy that represent targets for intervention.

BACKGROUND AND OBJECTIVES/UNASSIGNED:Patients with neurologic disease have a variety of unmet palliative care needs. Both the Accreditation Council for Graduate Medical Education and Academy of Neurology have emphasized the need for neuropalliative care education in recent years. Neurology training programs have widely variable practices in teaching neuropalliative care. This study aims to characterize current practices in providing neuropalliative care education across graduate neurology training and to identify barriers to its delivery. METHODS/UNASSIGNED:We surveyed program directors (PDs) of neurology residency and fellowship training programs in the United States regarding their current methods of teaching neuropalliative care topics, perceived importance of these topics, relevant subspecialty resources, and perceived barriers to providing neuropalliative care education. RESULTS/UNASSIGNED:Our survey was emailed to 777 PDs and fellowship directors. In total, 118 responses were included in the analytic sample (response rate 15.2%). Program directors generally perceived neuropalliative care education as important, with a median rank of 7 of 10. 91% of adult neurology residency programs and 66% of fellowship programs included palliative care topics in their didactics curricula. Topics emphasized varied depending on the training program's subspecialty. Respondents highlighted barriers to implementing neuropalliative care training, including inadequate trainee and faculty time and lack of adequate teaching faculty. DISCUSSION/UNASSIGNED:Neurology training programs continue to exhibit considerable variability in palliative care education curricula. Although most programs reported a presence of palliative care in their institutions, variability exists in the amount of palliative care education taught, the topics emphasized, and the teaching methods. Notably, there is an opportunity for fellowship programs to increase the amount of neuropalliative care topics taught in their curricula. Neurology residency and fellowship directors may benefit from using existing neuropalliative care curricula to enhance this area of education, partnering with local non-neurology faculty to teach palliative topics, and integrating palliative care topics into subspecialty training.

OBJECTIVE:Capturing a habitual event is often required to determine the etiology of events during video-EEG (vEEG) monitoring. vEEG studies that fail to capture a habitual event are typically considered non-diagnostic. In this study, we evaluated the clinical impact of non-diagnostic vEEG studies. METHODS:We identified non-diagnostic vEEG studies from a cohort of epilepsy monitoring unit (EMU) admissions. Patients were followed longitudinally in the outpatient clinic.Clinical impact was assessed by evaluating changes in diagnosis and antiseizure medication (ASM) management at EMU discharge and at the last clinic follow-up. RESULTS:Patients were categorized according to referral indication: (I) spell clarification in individuals with paroxysmal events (n = 10); (II) event differentiation in patients with epilepsy (n = 16); (III) reassessment of a prior epilepsy diagnosis (n = 20); and (IV) classification of seizure or epilepsy type (n = 18). Following EMU admission, one patient in Group I was diagnosed with seizures, while the prior epilepsy diagnosis was withdrawn in eight patients in Group III. At EMU discharge, ASM reduction was most frequent in Group III (11/20), whereas ASM escalation was most common in Group II (7/16). By the last clinic follow-up, two additional patients had been diagnosed with seizures. Further ASM escalation occurred in 14 patients: two in Group I, three in Group II, three in Group III, and six in Group IV. SIGNIFICANCE/CONCLUSIONS:Non-diagnostic vEEG studies can still provide meaningful diagnostic insight. Subsequent management strategies varied substantially depending on the indications for EMU admission and the clinical context.

BACKGROUND/PURPOSE/UNASSIGNED:Downbeat nystagmus (DBN) is an uncommon finding in comatose patients, especially as a manifestation of epileptiform activity. We report a 59-year-old man who developed DBN in the context of myoclonic status epilepticus following anoxic brain injury secondary to cardiac arrest. The DBN was phase-locked with generalized periodic epileptiform discharges (GPDs) on electroencephalography (EEG) and resolved with pharmacologic burst suppression. CONCLUSION/UNASSIGNED:This case suggests a potential link between DBN and cortical epileptiform activity, which we hypothesize may be due to bilateral cortical hyperexcitability and cerebellar disinhibition. The presence of DBN in this setting may indicate a poor prognosis.

BACKGROUND AND OBJECTIVES/OBJECTIVE:This systematic review (SR) provides updated evidence-based conclusions regarding the use of pharmacologic migraine prevention in adults to inform a new joint American Academy of Neurology (AAN) and American Headache Society practice guideline. METHODS:A multidisciplinary panel conducted an SR following the 2017 AAN Clinical Practice Guideline Process Manual. Randomized controlled trials evaluating pharmacologic preventive treatments for adults with episodic or chronic migraine were included. Searches encompassed MEDLINE, Embase, and ClinicalTrials.gov from database inception through June 6, 2024. Studies were screened in duplicate, with dual independent risk-of-bias assessment. Outcomes included change in monthly headache days, ≥50% responder rate, and validated patient-reported quality of life (QOL) measures. Raw mean differences, standardized mean differences, and risk ratios were calculated. A modified Grading of Recommendations Assessment, Development, and Evaluation process was used to classify certainty of evidence. RESULTS:A total of 217 studies met inclusion criteria. For episodic migraine, high-confidence evidence showed that galcanezumab and erenumab are more effective than placebo in reducing headache frequency. Moderate-confidence evidence supported benefit from atogepant, eptinezumab, fremanezumab, propranolol, topiramate, and valproate. Several additional oral agents including amitriptyline, bisoprolol, flunarizine, fluoxetine, levetiracetam, metoprolol, nifedipine, pizotifen, and telmisartan had low-confidence evidence suggesting possible benefit. For chronic migraine, high-confidence evidence supported reductions in headache frequency with fremanezumab, galcanezumab, and onabotulinumtoxinA. Moderate-confidence evidence supported benefit from atogepant, eptinezumab, erenumab, topiramate and valproate. Across both episodic and chronic migraine populations, erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant, atogepant, topiramate and onabotulinumtoxinA demonstrated improvements in patient-reported QOL outcomes on validated instruments. Evidence comparing active treatments was limited and generally of low or very low confidence, restricting conclusions about comparative effectiveness. DISCUSSION/CONCLUSIONS:This SR provides a comprehensive synthesis of evidence on pharmacologic migraine prevention in adults. High- and moderate-confidence findings confirm the efficacy of several established and newer preventive therapies and demonstrate improvements in patient-reported outcomes across multiple validated measures. These conclusions informed the development of evidence-based recommendations, presented in a companion publication, to guide clinicians in selecting preventive medications for adults with episodic and chronic migraine.

INTRODUCTION/BACKGROUND:Patient and arteriovenous malformation (AVM) characteristics that portend success after treatment for low-grade brain AVMs remain unknown. PATIENTS AND METHODS/METHODS:We utilised the MISTA multicentre registry to identify patients with Spetzler-Martin (SM) grade I or II AVMs treated with stand-alone curative-intent intervention (resection, stereotactic radiosurgery [SRS] or endovascular embolisation). Bivariate and multivariable analyses were performed to identify patient and AVM characteristics predictive of complete obliteration or favourable outcome (complete obliteration without new permanent deficit or post-treatment haemorrhage). RESULTS:A total of 522 patients were included (292 microsurgery, 152 SRS, 78 embolisation). Complete obliteration rates differed between microsurgery (95.9%), SRS (75.0%) and embolisation (71.8%) (P < .001); among patients classified as cured, digital subtraction angiography (DSA) confirmed obliteration in 96.1%, 75.9% and 52.4%, respectively. Favourable outcome was achieved in 89.4%, 64.5% and 67.9% (P < .001). In adjusted models for obliteration, elderly age (odds ratio [OR] 0.49, P = .022), larger nidus (OR 0.64, P = .005) and compacted morphology (OR 1.93, P = .019) were independent predictors overall; paediatric age predicted incomplete obliteration after microsurgery (OR 0.05, P = .045), and elderly age (OR 0.19, P = .001) and larger nidus (OR 0.59, P = .015) after SRS. For favourable outcome, SM grade II overall (adjusted OR [aOR] 0.58, P = .031) and elderly age after SRS (aOR 0.31, P = .019) were independent negative predictors. DISCUSSION/CONCLUSIONS:Low-grade AVMs showed high rates of complete obliteration, though DSA-confirmed rates were substantially lower after embolisation, underscoring the importance of angiographic confirmation. CONCLUSION/CONCLUSIONS:The predictors identified in this study may help guide management when 2 or 3 of the primary treatment options carry clinical equipoise.

Subjective cognitive decline (SCD) refers to cognitive concerns that may occur with or without objective impairment on standardized testing. Studies suggest that SCD may be an early clinical marker of Alzheimer's disease and related dementias, and that it can predict future objective cognitive decline and progression to dementia. However, the research that supports these conclusions is primarily based on samples with homogeneous socioeconomic and cultural backgrounds. The limited studies in samples with more diverse representations of racial, ethnic, gender, and sexual orientation characteristics show varying SCD prevalence, correlates, and outcomes. Here, we review this literature, focusing on how to apply the findings to advance our understanding of SCD. We further evaluate how our findings inform a roadmap for future research. Overall, we conclude that broader investigations across more diverse populations enhance our understanding of the factors that may differentially contribute to SCD and shape its utility as a clinical metric.