Marc R. Nuwer’s research while affiliated with Harbor-UCLA Medical Center and other places

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Publications (242)


American Clinical Neurophysiology Society Technical Standards for Electrical Stimulation With Intracranial Electrodes for Functional Brain Mapping and Seizure Induction
  • Article

February 2025

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53 Reads

Journal of Clinical Neurophysiology

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Fiona M Baumer

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Purpose These American Clinical Neurophysiology Society technical standards suggest best practices for electrical stimulation mapping (ESM) with subdural and stereotactic depth electrodes for seizure induction and mapping of brain function. Methods A working group was convened from American Clinical Neurophysiology Society membership with expertise in ESM. PubMed searches were performed to identify pertinent peer-reviewed literature. Recurrent meetings reviewed progress, built consensus by discussion, and developed evidence-based recommendations to the extent possible. Recommendations Stimulators used for ESM should have sufficient dynamic range, ability to interrupt a stimulus train, and ictal disrupt mechanism(s). Charge density should be calculated for the specific electrodes and ESM settings, the maximum safe limits being 52 to 57 μC/cm ² /phase for subdural electrodes and not established for stereotactic depth electrodes. Subdural ESM for functional mapping is typically performed at 50-Hz pulse frequency, 200- to 300-µs pulse width, 2- to 8-s train duration, and 1- to 20-mA current strength. Stereo ESM is commonly performed using 2 different pulse frequencies: 1 Hz (300–500 µs pulse width, train duration up to 30 s, and often a constant current of 3–5 mA), and 50 Hz (100–500 µs pulse width, train duration 2-8 s, and 0.5–10 mA current intensity). Conclusions This guideline provides technical standards for the performance of ESM, which will likely evolve over time with advances in technology and additional evidence (also see Graphical Abstract).


Figure Cost per EEG vs Annual EEG Demand
Model Parameters
Base Case Results for Annual Demand of 425 After-Hour Inpatient EEGs
The Cost of After-Hour Electroencephalography
  • Article
  • Full-text available

April 2024

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73 Reads

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2 Citations

Neurology: Clinical Practice

Background and Objectives High costs associated with after-hour electroencephalography (EEG) constitute a barrier for financially constrained hospitals to provide this neurodiagnostic procedure outside regular working hours. Our study aims to deepen our understanding of the cost elements involved in delivering EEG services during after-hours. Methods We accessed publicly available data sets and created a cost model depending on 3 most commonly seen staffing scenarios: (1) technologist on-site, (2) technologist on-call from home, and (3) a hybrid of the two. Results Cost of EEG depends on the volume of testing and the staffing plan. Within the various cost elements, labor cost of EEG technologists is the predominant expenditure, which varies across geographic regions and urban areas. Discussion We provide a model to explain why access to EEGs during after-hours has a substantial expense. This model provides a cost calculator tool (made available as part of this publication in eAppendix 1, links.lww.com/CPJ/A513) to estimate the cost of EEG platform based on site-specific staffing scenarios and annual volume.

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Response to Letters to the Editor by Gregory J, Rice K, McCarthy K, et al. 2023 Regarding: "Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society"

February 2024

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17 Reads

Journal of Clinical Neurophysiology



Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET The Neurodiagnostic Society

June 2023

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23 Reads

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2 Citations

Muscle & Nerve

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time.


Ventral and dorsal cervical spinal cord electrical epidural stimulation facilitated respiration differently in the presence of opioids in human via different neural circuits

May 2023

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35 Reads

Physiology

Opioid overdose is one of the leading causes of overdose related deaths in the United States of America, accounting for 70.6% of overdose fatalities in 2019 alone. A leading cause of death among opioid overdoses is respiratory depression. Epidural electrical stimulation (EES) emerges as a novel approach of facilitating rhythmic motor activities such as locomotion and respiration. Previous studies conducted in humans and rodent models demonstrated respiratory augmentations induced by EES delivered to the dorsal cervical spinal cord. Importantly, EES at the dorsal cervical spinal cord opposes opioid-induced respiratory depression in human. To reveal the mechanism underpins how cervical EES modulate the respiratory neural circuit, we conducted this comparative study between dorsal cervical EES to the ventral EES in patients with opioid-induced respiratory suppression or depression. We hypothesize that the ventral cervical EES activates the local motor neuronal pools while the dorsal EES recruits both sensory and motor cervical circuits as well as accesses supraspinal structures such as medulla. We recruited and consented 25 patients who underwent anterior (ventral) cervical spinal cord surgery and compared the effect of ventral cervical EES to to the effect of dorsal cervical ESS in a dataset that we collected from 18 patients undergoing cervical spinal surgery. In the 25 patients, the EES was deliver to the ventral surface of spinal cord ranging from cervical level 3 to 7 (C3 to C7) for no more than 90 seconds at the optimal intensity ranging from 0.5 mA to 5 mA with stimulation frequencies 5 Hz or 30 Hz. In both the dorsal and ventral EES groups, the subjects were anesthetized with low dose or high dose remifentanil that partially or completely depressed voluntary respiration. We observed three main differences between the dorsal and ventral cervical EEST in regulating respiration in the presence of remifentanil. First, dorsal cervical EES induced the resetting of inspiratory rhythm while ventral cervical EES did not. Second, dorsal but not ventral cervical EES induced longer lasting respiratory modulation after the stimulation stopped. Third, dorsal cervical EES induced both frequency and amplitude changes of respiration while ventral cervical EES modulated the amplitude of the respiration more significantly. These observations suggest that the dorsal and ventral cervical EES facilitate respiration via different neural circuits. This work was supported by the National Institute of Drug Abuse in the National Institutes of Health: R01 DA047637, Louis and Harold Price Foundation, H & H Evergreen Foundation, and J. Yang Family Foundation. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.



Abbreviations and Corresponding Definitions
Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society

March 2023

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136 Reads

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5 Citations

Journal of Clinical Neurophysiology

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET-The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These societies recognize that neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in neurodiagnostics. It represents recommendations of these societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. Because neurodiagnostics is a growing and dynamic field, the authors fully intend this document to change over time.


Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET - The Neurodiagnostic Society

March 2023

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12 Reads

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6 Citations

The Neurodiagnostic Journal

The Guidelines for Qualifications of Neurodiagnostic Personnel (QNP) document has been created through the collaboration of the American Clinical Neurophysiology Society (ACNS), the American Society of Neurophysiological Monitoring (ASNM), the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), and ASET - The Neurodiagnostic Society (ASET). The quality of patient care is optimized when neurophysiological procedures are performed and interpreted by appropriately trained and qualified practitioners at every level. These Societies recognize that Neurodiagnostics is a large field with practitioners who have entered the field through a variety of training paths. This document suggests job titles, associated job responsibilities, and the recommended levels of education, certification, experience, and ongoing education appropriate for each job. This is important because of the growth and development of standardized training programs, board certifications, and continuing education in recent years. This document matches training, education, and credentials to the various tasks required for performing and interpreting Neurodiagnostic procedures. This document does not intend to restrict the practice of those already working in Neurodiagnostics. It represents recommendations of these Societies with the understanding that federal, state, and local regulations, as well as individual hospital bylaws, supersede these recommendations. As Neurodiagnostics is a growing and dynamic field, we fully intend this document to change over time.


Monitoring scoliosis and other spinal deformity surgeries

June 2022

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13 Reads

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5 Citations

Handbook of Clinical Neurology

Surgery to correct a spinal deformity incurs a risk of injury to the spinal cord and roots. Injuries include postoperative paraplegia. Surgery for cervical myelopathy also incurs risk for postoperative motor deficits, as well as nerve injury most commonly at the C5 root. Risks can be mitigated by monitoring the nervous system during surgery. Ideally, monitoring detects an impending injury in time to intervene and correct the impairment before it becomes permanent. Monitoring includes several modalities of testing. Somatosensory evoked potentials measure axonal conduction in the spinal cord posterior columns. This can be checked almost continuously during surgery. Motor evoked potentials measure conduction along the lateral corticospinal tracts. Because motor pathway stimulation often produces a patient movement on the table, these often are tested periodically rather than continuously. Electromyography observes for spontaneous discharges accompanying injuries, and is useful to assess misplacement of pedicle screws. Literature demonstrates the usefulness of these techniques, their association with reducing motor adverse outcomes, and the relative value of the techniques. Neurophysiologic monitoring for scoliosis, kyphosis, and cervical myelopathy surgery are addressed, along with background information about those conditions.


Citations (59)


... Furthermore, regulatory bodies should establish mechanisms for reporting and addressing adverse events related to remote EEG devices, ensuring that patient safety is prioritized. 21 ...

Reference:

Advancements in remote EEG monitoring: Technology, applications, and future directions
Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET The Neurodiagnostic Society
  • Citing Article
  • June 2023

Muscle & Nerve

... Guidelines for qualifications of neurodiagnostic technologists exist in various countries. 92,93 Experience can vary, and responsibilities should be tailored accordingly regarding the performance of EEGs, reactivity assessments and maintaining technical quality of continuous EEG recordings. ...

Guidelines for Qualifications of Neurodiagnostic Personnel: A Joint Position Statement of the American Clinical Neurophysiology Society, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Society of Neurophysiological Monitoring, and ASET-The Neurodiagnostic Society

Journal of Clinical Neurophysiology

... Yet, the EZ is a theoretical concept since its elucidation before resection is uncertain 3 . Even after a successful resection, the EZ cannot be precisely defined since the resected area can also be larger than its actual extent 4 . Therefore, there is currently no method of delineating the EZ directly; instead, this area is defined indirectly through several diagnostic tests whose results are often inconclusive or nonconcordant 5 . ...

Neurophysiology during epilepsy surgery
  • Citing Article
  • June 2022

Handbook of Clinical Neurology

... Adolescent Idiopathic Scoliosis (AIS) is characterized by a lateral curvature of the spine, typically measured using Cobb's angle, of at least 10 degrees, and a rotation of vertebral bodies. 1,2 This condition is prevalent among adolescents in the early stages of puberty, impacting approximately 1-4% of this population, with a higher occurrence in young women. 3,4 The etiology of scoliosis remains partially unknown, with various factors contributing to its development. ...

Monitoring scoliosis and other spinal deformity surgeries
  • Citing Article
  • June 2022

Handbook of Clinical Neurology

... Enhanced feature engineering and spatial filtering have been shown to increase the signal-to-noise ratio of EEG and ML performance (Blankertz et al., 2008;Rashid et al., 2020;Rivet et al., 2009;Singh & Krishnan, 2023). Moreover, alternative neuroimaging methods, which demonstrate improved signal quality, such as magnetoencephalography or electrocorticography, may enable improved classification results (Hill et al., 2012;Ploner & May, 2018;Schalk & Leuthardt, 2011;Simon et al., 2022;Singh, 2014). Whilst these approaches also suffer from limitations (e.g., increased expense and reduced practicality of magnetoencephalography) (Ploner & May, 2018;Singh, 2014), the potential for improved model performance necessitates exploration. ...

Electroencephalography, electrocorticography, and cortical stimulation techniques
  • Citing Chapter
  • January 2022

Handbook of Clinical Neurology

... To carry out this mapping, specifically trained personnel like neurophysiologists or technicians are essential. They are responsible for the preoperative setup, operation of devices, and crucially, the real-time evaluation of data during surgery [30]. However, it is worth noting that these resources may not always be readily available, especially during night-time procedures or in regions with limited medical infrastructure. ...

Overview of intraoperative neuromonitoring
  • Citing Chapter
  • January 2022

Handbook of Clinical Neurology

... Moreover, long-term mechanical ventilation elevates the risk of pneumonia (Garcia-Leoni et al., 2010). Although pre-clinical studies have shown potential to improve breathing via electrical stimulation of cervical and/or thoracic regions (Dimarco and Kowalski, 2013;Huang et al., 2016;Huang et al., 2022;Kowalski et al., 2019;Malone et al., 2022;Mercier et al., 2017), translation of these findings to humans with spinal cord injury has thus far been limited (DiMarco et al., 2006(DiMarco et al., , 2009Kandhari et al., 2022;Malone et al., 2021). Thus, new therapies that have the capacity to restore brainstem control of respiration to people with cervical spinal cord injury are needed. ...

Epidural electrical stimulation of the cervical spinal cord opposes opioid‐induced respiratory depression

... 2,3,6,7 Referral completion rates and visit durations are key for increasing patient satisfaction, decreasing repeat admissions to the emergency department, and improving access to subspecialty care. 1,5,8 This issue is especially pertinent in pediatric populations, where delays in care or mismanagement of ocular conditions can have long-term implications due to early childhood ocular development. 9 Patient demographic variables are another key factor for understanding referral completion rates and ED/Urgent Care visit durations. ...

Fast Neuro: A Care Model to Expedite Access to Neurology Clinic
  • Citing Article
  • January 2022

Neurology: Clinical Practice

... Additionally, current QEEG guidelines for clinical practice underscore the lack of predictive metrics, emphasizing that its explanatory value often surpasses its predictive capabilities [18]. This highlights the need for further validation and standardization, although emerging trends in multivariable and machine learning applications show promise [19,20]. ...

Practice Guideline: Use of Quantitative Electroencephalography for the Diagnosis of Mild Traumatic Brain Injury Report of the Guideline Committee of the American Clinical Neurophysiology Society
  • Citing Article
  • April 2021

Journal of Clinical Neurophysiology

... A recent survey of 93 CNP program directors revealed that 86% were in favor of a universal timeline and 71% were in favor of a formal match process. 4 We observed similar support for a universal timeline for all neurology fellowships among both applicants (89%) and program directors (88%). Thirty-nine percent of CNP fellowship directors favored an independent match, whereas 61% favored aligning efforts with affiliate societies. ...

Clinical Neurophysiology Fellowship Program Directors Survey on a Standardized Fellowship Match Process: A Call for Action
  • Citing Article
  • April 2021

Journal of Clinical Neurophysiology