S Andrew Josephson

San Francisco VA Medical Center, San Francisco, California, United States

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Publications (112)655.86 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Many medical school metrics are used by residency programs to differentiate residency applicants. The importance of each metric in the field of neurology is unclear. This is a single-site retrospective evaluation of characteristics that predict resident quality. Several measures from all 57 adult neurology residents over 8 years were obtained including Step I scores, college and medical school rankings, in-service training examination scores, advanced degrees, and number of publications during residency. Two program directors, blinded to these data and each other's ratings, rated the quality of all residents at the end of the residency. The data were then anonymized for all analyses. There was no significant relationship between Step I scores and resident quality, though Step I scores correlated significantly with in-service training examination scores. Medical students with PhDs did not perform differently in terms of resident quality, number of publications in residency, or in-service training examination scores. Resident quality was correlated with the ranking of each applicant's undergraduate college, but not the ranking of their medical school. While Step I is used by many residency programs in ranking potential residents, it does not correlate with overall resident quality, although Step I scores may predict success on future standardized medical examinations. Students with PhDs do not differ from other residents across several metrics. Applicants from highly selective colleges, though not highly selective medical schools, had significantly higher quality ratings. Further research is needed to determine characteristics of medical students that predict performance during neurology residency. Copyright © 2015 Elsevier B.V. All rights reserved.
    Clinical neurology and neurosurgery 08/2015; 135. DOI:10.1016/j.clineuro.2015.05.007 · 1.25 Impact Factor
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    ABSTRACT: Status epilepticus is a common neurologic emergency with significant associated morbidity, mortality, and health care costs, yet limited data exist detailing trends in status epilepticus-related hospitalizations and mortality. To examine trends in status epilepticus-related hospitalizations and mortality. We performed 2 retrospective serial cross-sectional studies including 408 304 status epilepticus-related hospital visits using generalizable national data from January 1, 1999, to December 31, 2010, from the Centers for Disease Control and Prevention and the Nationwide Inpatient Sample. Centers for Disease Control and Prevention death certificate data, using International Statistical Classification of Diseases, Tenth Revision, codes, were used to determine nonstandardized and age-standardized rates of status epilepticus as the underlying cause of death in the United States. Data from the Nationwide Inpatient Sample were used to estimate population-standardized status epilepticus-related hospitalization rates using International Statistical Classification of Diseases, Ninth Revision, codes. Status epilepticus-related hospitalizations were categorized by whether status epilepticus was the principal diagnosis, whether the patient was intubated, and by primary insurance type. Temporal trends were tested using Poisson regression and summarized with quarterly incident rate ratios. In 2010, status epilepticus was the reported underlying cause of death in 613 deaths (approximately 2 per 1 000 000 persons). Age-standardized status epilepticus-related mortality per 1 000 000 persons increased by only 5.6% (incident rate ratio, 1.004; 95% CI, 1.002-1.006) from 1.79 in 1999 to 1.89 in 2010, while population-standardized hospitalizations for status epilepticus per 100 000 persons increased by 56.4% (incident rate ratio, 1.013; 95% CI, 1.012-1.013) from 8.86 in 1999 to 13.86 in 2010. The largest increase (181.6%; incident rate ratio, 1.030; 95% CI, 1.029-1.030) was seen among intubated patients with nonprincipal diagnoses of status epilepticus. Among varied insurance providers, the largest increase (81.3%) was seen in Medicare patients. A disconnect exists between the relatively stable status epilepticus-related mortality and the marked increase in status epilepticus hospitalizations, likely reflecting an increase in status epilepticus diagnoses through improved diagnostic sensitivity and changes in billing and coding. The definition and general approach to status epilepticus, including resource use, should evolve with these changing epidemiologic trends.
    04/2015; 72(6). DOI:10.1001/jamaneurol.2015.0188
  • Felicia C Chow, Brian S Schwartz, S Andrew Josephson
    Neurology 01/2015; 84(1):e1-4. DOI:10.1212/WNL.0000000000001097 · 8.30 Impact Factor
  • Sheila Chan, S Andrew Josephson, Laura Rosow, Wade S Smith
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    ABSTRACT: Patients admitted to an intensive care unit (ICU) with a primary neurologic disorder often receive multiple radiation-based diagnostic studies of the head and neck. Although radiation exposure puts them at risk of intracranial and neck tumors, the amount of radiation received is largely unknown. We sought to accurately collect cumulative radiation exposure data from radiation-based studies in a retrospective cohort of patients admitted to the neuroscience ICU (NICU) at a single institution. Radiation doses of studies were converted to estimated effective doses in mSv via literature-published formulas. To impact ordering practices, we piloted an educational initiative on patient radiation exposure to a cohort of physicians caring for patients with a diagnosis of acute subarachnoid hemorrhage. Patients were randomized to have radiation exposure data posted at the bedside for physician viewing. We identified 641 patients from July 2010 to March 2011 who had received at least 1 computed tomography-based study of the head. Patients received on average 18.4 mSv of radiation from head and neck imaging. Patients with subarachnoid hemorrhage received the highest average levels of radiation exposure (37.1 mSv). Attributable risk of carcinogenesis was estimated to be low. A pilot educational initiative did not reduce the total estimated effective dose per patient. Accurate reporting of estimated effective doses for NICU patients is feasible and can be provided to ordering physicians to assist with clinical decision making and potentially lower exposure risk. Further strategies are needed to reduce unnecessary radiation exposure at the physician ordering level.
    01/2015; 5(1):9-14. DOI:10.1177/1941874414542440
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    ABSTRACT: Dementia is an important risk factor for delirium, but the optimal strategy for incorporating cognitive impairment into delirium risk assessment at the time of hospital admission is unknown. We compared 2 informant-based screening tools for dementia and mild cognitive impairment [AD8 and D=(MC)] to the Mini Mental State Examination (MMSE) and Mini-cog in predicting hospital-acquired delirium. This prospective cohort study at an academic medical center consisted of 162 medical inpatients over age 50 years without delirium upon admission. Each participant was evaluated using the MMSE, Mini-cog, AD8, and D=(MC) upon admission and was assessed daily for delirium. An MMSE≤24 carried a 5.5 [95% confidence intervals (CI), 2.7-11.1] relative risk for delirium, whereas cognitive impairment detected by the Mini-cog, D=(MC), or AD8 carried a 2-fold risk. Adding the D=(MC) to the MMSE increased the sensitivity for predicting delirium from 52% (range, 32% to 73%) for the MMSE alone to 65% (range, 46% to 85%) if either test was positive. If both were positive, specificity was maximized at 97% (range, 94% to 100%), but sensitivity was 17% (range, 2% to 33%). The MMSE and Mini-cog identify a large proportion of patients at risk for hospital-acquired delirium, but the combination of performance-based and an informant-based screens may maximize specificity and sensitivity.
    Alzheimer Disease and Associated Disorders 10/2014; DOI:10.1097/WAD.0000000000000066 · 2.69 Impact Factor
  • Neel S. Singhal, S. Andrew Josephson
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    ABSTRACT: Delirium and neurologic impairment are extremely common in the intensive care setting, and their delayed identification are important contributors to patient morbidity. Even in comatose patients, the clinical neurologic examination remains the most accurate and effective tool in assessing nervous system function. Rapid identification of neurologic deficits with a practical and easily reproducible neurologic examination is a core skill for effectively caring for critically ill patients. The purpose of this tutorial is to discuss techniques of neurologic examination and localization with an emphasis on comatose patients. Commonly encountered cases of encephalopathy and coma along with clinical pearls are presented.
    Journal of critical care 08/2014; 29(4). DOI:10.1016/j.jcrc.2014.02.014 · 2.19 Impact Factor
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    ABSTRACT: Objective: Some have argued that physicians should not presume to make thrombolysis decisions for incapacitated patients with acute ischemic stroke because the risks and benefits of thrombolysis involve deeply personal values. We evaluated the influence of the inability to consent and of personal health-related values on older adults' emergency treatment preferences for both ischemic stroke and cardiac arrest.Methods: 2,154 U.S. adults age 50 and older read vignettes in which they had either suffered an acute ischemic stroke and could be treated with thrombolysis, or had suffered a sudden cardiac arrest and could be treated with cardiopulmonary resuscitation. Participants were then asked (1) whether they would want the intervention, or (2) whether they would want to be given the intervention even if their informed consent could not be obtained. We elicited health-related values as predictors of these judgments.Results: Older adults were as likely to want stroke thrombolysis when unable to consent (78.1%) as when asked directly (76.2%), while older adults were more likely to want CPR when unable to consent (83.6% compared to 75.9%). Greater confidence in the medical system and reliance on statistical information in decision-making were both associated with desiring thrombolysis.Interpretation: Older adults regard thrombolysis no less favorably when considering a situation in which they are unable to consent. These findings provide empirical support for recent professional society recommendations to treat ischemic stroke with thrombolysis in appropriate emergency circumstances under a presumption of consent. ANN NEUROL 2014. © 2014 American Neurological Association
    Annals of Neurology 08/2014; 76(2). DOI:10.1002/ana.24209 · 11.91 Impact Factor
  • JAMA The Journal of the American Medical Association 04/2014; 311(16):1689-91. DOI:10.1001/jama.2014.3302 · 30.39 Impact Factor
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    ABSTRACT: Object Intraoperative rerupture during open surgical clipping of cerebral aneurysms in subarachnoid hemorrhage (SAH) is a relatively frequent and potentially catastrophic occurrence. Patients who suffer rerupture have been shown to have worse outcomes at discharge compared with those who do not have rerupture. Perioperative injury likely plays a large part in the clinical worsening of these patients. However, due to the increased vessel manipulation and repeat exposure to acute hemorrhage, it is possible that secondary injury from increased incidence of vasospasm also contributes. Identifying an increased rate of vasospasm in these patients would justify early aggressive treatment with measures to prevent delayed cerebral ischemia. The authors investigated whether patients who suffer intraoperative rerupture during surgical treatment of ruptured cerebral aneurysms are at increased risk of developing vasospasm. Methods Five hundred consecutive patients treated with open surgical clipping for SAH were reviewed, and clinical and imaging data were collected. Angiographic vasospasm was defined as vessel narrowing believed to be consistent with vasospasm on angiography. Symptomatic vasospasm was defined as angiographic vasospasm in the setting of a clinical change attributable to vasospasm. Rates of angiographic and symptomatic vasospasm among patients with and without intraoperative rerupture were compared. Results There were no significant differences between the groups with and without rupture with respect to age, sex, modified Fisher grade, history of hypertension, or smoking. The group with intraoperative rupture had more patients with Hunt and Hess Grade I. Angiographic vasospasm was noted in 279 (66%) of the 425 patients without rerupture compared with 49 (65%) of the 75 patients with rerupture (p = 1.0, Fisher's exact test). Symptomatic vasospasm was noted in 154 (36%) of the 425 patients without rerupture, compared with 31 (41%) of the 75 patients with rerupture (p = 0.44, Fisher's exact test). In multivariate analysis, higher modified Fisher grade was significantly predictive of vasospasm, whereas older age and male sex were protective. Conclusions This study found no significant influence of intraoperative rerupture during open surgical clipping on the rate of angiographic or symptomatic vasospasm. Brief exposure to acute hemorrhage and vessel manipulation associated with rerupture events did not affect the rate of vasospasm. Risk of vasospasm was related to increased modified Fisher grade, and inversely related to age and male sex. These results do not justify early, targeted vasospasm therapy in patients with intraoperative rerupture.
    Journal of Neurosurgery 12/2013; 120(2). DOI:10.3171/2013.10.JNS13934 · 3.15 Impact Factor
  • Annals of Neurology 12/2013; 74(6):A5-7. DOI:10.1002/ana.24091 · 11.91 Impact Factor
  • Annals of Neurology 11/2013; 74(5):A7-9. DOI:10.1002/ana.24077 · 11.91 Impact Factor
  • Yana L Kriseman, Han Lee, Sharon Chung, S Andrew Josephson
    10/2013; 3(4):221-227. DOI:10.1177/1941874413483756
  • Stephen L Hauser, S Andrew Josephson, S Claiborne Johnston
    Annals of Neurology 10/2013; 74(4):A5-A25. DOI:10.1002/ana.24043 · 11.91 Impact Factor
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    S Andrew Josephson, S Claiborne Johnston, Stephen L Hauser
    Annals of Neurology 09/2013; 74(3):A7-A8. DOI:10.1002/ana.24023 · 11.91 Impact Factor
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    ABSTRACT: Risk factors for delirium are well-described, yet there is no widely used tool to predict the development of delirium upon admission in hospitalized medical patients. To develop and validate a tool to predict the likelihood of developing delirium during hospitalization. Prospective cohort study with derivation (May 2010-November 2010) and validation (October 2011-March 2012) cohorts. Two academic medical centers and 1 Veterans Affairs medical center. Consecutive medical inpatients (209 in the derivation and 165 in the validation cohort) over age 50 years without delirium at the time of admission. Delirium assessed daily for up to 6 days using the Confusion Assessment Method. The AWOL prediction rule was derived by assigning 1 point to each of 4 items assessed upon enrollment that were independently associated with the development of delirium (Age ≥ 80 years, failure to spell "World" backward, disOrientation to place, and higher nurse-rated iLlness severity). Higher scores were associated with higher rates of delirium in the derivation and validation cohorts (P for trend < 0.001 and 0.025, respectively). Rates of delirium according to score in the combined population were: 0(1/50, 2%), 1(5/141, 4%), 2(15/107, 14%), 3(10/50, 20%), and 4(7/11, 64%) (P for trend < 0.001). Area under the receiver operating characteristic curve for the derivation and validation cohorts was 0.81 (0.73-0.90) and 0.69 (0.54-0.83) respectively. The AWOL prediction rule characterizes medical patients' risk for delirium at the time of hospital admission and could be used for clinical stratification and in trials of delirium prevention. Journal of Hospital Medicine 2013. © 2013 Society of Hospital Medicine.
    Journal of Hospital Medicine 09/2013; 8(9). DOI:10.1002/jhm.2062 · 2.08 Impact Factor
  • S Andrew Josephson
    05/2013; 70(7):1-2. DOI:10.1001/jamaneurol.2013.2968
  • S Andrew Josephson, S Claiborne Johnston, Stephen L Hauser
    Annals of Neurology 05/2013; 73(5):A5-6. DOI:10.1002/ana.23911 · 11.91 Impact Factor
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    ABSTRACT: Key points CXCL13 and CXCL12 mediate chemotaxis of CNS lymphoma cells and CXCL13 concentration in CSF is prognosticCXCL13 plus IL-10 are highly specific for the diagnosis of CNS lymphoma.
    Blood 04/2013; DOI:10.1182/blood-2013-01-476333 · 10.43 Impact Factor
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    ABSTRACT: To determine the frequency and clinical predictors of seizures and markers of epileptiform activity in a non-critically ill general inpatient population. We performed a retrospective cohort study of patients 18 years and older who underwent inpatient electroencephalography (EEG) between January 1, 2005, and December 31, 2010, for an indication of spells or altered mental status. The EEGs and reports were reviewed for ictal activity, interictal epileptiform abnormalities, and nonepileptiform abnormalities. Demographic and clinical data were gathered from the electronic medical record to determine seizure predictors. Of 2235 patients screened, 1048 met the inclusion criteria, of which 825 (78.7%) had an abnormal EEG finding. Seizures occurred in 78 of 1048 patients (7.4%), and interictal epileptiform discharges were noted in 194 of 1048 patients (18.5%). An intracranial mass and spells as the indication for the EEG were independently associated with the group of patients experiencing seizures in a multivariate logistic regression model (adjusted for age, sex, EEG indication, intracranial mass, stroke, and history of epilepsy). Ninety-seven percent of patients (69 of 71) experienced their first seizure within 24 hours of monitoring, and the presence of seizures was associated with a lower likelihood of being discharged (odds ratio, 0.45; 95% CI, 0.27-0.76). Seizures occurred at a high frequency in hospitalized patients with spells and altered mental status. The EEG may be an underused investigative tool in the hospital with the potential to identify treatable causes of these common disorders.
    Mayo Clinic Proceedings 04/2013; 88(4):326-31. DOI:10.1016/j.mayocp.2012.12.013 · 5.81 Impact Factor
  • Stephen L Hauser, S Andrew Josephson, S Claiborne Johnston
    Annals of Neurology 03/2013; 73(3):A5-6. DOI:10.1002/ana.23886 · 11.91 Impact Factor

Publication Stats

1k Citations
655.86 Total Impact Points

Institutions

  • 2015
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2003–2015
    • University of California, San Francisco
      • Department of Neurology
      San Francisco, California, United States
  • 2008
    • Hôpital Universitaire Robert Debré
      Lutetia Parisorum, Île-de-France, France
  • 2007
    • Harvard University
      Cambridge, Massachusetts, United States