Less than 50 years since tau was first isolated from a porcine brain, its detection in femtolitre concentrations in biological fluids is revolutionizing the diagnosis of neurodegenerative diseases. This review highlights the molecular and technological advances that have catapulted tau from obscurity to the forefront of biomarker diagnostics. Comprehensive updates are provided describing the burgeoning clinical applications of tau as a biomarker of neurodegeneration. For the clinician, tau not only enhances diagnostic accuracy, but holds promise as a predictor of clinical progression, phenotype, and response to drug therapy. For patients living with neurodegenerative disorders, characterization of tau dysregulation could provide much-needed clarity to a notoriously murky diagnostic landscape.

Objectives: To identify clinical factors that may assist emergency physicians to delineate between patients with new onset seizures (NOS) versus patients with recurrent undiagnosed seizures (RUS) among those presenting with apparent 'first seizures' to EDs. In addition, to provide a summary of current evidence-based guidelines regarding the workup of seizure presentations to ED. Methods: This retrospective cohort study included patients aged over 17 years who presented to a tertiary hospital ED between 1 January 2008 and 30 November 2016 with seizurerelated ICD-10-AM discharge codes. Exclusion criteria included pre-existing epilepsy and non-seizure diagnoses. Medical records were reviewed and relevant data extracted. Results: Seventy-five patients had NOS (54.7% [41/75] female, median age 71 years) and 22 patients had RUS (59.1% [13/22] female, median age 64 years). Non-motor index seizures were more than four times as common among RUS patients (27.3% [6/22] RUS vs 6.7% [5/75] NOS; P = 0.015). 95.5% (21/22) of RUS patients met epilepsy diagnostic criteria compared to 44.0% (33/75) of NOS patients (P < 0.001). No differences in patient demographics, seizure aetiology or seizure risk factors were identified. Conclusions: Emergency physicians should be wary of patients presenting with non-motor 'first seizures': they are more likely to have experienced prior seizures (the 'recurrent untreated seizure' group), and thus meet epilepsy diagnostic criteria. Almost half of those with actual NOS may also meet epilepsy criteria, largely driven by abnormal neuroimaging. Distinguishing RUS from NOS patients in the ED allows accurate prognostication and timely initiation of appropriate therapy.

Background Healthcare workers often abbreviate for convenience, but ambiguous abbreviations may cause miscommunication, which jeopardises patient care. Robust large‐scale research to quantify abbreviation frequency and ambiguity in medical documents is lacking. Aims To calculate the frequency of abbreviations used in discharge summaries, the proportion of these abbreviations that are ambiguous and the potential utility of auto‐expansion software. Methods We designed a software programme to extract all instances of abbreviations from every General Medical Unit discharge summary from the Royal Melbourne Hospital in 2015. We manually expanded abbreviations using published inventories and clinical experience, logging multiple expansions for any abbreviation if identified. Abbreviations were classified based on well defined criteria as standardised and likely to be well understood, or ambiguous. Outcome measures included the range and frequency of standardised and ambiguous abbreviations, and the feasibility of electronic auto‐expansion software based on these measures. Results Of the 1 551 537 words analysed from 2336 documents, 137 997 (8.9%) were abbreviations with 1741 distinct abbreviations identified. Most abbreviations (88.7%) had a single expansion. The most common abbreviation was PO (per os/orally), followed by BD (bis in die/twice daily) and 68.1% of abbreviations were standardised, largely pertaining to pathology/chemicals. This meant, however, that a large proportion (31.9%) of abbreviations (2.8% of all words) were ambiguous. The most common ambiguous abbreviation was Pt (patient/physiotherapy), followed by LFT (liver function test/lung function test). Conclusions Close to one‐third of abbreviations used in general medical discharge summaries were ambiguous. Electronic auto‐expansion of ambiguous abbreviations is likely to reduce miscommunication and improve patient safety.

Objective: This study was undertaken to identify factors that predict discordance between the screening instruments Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and Generalized Anxiety Disorder scale (GAD-7), and diagnoses made by qualified psychiatrists among patients with seizure disorders. Importantly, this is not a validation study; rather, it investigates clinicodemographic predictors of discordance between screening tests and psychiatric assessment. Methods: Adult patients admitted for inpatient video-electroencephalographic monitoring completed eight psychometric instruments, including the NDDI-E and GAD-7, and psychiatric assessment. Patients were grouped according to agreement between the screening instrument and psychiatrists' diagnoses. Screening was "discordant" if the outcome differed from the psychiatrist's diagnosis, including both false positive and false negative results. Bayesian statistical analyses were used to identify factors associated with discordance. Results: A total of 411 patients met inclusion criteria; mean age was 39.6 years, and 55.5% (n = 228) were female. Depression screening was discordant in 33% of cases (n = 136/411), driven by false positives (n = 76/136, 56%) rather than false negatives (n = 60/136, 44%). Likewise, anxiety screening was discordant in one third of cases (n = 121/411, 29%) due to false positives (n = 60/121, 50%) and false negatives (n = 61/121, 50%). Seven clinical factors were predictive of discordant screening for both depression and anxiety: greater dissociative symptoms, greater patient-reported adverse events, subjective cognitive impairment, negative affect, detachment, disinhibition, and psychoticism. When the analyses were restricted to only patients with psychogenic nonepileptic seizures (PNES) or epilepsy, the rate of discordant depression screening was higher in the PNES group (n = 29, 47%) compared to the epilepsy group (n = 70, 30%, Bayes factor for the alternative hypothesis = 4.65). | MATERIALS AND METHODS | SettingData were obtained from patients admitted to VEM units of the comprehensive epilepsy programs at the Royal Melbourne Hospital and the Alfred Hospital, in Melbourne, Australia, between April 2018 and March 2020. The diagnostic procedures have previously been described. 17 Patients admitted for VEM undergo comprehensive epileptological and psychiatric assessments. Seizure-and medication-related clinical data were extracted from medical records.Significance: Patients with seizure disorders who self-report a variety of psychiatric and other symptoms should be evaluated more thoroughly for depression and anxiety, regardless of screening test results, especially if they have PNES and not epilepsy.Clinical assessment by a qualified psychiatrist remains essential in diagnosing depressive and anxiety disorders among such patients.

BackgroundNew-onset seizures are frequently encountered in community and hospital settings. It is likely that seizures presenting in these distinct settings have different etiologies and prognoses, requiring different investigation and treatment approaches. We directly compare the presentation and management of patients with community- and hospital-onset first seizures attending the same hospital.MethodsWe reviewed the medical records of patients aged 18 years or older with discharge International Classification of Diseases, Australian Classification (ICD-10-AM) codes of G40 (epilepsy), G41 (status epilepticus), and R56.8 (unspecified convulsions), who attended a general hospital in Melbourne, Australia, from January 1, 2008, through November 30, 2016. Patients with new-onset seizures were included for analysis.ResultsA total of 367 patients were discharged with a relevant ICD-10-AM code. Among them, 151 patients met the inclusion criteria: 97 presented to the emergency department with community-onset seizure (median age 70 years), and 54 experienced seizures during hospitalization for other indications (median age 80.5 years). Provoked seizures were more common in the latter group (26.8% vs 63.0%, p < 0.001), with exposure to proconvulsant drugs a major risk factor. Despite not fulfilling the International League Against Epilepsy (ILAE) diagnostic criteria, 72.5% (58/80) who survived to discharge were prescribed antiepileptic drug (AED) therapy, whereas 19.0% (12/63) of those who met the ILAE criteria were not.ConclusionsHospitalized elderly patients are at an increased risk of provoked seizures, and caution should be exercised when prescribing potential proconvulsant medications and procedures. A more standardized approach to AED prescribing is needed. Further studies should consider morbidity, mortality, and health economic effects of first seizures and assess optimal management to improve outcomes in this cohort.

Distinguishing neurodegenerative from primary psychiatric conditions is often challenging for clinicians, particularly when assessing older people presenting with neuropsychiatric symptoms. Measurement of fluid biomarkers of neurodegeneration is an emerging approach offering improved diagnostic accuracy. This report explores the use of emerging fluid biomarkers to address diagnostic challenges, framed around a case where the diagnosis of delirium with dementia was revised based on biomarker analysis, enabling treatment of a primary mood disorder with disabling psychiatric symptoms.

IntroductionSeizures are common in hospitals, both as presentations to Emergency Departments (ED) and as hospital onset seizures (HOS), occurring in ward patients hospitalised for non-seizure reasons. Prompt identification of seizure aetiology is important, as it affects prognosis and management choices. Acute symptomatic seizures due to acute disturbance of brain function have a far lower risk of recurrence compared to unprovoked seizures. Timely investigations and specialist review assesses individual risk for seizure recurrence, which then guides therapeutic decisions including antiepileptic drug (AED) use. This study includes a larger proportion of older patients than usually reported, and as such, provides important insights into seizure aetiology and management strategies in this demographic.MethodsThis retrospective survey of medical charts reviewed patients aged 18 or over with a hospital separation coded as ICD-10 G40 (Epilepsy), G41 (Status epilepticus), or R56.9 (convulsions not otherwise specified), presenting between 1 January 2008 through 30 November 2016, to a large metropolitan private hospital. 97 episodes of ED attendance for first seizure and 54 episodes of HOS were identified.ResultsMedian age was 70 years in ED-cohort and 80.5 years in HOS-cohort. Symptomatic seizure risk factors were identified in 62.89% of ED-cohort and 83.33% of HOS-cohort, including exposure to known epileptogenic drugs in 38.89% of HOS-cohort. Antiepileptic drugs (AEDs) were prescribed on discharge to 74.23% of ED-cohort and 81.48% of HOS-cohort, but far fewer had scheduled Neurologist review (58.76% of ED- and 35.19% of HOS-cohorts).ConclusionThis study includes a larger proportion of older patients than usually reported, and as such, provides important insights into seizure aetiology and management strategies in this demographic. This includes caution when prescribing known epileptogenic drugs; mindful prescription of AED on discharge; and ensuring adequate Neurologist follow-up to monitor further seizure activity, addressing seizure risk factors, and ongoing need for AED.

IntroductionFirst seizure diagnosis may be delayed due to financial, geographical or social barriers to healthcare, or misdiagnosis with differentials including syncope or stroke. Seizures may recur until correct diagnosis and appropriate treatment is instituted; meanwhile, patients may experience increased seizure-related morbidity and mortality. We compare patient and seizure characteristics between a first-ever ‘new-onset’ seizure (NOS) cohort, and a recurrent-untreated seizure (RUS) cohort.MethodMedical charts were reviewed to extract information on patient demographics and clinical characteristics using a standardised proforma. Inclusion criteria were patients aged 18 or over who attended a tertiary-level Melbourne hospital between 1 January 2008 and 30 November 2016 with discharge codes ICD-10 G40-Epilepsy, G41-Status epilepticus, or R56.9-Unspecified convulsions.Results367 episodes were identified. 151 episodes met inclusion criteria: new-onset seizures (115) and recurrent-untreated seizures.36 216 excluded cases included pre-existing epilepsy (186), and non-seizure events.30 RUS-cohort experienced a median of two seizures prior to coming to medical attention, most commonly focal impaired awareness seizures (50.00%). Considering the index seizure, focal seizures were more common in RUS-cohort (36.11 vs 24.35%) while primary generalised seizures predominated in NOS-cohort (62.61% vs 50.00%). Compared to NOS-cohort, RUS-cohort was more likely to have unprovoked seizures (72.22% vs 55.65%), identifiable remote risk factors (41.67% vs 26.09%), younger age (69 vs 76), normal MRI and EEG, and be discharged on antiepileptic drugs (86.11% vs 73.91%). RUS-cohort was more likely to receive Neurology outpatient follow-up (72.22% vs 39.99%), and in a more timely manner compared to NOS-cohort (30.56% vs 11.31% saw a Neurologist within a month of discharge).ConclusionRecurrent-untreated seizures often have subtler semiology and are more likely to have normal MRI and EEG results than patients presenting immediately following new-onset seizures. RUS-cohort tend to receive more inpatient investigations and AED prescriptions, and are offered more timely neurology follow-up than NOS-cohort.