Frank Lefevre

Ketogenic Diet for the Treatment of Refractory Epilepsy in Children: A Systematic Review of Efficacy

Objectives. To systematically review and synthesize the available evidence on the efficacy of the ketogenic diet in reducing seizure frequency for children with refractory epilepsy. Data Sources. Medline searches were performed using the keywords epilepsy/therapy, dietary therapy, and epilepsy, and the text word ketogenic diet. The Cochrane Library of clinical trials was searched using the term ketogenic diet. Bibliographies of recent review articles and relevant primary research reports, as well asCurrent Contents were reviewed for additional relevant citations. Study Selection. Studies were selected for inclusion in the review that reported the reduction of seizure frequency following treatment with the ketogenic diet in children with refractory epilepsy. The outcome measures used were the percentage of patients with: 1) complete elimination of seizures, 2) >90% reduction in seizures, and 3) >50% reduction in seizures. Results. The evidence consists entirely of uncontrolled studies. Of 11 studies identified for this review, 9 are retrospective series of patients from a single institution. Two studies are prospective, 1 of which is a multicenter trial. The results of these studies are consistent in showing that some children benefit from the ketogenic diet, demonstrated by a significant reduction in seizure frequency. Estimates of the rates of improvement by combined analysis (confidence profile method) are complete cessation of all seizures in 16% of children (95% confidence interval [CI]: 11.0–21.7); a greater than 90% reduction in seizures in 32% (95% CI: 25.3–39.8); and a greater than 50% reduction in seizures in 56% (95% CI: 41.2–69.7). It is unlikely that this degree of benefit can result from a placebo response and/or spontaneous remission. Conclusions. Although controlled trials are lacking, the evidence is sufficient to determine that the ketogenic diet is efficacious in reducing seizure frequency in children with refractory epilepsy.

Alcohol consumption among HIV-infected patients

This prospective, cohort study analyzed the prevalence of alcoholism and patterns of alcohol intake over time in a cohort of HIV-infected patients, predominantly homosexual/bisexual men. One hundred eleven HIV-positive subjects were recruited from a comprehensive HIV clinic associated with a large Midwestern university hospital. Each participant completed the Michigan Alcoholism Screening Test (MAST) survey and a standardized quantity—frequency questionnaire on alcohol intake at enrollment. The quantity—frequency scale was repeated every six months for a total of 30 months. Forty-five of the 111 subjects (41%) met the criteria for alcoholism, as defined by a MAST score 5 or higher. There was a significant decrease in alcohol consumption over time, from 6.4 drinks/week in the initial time period to 3.9 drinks/week by the final time period (p<0.001).

Predicting survival from in-hospital CPR - Meta-analysis and validation of a prediction model

Objective: To better clarify patient factors that predict survival from in-hospital cardiopulmonary resuscitation (CPR), using two methods: 1) meta-analysis and 2) validation of a prediction model, the pre-arrest morbidity (PAM) index.Design: Meta-analysis of previously published studies by standard techniques. Retrospective chart review of validation sample.Setting: University-affiliated teaching hospital.Patients/participants: Meta-analytic sample of 21 previous studies from 1965–1989. The validation sample consisted of all patients surviving resuscitation from the authors’ hospital during the period September 1986 to January 1991. A matched sample of patients who did not survive from the same time period was used as the comparison group.Interventions: None.Measurements and main results: The strongest negative predictors of survival, by meta-analysis, were renal failure (r=0.088, p<0.0002), cancer (r=0.08, p<0.0002), and age more than 60 years (r=0.063, p<0.006). Sepsis (r=0.046, p<0.02), recent cerebrovascular accident (CVA) (r=0.038, p<0.04), and congestive heart failure (CHF) class III/IV (r=0.036, p<0.05) were weaker negative predictors. Presence of acute myocardial infarction (AMI) was a significant positive predictor of survival (r=0.15, p<0.0001). The PAM score was highly predictive of survival in a logistic regression model (p<0.0003, R2=9.6%). No patient who survived to discharge had a PAM score higher than 8.Conclusion: Meta-analysis reveals that the most significant negative predictors of survival from CPR are renal failure, cancer, and age more than 60 years, while AMI is a significant positive predictor. The PAM index is a useful method of stratifying probability of survival from CPR, especially for those patients with high PAM scores, who have essentially no chance of survival.

Heart failure between 1986 and 1994: Temporal trends in drug-prescribing practices, hospital readmissions, and survival at an academic medical center

Since 1987, publications in widely circulated medical journals have reported improved survival and lower hospital readmission rates when patients with heart failure and systolic dysfunction are treated with angiotensin-converting enzyme (ACE) inhibitors. We describe changes in ACE inhibitor use among patients hospitalized with heart failure between 1986 and 1993. Simultaneous trends in readmissions and survival rates are reported. Subjects were 612 consecutive patients hospitalized with a principal diagnosis of heart failure at an academic medical center during the period of Sept. 1, 1986, to Dec. 31, 1987 (interval I) or during the period Aug. 1, 1992, to Nov. 30, 1993 (interval II). Medical records were reviewed for 434 patients, consisting of all patients hospitalized with heart failure during interval II and a randomly selected 50% subset of patients hospitalized during interval I. Among 145 patients with systolic dysfunction whose medical records were reviewed, ACE inhibitor prescriptions significantly increased between interval I and interval II (43% vs 71%, p < 0.01, odds ratio 3.22, 95% confidence interval 1.62 to 6.42). Prescriptions of ACE inhibitors combined with digoxin and a diuretic also increased (37% vs 56%, p = 0.02, odds ratio 2.22, 95% confidence interval 1.14 to 4.32). Among all 612 patients, 6-month heart failure readmission rates increased from 13% to 21% (p = 0.02, odds ratio 1.79, 95% confidence interval 1.10 to 2.82). There was no significant change in survival rate between interval I and interval II, however, survival rate was marginally significantly improved among patients with systolic dysfunction. Our results suggest that drug-prescribing practices have significantly changed between 1986 and 1993. The absence of observed improvement in outcomes may result from changes in hospital admission criteria for heart failure.

Screening for Undetected Mental Disorders in High Utilizers of Primary Care Services

AbstractOBJECTIVE: To define the prevalence and detection rates of mental disorders among high utilizers as compared with typical utilizers, and to examine the effect of case-mix adjustment on these parameters. DESIGN: Cross-sectional study. SETTING: General internal medicine outpatient clinic associated with an urban, academic medical center. PATIENTS: From patients attending a general medicine clinic, 304 were selected randomly in three utilization groups, defined by number of clinic visits: (1) high utilizers; (2) case-mix adjusted high utilizers; and (3) typical utilizers (control patients). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of any mental disorder was ascertained by the PRIME-MD screening instrument. Chart review on all patients was performed to ascertain mental disorders detected by primary care physicians. The prevalence of mood disorders was markedly higher in high utilizers (29%) than in adjusted high utilizers (15%) or controls (10%) (p<.001). Anxiety disorders were slightly, but not statistically, more prevalent in the group adjusted for case mix (16%) than in other high utilizers (12%) or controls (9%). Alcoholism was significantly more prevalent in controls (12%) than in adjusted (6%) or other high utilizers (3%) (p<.03). The discrepancy in detection rates between PRIME-MD and chart review for any mental disorder was less for high utilizers (37% vs 31%) as compared with adjusted high utilizers (31% vs 11%) or controls (24% vs 8%). CONCLUSIONS: Mood disorders are associated with a high overall burden of illness, while anxiety disorders are more predominant among outliers after case-mix adjustment. Detection rates differ substantially by utilization pattern. Screening efforts can be more appropriately targeted with knowledge of these patterns.

ST segment depression detected by continuous electrocardiography in patients with acute ischemic stroke or transient ischemic attack.

Forty percent of patients with a history of ischemic stroke or transient ischemic attack (TIA) have concomitant coronary artery disease. ST segment depression, detected by continuous electrocardiography, is associated with increased cardiac morbidity and mortality in patients with known coronary artery disease. While electrocardiographic changes have been associated with acute stroke, the etiology and significance of these changes remain unclear. In this pilot study we report the prevalence of ST segment depression and ventricular arrhythmias in patients with acute ischemic stroke or TLA monitored by continuous electrocardiography. Clinical predictors of ST segment depression and ventricular arrhythmia are also identified. Methods Consecutive patients presenting with acute ischemic stroke or TLA were enrolled within 72 hours of hospital admission and monitored by continuous electrocardiography for 48 hours. The electrocardiographic results were analyzed for periods of ST segment depression and ventricular arrhythmias. Results Of 51 patients with ischemic stroke or TIA, 15 (29%) had episodes of ST segment depression (95% confidence interval, 15% to 43%), and 18 (35%) had ventricular arrhythmias (95% confidence interval, 21% to 49%). In logistic regression analysis, increasing age (P<.02) and a left-sided neurological event (P<.01) were significant predictors of ST segment depression. Increasing numbers of atherosclerotic risk factors, a history of cardiac disease, and increasing or decreasing mean arterial pressure were not predictive of ST segment depression. Conclusions Patients with acute ischemic stroke or TIA have a 29% prevalence of ST segment depression within the first 5 days after their event. In comparison, the prevalence of ST depression is 2.5% to 8% in asymptomatic adults and 43% to 60% in patients with symptomatic coronary artery disease. The association of ST segment depression with left-sided neurological events suggests that the electrocardiographic changes are in part neurologically mediated. Further study is necessary to better define the brain-heart interaction and to determine whether ST segment depression in patients with ischemic stroke or TLA reflects underlying coronary artery disease.

A survey of physician training programs in risk management and communication skills for malpractice prevention.

M alpractice lawsuits serve as a great source of pain, consternation and loss for physicians and patients alike, usually leaving all parties involved in the process with a sense of betrayal. A significant number of physicians will be sued at least once in their career, especially if they practice in some of the more vulnerable specialties.’ In addition, there is some evidence that the threat of malpractice lawsuits changes the practice style of many physicians, leading to the practice of “defensive medicine” and raises the total cost of health care? Clearly, the prevention of medical malpractice is an issue that deserves considerable attention from physicians and from those who train them. Empirical evidence suggests that medical negligence may play a relatively minor role in malpractice lawsuits. As demonstrated by Localio, et al., one in thirty-five cases of negligence or incompetence actually results in a lawsuit. Conversely, the number of malpractice suits far exceeds the number of “true negligence” claims: only one in six malpractice claims involved negligence, as judged by disinterested analysts. Thus, while negligence or incompetence may be the source of a small number of suits, the data suggest that the majority of medical malpractice suits may not be driven by clinical quality of care, but by other factors? Inadequate communication between physicians, patients, and the patient’s family has emerged as one factor that is an important determinant of malpractice lawsuits? Hickson, et al.: reported interviews with 127 parents who sued as a result of perinatal injury to their child. The authors found that 13 percent of these families reported “the physician would not listen”; 32 percent reported that the physician “would not talk openly;” 48 percent felt that the

Evidence-based assessment of ERCP in the treatment of pancreatitis

This article reports the results of an evidencebased assessment of ERCP for the treatment of pancreatitis.1 Pancreatitis encompasses a number of distinct entities with differing etiologies, clinical expression, and treatment options. Each is addressed separately to the extent allowed by the available literature. Also, there are a number of different endoscopic techniques used for varying clinical situations. For the purposes of this paper, “ERCP” will refer to the spectrum of interventional endoscopic techniques that are used in the treatment of pancreatitis. METHODS The methods used in the systematic review are summarized in the Methods article included in this supplement2 and are described in detail in the fullevidence report.1 The protocol for this systematic review prospectively defined study objectives; search strategy; patient populations of interest; study selection criteria; outcomes of interest; data elements to be abstracted and methods for abstraction; and methods for study quality assessment. Briefly, the initial selection criteria for this systematic review were full-length reports of comparative studies published in English in peer-reviewed journals. A minimum of 25 patients per treatment arm were required. Assessment of study quality was adapted from that of the U.S. Preventive Health Services Task Force.3 Outcomes of interest included measures of technical success, clinical success, resource utilization, and procedure-related morbidity. Because of a paucity of literature, especially the lack of comparative trials, very few studies on the treatment of recurrent or chronic pancreatitis met the initial selection criteria. Therefore, the selection criteria were relaxed so that this question could be examined. Concurrently controlled studies comparing ERCP to a therapeutic alternative were included regardless of sample size. Single-arm observational studies (subject serves as own control) of ERCP treatment of chronic pancreatitis with a minimum of 25 patients were included if the study selected a well-defined population and used appropriate outcome measures. Baseline evaluation and 6-month follow-up data were required. Single-arm studies of an ERCP in pancreas divisum were also included subject to the above conditions, but regardless of sample size.

Medical school attended as a predictor of medical malpractice claims

Objectives: Following earlier research which showed that certain types of physicians are more likely to be sued for malpractice, this study explored (1) whether graduates of certain medical schools have consistently higher rates of lawsuits against them, (2) if the rates of lawsuits against physicians are associated with their school of graduation, and (3) whether the characteristics of the medical school explain any differences found. Design: Retrospective analysis of malpractice claims data from three states merged with physician data from the AMA Masterfile (n=30 288). Study subjects: All US medical schools with at least 5% of graduates practising in three study states (n=89). Main outcome measures: Proportion of graduates from a medical school for a particular decade sued for medical malpractice between 1990 and 1997 and odds ratio for lawsuits against physicians from high and low outlier schools; correlations between the lawsuit rates of successive cohorts of graduates of specific medical schools. Results: Medical schools that are outliers for malpractice lawsuits against their graduates in one decade are likely to retain their outlier status in the subsequent decade. In addition, outlier status of a physician’s medical school in the decade before his or her graduation is predictive of that physician’s malpractice claims experience (p<0.01). All correlations of cohorts were relatively high and all were statistically significant at p<0.001. Comparison of outlier and non-outlier schools showed that some differences exist in school ownership (p<0.05), years since established (p<0.05), and mean number of residents and fellows (p<0.01). Conclusions: Consistent differences in malpractice experience exist among medical schools. Further research exploring alternative explanations for these differences needs to be conducted.

Surgery in the patient with neurologic disease

Patients with neurologic disease who require surgery present distinct issues and challenges for the medical consultant. Although it is not possible to offer a unified approach to neurologic patients, the primary care consultant should understand the clinical issues that are common to these patients, and the individual considerations necessitated by the nature of the neurologic disorder and the clinical characteristics of the patient. The preoperative evaluation combines elements of literature evidence on risk assessment with a thorough understanding of the planned procedure and local practice patterns, and clinical judgment as to the estimated risk-benefit ratio. Perioperative management necessitates attention to many general principles of perioperative care, such as awareness of the potential for cardiopulmonary complications and the need for DVT prophylaxis. In addition, there are management issues for neurologic patients, such as blood pressure control and evaluation of hyponatremia, which may differ from other surgical patients. In these circumstances, the interaction of the neurologic condition with the medical condition and the implications of treatment on the underlying neurologic process also need to be considered.