n n n xvi CONTENTS 2.3.8 Distributions of Functions of Random Variables 2.4 Mathematical Expectation 2.4.1 Expected Value of a Random Variable 2.4.2 Expectation of a Function of a Single Random Variable 2.4.3 Expectations of Functions of Several Random Variables 2.4.4 Moments ' 2.4.

ObjectiveTo characterize continuous EEG (cEEG) use patterns in the critically ill and to determine the association with hospitalization outcomes for specific diagnoses.MethodsWe performed a retrospective cross-sectional study with National Inpatient Sample data from 2004 to 2013. We sampled hospitalized adult patients who received intensive care and then compared patients who underwent cEEG to those who did not. We considered diagnostic subgroups of seizure/status epilepticus, subarachnoid or intracerebral hemorrhage, and altered consciousness. Outcomes were in-hospital mortality, hospitalization cost, and length of stay.ResultsIn total, 7,102,399 critically ill patients were identified, of whom 22,728 received cEEG. From 2004 to 2013, the proportion of patients who received cEEG increased from 0.06% (95% confidence interval [CI] 0.03%–0.09%) to 0.80% (95% CI 0.62%–0.98%). While the cEEG cohort appeared more ill, cEEG use was associated with reduced in-hospital mortality after adjustment for patient and hospital characteristics (odds ratio [OR] 0.83, 95% CI 0.75–0.93, p < 0.001). This finding held for the diagnoses of subarachnoid or intracerebral hemorrhage and for altered consciousness but not for the seizure/status epilepticus subgroup. Cost and length of hospitalization were increased for the cEEG cohort (OR 1.17 and OR 1.11, respectively, p < 0.001).ConclusionsThere was a >10-fold increase in cEEG use from 2004 to 2013. However, this procedure may still be underused; cEEG was associated with lower in-hospital mortality but used for only 0.3% of the critically ill population. While administrative claims analysis supports the utility of cEEG for critically ill patients, our findings suggest variable benefit by diagnosis, and investigation with greater clinical detail is warranted.

Status epilepticus is an emergency; however, prompt treatment of patients with status epilepticus is challenging. Clinical trials, such as the ESETT (Established Status Epilepticus Treatment Trial), compare effectiveness of antiepileptic medications, and rigorous examination of effectiveness of care delivery is similarly warranted. We reviewed the medical literature on observed deviations from guidelines, clinical significance, and initiatives to improve timely treatment. We found pervasive, substantial gaps between recommended and “real-world” practice with regard to timing, dosing, and sequence of antiepileptic therapy. Applying quality improvement methodology at the institutional level can increase adherence to guidelines and may improve patient outcomes.

ObjectiveTo describe geographic variation in neurologist density, neurologic conditions, and neurologist involvement in neurologic care.MethodsWe used 20% 2015 Medicare data to summarize variation by Hospital Referral Region (HRR). Neurologic care was defined as office-based evaluation/management visits with a primary diagnosis of a neurologic condition.ResultsMean density of neurologists varied nearly 4-fold from the lowest to the highest density quintile (9.7 [95% confidence interval (CI) 9.2–10.2] vs 43.1 [95% CI 37.6–48.5] per 100,000 Medicare beneficiaries). The mean prevalence of patients with neurologic conditions did not substantially differ across neurologist density quintile regions (293 vs 311 per 1,000 beneficiaries in the lowest vs highest quintiles, respectively). Of patients with a neurologic condition, 23.5% were seen by a neurologist, ranging from 20.6% in the lowest quintile regions to 27.0% in the highest quintile regions (6.4% absolute difference). Most of the difference comprised dementia, pain, and stroke conditions seen by neurologists. In contrast, very little of the difference comprised Parkinson disease and multiple sclerosis, both of which had a very high proportion (>80%) of neurologist involvement even in the lowest quintile regions.ConclusionsThe supply of neurologists varies substantially by region, but the prevalence of neurologic conditions does not. As neurologist supply increases, access to neurologist care for certain neurologic conditions (dementia, pain, and stroke) increases much more than for others (Parkinson disease and multiple sclerosis). These data provide insight for policy makers when considering strategies in matching the demand for neurologic care with the appropriate supply of neurologists.

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Objective Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has a myriad of neurological manifestations and its effects on the nervous system are increasingly recognized. Seizures and status epilepticus (SE) are reported in the novel coronavirus disease (COVID-19), both new onset and worsening of existing epilepsy, however the exact prevalence is still unknown. The primary aim of this study was to correlate the presence of seizures, status epilepticus, and specific critical care EEG patterns with patient functional outcomes in those with COVID-19. Methods This is a retrospective, multicenter cohort of COVID-19 positive patients in Southeast Michigan who underwent electroencephalography (EEG) from March 12 th through May 15 th , 2020. All patients had confirmed nasopharyngeal PCR for COVID-19. EEG patterns were characterized per 2012 ACNS critical care EEG terminology. Clinical and demographic variables were collected by medical chart review. Outcomes were divided into recovered, recovered with disability, or deceased. Results Out of the total of 4100 patients hospitalized with COVID-19, 110 patients (2.68%) had EEG during their hospitalization; 64% were male, 67% were African American with mean age of 63 years (range 20-87). The majority (70%) had severe COVID-19 were intubated or had multiorgan failure. The median length of hospitalization was 26.5 days (IQR=15 to 44 days). During hospitalization, of the patients who had EEG, 21.8% had new onset seizure including 7% with status epilepticus, majority (87.5%) with no prior epilepsy. Forty-nine (45%) patients died in the hospital, 46 (42%) recovered but maintained a disability and 15 (14%) recovered without a disability. The EEG findings associated with outcomes were background slowing/attenuation (recovered 60% vs recovered/disabled 96% vs died 96%, p<0.001) and normal (recovered 27% vs recovered/disabled 0% vs died 1%, p<0.001). However, these findings were no longer significant after adjusting for severity of COVID-19. Conclusion In this large multi-center study from Southeast Michigan, one of the early COVID-19 epicenters in the US, none of the EEG findings were significantly correlated with outcomes in critically ill COVID-19 patients. Although seizures and status epilepticus could be encountered in COVID-19, the occurrence did not correlate with the patients’ functional outcome.