Non-epileptic seizures are difficult to diagnose and hard to treat. In this episode, we delve into the specifics of this disorder and discuss the obstacles to effective treatment. We are joined by the wonderful Dr. Laura Strom, an epileptologist at the University of Colorado who specializes in the treatment of patients with non-epileptic seizures. She went to medical school at Penn State University College of Medicine and completed her neurology residency and epilepsy fellowship at the University of Colorado. She is the head of the non-epileptic seizure clinic at the University of Colorado and is the primary investigator in an ongoing study for patients with non-epileptic seizures. Her clinic provides comprehensive neurologic and psychiatric treatment to patients with non-epileptic seizures and has treated more than 600 patients as of 2020.

For this episode, I was assisted by my first ever co-host, Jamie Moffa. Jamie is an MD PhD candidate at Washington University with an interest in the intersection between neurology and psychiatry.

Time stamps:

• 3:49 Why neurology
• 6:28 Why functional neurological disorders?
• 9:17 How did you learn to treat patients with non-epileptic seizures?
• 14:20 Non-medical book recommendation?
• 15:45 Patient case of non-epileptic seizures (NES)
• 18:04 What should you call this disorder?
• 19:50 What are non-epileptic seizures?
• 22:25 Clinical symptoms that help distinguish between NES and epileptic seizures
• 23:45 Functional MRI in non-epileptic seizures
• 26:30 What elements of the history suggest NES?
• 29:45 Medical co-morbidities associated with NES
• 31:30 How to discuss a diagnosis of NES
• 37:10 Common misconceptions about NES
• 39:02 Treatment for NES
• 40:45 Group therapy for NES
• 45:05 Larger applicability of group therapy model
• 48:27 How do you talk with resistant patients about psychological treatment?
• 52:40 How do you help patients who can't get access to mental health resources?
• 55:10 What is the role of neurologists in the care of NES patients?
• 58:45 Insurance coverage for patients with NES
• 1:01:40 Other obstacles to treatment for patients
• 1:06:45 Patient success story

Disclosures:

Dr. Strom report no relevant financial disclosures. Brain Boy Neurology reports no relevant financial disclosures.

Links:

Neuroimaging in non-epileptic seizures:

https://academic.oup.com/brain/advance-article/doi/10.1093/brain/awab131/6179314

Clinical calculator to determine likelihood of non-epileptic (dissociative) seizures:

https://wesleykerr.shinyapps.io/Combined/?_ga=2.119397517.543235477.1603997676-716097154.1580437477

Seizures are the bread and butter of the neurological consult service. Gaining proficiency in the workup and management of first-time seizures makes a young neurologist’s life much easier. To shed some light on this topic, I sit down with the incredible Dr. Brian Day, an Epileptologist at Washington University, to discuss the ins and outs of first-time seizure management. Dr. Day got his MD and PhD at the University of Kentucky and completed his neurology training at Washington University. He then did a fellowship in Epilepsy and currently works treating patients with seizure disorders.

Time stamps:

• 1:00: My experience with epilepsy
• 5:23: Why neurology
• 12:13: What did you study for your PhD?
• 16:43: Why epilepsy?
• 21:53: What do you like to do in your free time?
• 25:53: Patient case of new onset seizure
• 27:57: What is a seizure?
• 30:16: How can you tell if shaking is a seizure?
• 37:45: Non-epileptic events
• 41:41: Provoked vs unprovoked seizures
• 42:53: Medications that can provoke a seizure
• 47:38: Can certain longstanding medications cause seizures?
• 49:25: How to counsel seizure patients about alcohol consumption
• 51:58: Acute symptomatic vs remote seizures
• 56:08: Neuroimaging for new onset seizure
• 58:43: Screening for mesial temporal sclerosis
• 59:53: What to look for on brain MRI
• 1:00:53: What to look for on EEG
• 1:05:53: Lab workup/when to get a lumbar puncture
• 1:07:46: Can a UTI provoke a seizure?
• 1:12:08: Focal vs generalized seizures
• 1:13:44: Neurological exam for seizures
• 1:16:52: Do multiple seizures in a day change prognosis?
• 1:19:13: Role of serum lactate/prolactin
• 1:21:08: When do you start antiepileptics?
• 1:23:43: What to do with an abnormal EEG
• 1:25:05: Deep vs cortical brain MRI lesions and seizure risk
• 1:28:08: How to manage unprovoked seizure patients older than 60
• 1:30:19: Benzo bridges
• 1:32:43: Follow up for patients
• 1:33:46: Counseling patients with first time seizures
• 1:37:43: Summary

Disclosures:

Dr. Day report no relevant financial disclosures. Brain Boy Neurology reports no relevant financial disclosures.

Sleep deprivation is the norm in medical training. But does it have to be? I sit down with the Dr. Gabriela De Bruin to discuss the effects of sleep deprivation on residents and patients. We review the medical literature on the topic and discuss alternative work schedules. Dr. Gabriela De Bruin is a neurologist at Washington University who specializes in the treatment of patients with sleep disorders. She completed medical school at the Federal university of Ceara in Brazil and then came to Washington University for her neurology residency. After residency she completed a fellowship in sleep medicine.

Time stamps:

- 02:40: Dr. De Bruin background

- 10:08: Non-medical book recommendation

- 11:25: Sleep deprivation during residency

- 12:23: Acute vs chronic sleep deprivation

- 14:30: How much sleep should you get each night?

- 17:30: Adverse health effects of sleep deprivation

- 22:50: Sleep deprivation and cognition, attention, and motor skills

- 25:18: Sleep deprivation compared to alcohol intoxication

- 28:17: Personal perception of sleepiness

- 31:50: Research on the impact of sleep on patient care

- 35:48: Sleep deprivation and length of stay and patient mortality

- 39:30: Duty hours reform

- 44:36: Impact of duty hours on patient safety outcomes

- 48:48: Why didn’t duty hours reform improve patient outcomes?

- 51:38: Long shifts vs a night float system

- 57:50: Strategies to reduce and mitigate the effects of sleep deprivation

Disclosures:

Dr. De Bruin report no relevant financial disclosures. Brain Boy Neurology reports no relevant financial disclosures.

Links:

1. Dawson, Drew, and Kathryn Reid. "Fatigue, alcohol and performance impairment." Nature 388.6639 (1997): 235-235 (https://www.nature.com/articles/40775)
2. Landrigan, Christopher P., et al. "Effect of reducing interns' work hours on serious medical errors in intensive care units." New England Journal of Medicine 351.18 (2004): 1838-1848 (https://www.nejm.org/doi/full/10.1056/NEJMoa041406)
3. Lockley, Steven W., et al. "Effect of reducing interns' weekly work hours on sleep and attentional failures." New England Journal of Medicine 351.18 (2004): 1829-1837. (https://www.nejm.org/doi/full/10.1056/NEJMoa041404)
4. Desai, Sanjay V., et al. "Education outcomes in a duty-hour flexibility trial in internal medicine." New England Journal of Medicine 378.16 (2018): 1494-1508. (https://www.nejm.org/doi/full/10.1056/NEJMoa1800965)

Puzzling over your rank list? Confounded by all the choices? We’re here to help. I sit down with my co-chiefs, Matt Brier and Mysti Harrison, to discuss strategies for choosing a neurology residency. Matt and Mysti are the academic chief residents at Washington University. They planned and carried out recruitment for our neurology program this year. They share tips and insights from the recruting experience.

Time stamps:

- 03:25: The rank process at WashU

- 06:18: Mysti’s experience choosing a residency

- 10:12: Matt’s experience choosing a residency

- 13:30: Choosing a program you’ve only seen via Zoom

- 16:20: Residency structure

- 21:45: Call structure

- 25:20: Program prestige

- 27:30: Factoring in family

- 30:15: Fellowship options

- 33:40: Advice for MD/PhD students

- 38:00: Informing your top program and thank you notes

- 41:30: Setting your list

- 44:05: Advanced vs categorical spots

- 49:15: Putting your best foot forward on the interview trail

- 52:18: Writing a personal statement

Disclosures:

Dr. Brier and Dr. Harrison report no relevant financial disclosures. Brain Boy Neurology reports no relevant financial disclosures.

Links:

NRMP Program rating and interview scheduling app (https://www.nrmp.org/prism-interview-scheduling-tool/)

Multiple Sclerosis can present in a variety of different ways, often making diagnosis challengin. In this week’s episode, I interview Dr. Salim Chahin, a neurologist here at Washington University who specializes in the treatment of patients with Multiple Sclerosis (MS). We discuss how to evaluate a patient with suspected MS using a case of optic neuritis. Dr. Chahin went to medical school in Damascus University School of Medicine in Damascus, Syria. He completed a residency in Neurology at the University of Iowa Hospital and completed a fellowship in MS at the University of Pennsylvania. He is a faculty member in the MS department here at Washington University.

Time stamps:

- 01:54: Dr. Chahin’s background

- 07:11: Nonmedical book recommendation

- 10:00: Clinical case of optic neuritis

- 10:59: Questions to ask in patients with suspected MS

- 14:03: Common presenting syndromes for MS

- 17:38: Characteristics of vision loss specific to MS

- 18:47: Neurological exam in patients with suspected MS

- 22:46: Lab workup in MS patients

- 28:40: Differential diagnosis for MS

- 32:28: Lumbar puncture in MS

- 38:14: McDonald criteria for MS diagnosis

- 42:56: Counseling patients with optic neuritis on their future risk of developing MS

- 46:14: Summary and key takeaways

Disclosures:

Dr. Chahin has received consulting and/or speaking free from Biogen, Genentech, Novartis, and Sanofi Genzyme. Brain Boy Neurology reports no relevant financial disclosures.

Links:

McDonald Criteria for MS diagnosis: https://www.nationalmssociety.org/For-Professionals/Clinical-Care/Diagnosing-MS/Diagnosing-Criteria

Weakness is the one of the most common consults we get in neurology and often the most challenging. In this week’s episode, I interview Dr. Robert Bucelli, a neurologist at Washington University specializing in neuromuscular disorders, and ask him for tips for evaluating weakness. We discuss how to tailor your history and exam to a chief complaint of weakness. We talk about all the relevant questions to ask and how these questions allow you to narrow down your differential and guide further testing. We use a case of statin induced myopathy as the basis for our discussion. Dr. Bucelli got his MD and Phd from the University of Buffalo. He then completed a neurology residency at Washington University followed by a fellowship in Neuromuscular disorders and has been a faculty member here at Washington University ever since. He is the five-time recipient of the Eliasson Award for Teaching Excellence, an award given annually by neurology residents to attending physicians that demonstrate excellence in teaching.

Time stamps:

- 03:50: Dr. Bucelli’s background

- 15:20: Advice for developing as a neurology resident

- 23:20 Clinical case of statin induce myopathy

- 30:09: Proximal vs distal weakness

- 35:15: Asymmetric vs symmetric weakness

- 36:20: Neurological examination for weakness

- 45:23: Upper vs lower motor neuron signs

- 48:30: Assessing muscle tone on exam

- 50:50: Patient exam

- 53:00: Diagnostic workup of proximal weakness

- 55:30: Three types of statin induced myopathy

- 1:01:50: Diagnostic workup to differentiate between different causes of stain induced myopathy

- 1:03:20: Summary and key takeaways

Disclosures:

Dr. Bucelli is a consultant for the company NeuroQuestions LLC. Brain Boy Neurology reports no relevant financial disclosures.

Alzheimer's disease is a devasting illness with no effective treatment. But research is progressing rapidly and current clinical trials offer hope for a future disease-modifying therapy. In this week’s episode, I interview Dr. David Holtzman on the current state of Alzheimer’s research. We discuss his professional development as a physician scientist, his founding of the company C2N diagnostics, and his opinions on the current state and future of Alzheimer’s research. Dr. Holzman got his MD from Northwestern University and then completed a neurology residency and post-doctoral research at UCSF. He is the chairman of the neurology department at Washington University and is the scientific director of the Hope Center for Neurological Disorders. He is the Associate Director of the Knight ADRC and the president of the American Neurological Association.

Time stamps:

• 02:18: Introduction and professional background
• 14:53: Starting an independent research lab
• 18:08: Becoming chairman of neurology at Washington University
• 24:24: Founding C2N diagnostics
• 29:30: Alzheimer’s background and patient case
• 32:15: Patient education on Alzheimer’s disease (AD)
• 36:30: Mechanisms of disease activity in AD
• 47:12: Future disease modifying treatments for AD
• 55:20: Future biomarkers for AD
• 57:40: Emerging research areas for AD

Disclosures:

Dr. Holtzman is the scientific co-founding member of C2N diagnostics. He has performed consulting work for Eli Lilly and Denali therapeutics. Brain Boy Neurology reports no relevant financial disclosures.

In this week’s episode I interview Dr. Rachel Darken on the diagnosis and treatment of migraine. Dr. Rachel Darken is a Neurologist here at Washington University who treats patients with headache and sleep disorders. She got her MD and PhD from Cornell University. She completed a Neurology residency here at Washington University followed by a research fellowship and became a faculty member at Washington University after completion of her fellowship.

Time stamps:

• 1:18: Introduction and professional background
• 9:20: Migraine patient case
• 10:20: Approaching patients with headache
• 23:27: Screening for migraine aura
• 27:35: Neurological exam for headache
• 31:20: International classification of headache disorders (ICHD) 3 criteria
• 33:40: Lab workup and neuroimaging
• 35:30: Family history in migraine
• 37:32: Patient education
• 38:50: Approach to treatment
• 43:40: Acute treatment options
• 49:35: Nonpharmacologic treatment for migraines/ trigger identification
• 51:15: Headache diary for migraine
• 53:45: Modifying treatment to response/patient education
• 58:00: Migraine prognosis

Disclosures:

Dr. Rachel Darken reports no relevant financial disclosures. Brain Boy Neurology reports no relevant financial disclosures.