University of Virginia Health System

1. Location: University of Virginia Medical Center
2. Specialty/Subspecialty: Neurology – Epilepsy Fellowship
3. Program Director: Nathan B. Fountain, M.D.

a. Mailing Address: P.O. Box 800394, Charlottesville, VA 22908
b. Delivery Address: 2028 McKim Hall, UVa Medical Center
c. Phone: (434)924-5818
d. Fax: (434)982-1726
e. E-Mail: nbf2p@virginia.edu

4. Fellowship Coordinator Contact: Diane Payne, 434-924-5312

B. INTRODUCTION

1. History: The FE Dreifuss Comprehensive Epilepsy Program (CEP) was one of the first three comprehensive epilepsy programs funded by NIH in 1974. These programs were funded by NIH to develop specialized multidisciplinary epilepsy care, encourage clinical research, and disseminate epilepsy-related information through education at all levels, including fellowship training. They formed the basis for comprehensive epilepsy programs and epilepsy centers that are widely distributed today. Dr. Fritz E. Dreifuss, a founding father of epileptology, was the CEP director from its inception until his death in 1997. Dr. Nathan Fountain has been the director since then. The director of the CEP is also the fellowship director. The CEP has trained fellows essentially every year since its inception. The CEP has trained 50 fellows, 20 under the current director. Traditionally, 35% of fellows have gone into full-time academic positions and most have academic affiliations. Eight have become directors of epilepsy programs or EEG labs, 2 department chairman, and one dean.
2. Duration: The fellowship is designed for a two-year experience, but one-year programs are also available. The first year is formally a clinical neurophysiology fellowship, accredited by the ACGME, and contains training concentrated in EEG, but including EMG and sleep. Training in the second year is focused on clinical epilepsy, epilepsy surgery, and a hypothesis driven research project. A third year of training is possible with extramural support, concentrating more fully on research and epilepsy surgery. There is currently no mechanism for accrediting epilepsy fellowships, so the second year cannot be formally accredited. However, the American Board of Psychiatry and Neurology (ABPN), and therefore the American Board of Medical Specialties, has formally acknowledged epilepsy fellowship training at UVA as subspecialty fellowship training.
3. Prerequisite Training: First year (“clinical neurophysiology”) fellows will have completed training in an accredited neurology residency. Second year (“epilepsy”) fellows will have completed training in a accredited clinical neurophysiology “residency” (fellowship).
4. Goals and Objectives: This curriculum is designed to provide didactic teaching and appropriate supervised patient encounters for subspecialty training in the field of epilepsy. The graduate will be able to diagnose and care for patients with epilepsy, including those with complications and diagnostic uncertainties. The graduate will be able to apply outpatient and inpatient EEG evaluations (including ambulatory and video/EEG monitoring studies), neuroimaging and other tests, to the management of patients with epilepsy; and to provide or organize appropriate treatment, including medications, surgery, vagus nerve stimulation, and investigational drugs and devices.
5. Program Certifications: The fellowship follows an ACGME accredited one year ”residency” in clinical neurophysiology, during which trainees receive basic education in routine EEG, as well as EMG and sleep studies. Most fellows will have completed clinical neurophysiology training at the University of Virginia. The fellowship director and all faculty are boarded by the American Board of Psychiatry and Neurology, and most also credentialed through the ABPN “Added Qualifications in Clinical Neurophysiology Examination” and the American Board of Clinical Neurophysiology (ABCN). There are currently no separate boarding bodies for epilepsy.

C. RESOURCES

1. Teaching Staff:

a. Epileptologists: The epilepsy faculty include Drs. Nathan Fountain, Mark Quigg, Jaideep Kapur, Edward Bertram, Howard Goodkin, Robert Rust, William Taft. Dr. Nathan Fountain is the director of the Epilepsy Fellowship. He has completed clinical neurophysiology and epilepsy fellowships and is accredited by the APBN Added Qualifications Examination and the ABCN. Drs. Quigg, Kapur, Bertram and Goodkin are certified by the APBN Added Qualification and/or the ABCN. All faculty pursue research in epilepsy or related areas.
b. Inpatient nurse specialist: Jane von Gaudecker, RN is the inpatient nurse coordinator.
c. Epilepsy Neurosurgeons: Drs. Edward Laws, William Elias, and Mark Shaffrey.
d. Epilepsy clinical neurophysiologists: Donna Broshek, PhD, Carol Manning, PhD (3 post docs and fellows) and Jeff Barth, PhD (5 post docs and fellows)
e. Outpatient nurse specialists: Mallie Haynes, RN, Susan Goode, RN, Arika Roy, RN,CNP, and Ann Woods, RN.

2. Facilities

a. Outpatient clinics: The University of Virginia FE Dreifuss Comprehensive Epilepsy Program (CEP) Epilepsy Clinic is a free-standing clinic located 1 mile from the University Hospital, at the Fontaine Research Parke. The clinic provides ~5000 visits annually with ~2200 patients active in the program at any one time. Outpatient care is also provided through satellite clinics in Southwest Virginia (Abingdon,Tazewell, and Wise), with services coordinated through the master clinic at the University of Virginia in Charlottesville.
b. Epilepsy Monitoring Unit: The Epilepsy Unit on the sixth floor of the University of Virginia Hospital is a self-contained 6-bed unit hardwired for cable telemetry EEG with digital video and has ~200 admissions per year. Resources include routine use of epilepsy nurse specialists, 24-hour monitoring assistants, and ictal SPECT.
c. EEG Laboratory: The EEG Laboratory on the ground floor of the University Hospital performs >3000 studies per year, including routine EEG, 24 hour ambulatory EEG, outpatient video/EEG and evoked potentials.
d. Neuroimaging: CT and MRI imaging are provided through 3 high field magnets at the University Hospital and the Fontaine Research Park. Multi-head scanners for CT-PET and SPECT imaging are located at the University Hospital.
e. Neurosurgery: Approximately 6-10 epilepsy surgery candidates are evaluated at weekly Epilepsy Surgery Conferences, with ~20 surgeries per year. Intracranial depth, subdural strip and subdural grid electrodes are placed in ~ 12 patients per year. Extraoperative cortical mapping is performed for 6-10 patients per year. Intraoperative cortical mapping and electrocorticography are performed for awake craniotomies.
f. Epilepsy Clinical Research Program: The Epilepsy Clinical Research Program provides a specific infrastructure for coordinating and conducting clinical research studies beyond standard industry sponsored drug trials, to include hypothesis driven investigator initiated research. It is housed adjacent to the Epilepsy Clinic at the Fontaine Research Park. The Nurse Coordinator organizes and coordinates protocol flow and budget management. The Regulatory Documents Assistant insures that all protocols, consent forms, templates and other documents are submitted and current for the regulatory bodies, including the Human Investigations Committee, the General Clinical Research Center, the Institutional Biosafety Committee, the Office of Sponsored Programs, the Animal Welfare Committee, and the FDA. The Research Coordinators schedule patient visits in protocols, obtain specimens, complete case report forms, and dispense experimental drugs. We typically conduct 1-2 NIH sponsored studies, 7-10 industry sponsored studies, and 3-4 non-industry sponsored studies, including one under an investigator-initiated IND.
g. Epilepsy Clinical Database: Patients seen in the Epilepsy Clinic have standardized detailed data collected into the Epilepsy Clinical Database as part of standard care, including current and past medication use and reasons for discontinuation. Information on seizure and epilepsy syndrome and EEG and neuroimaging are also collected. Data is reviewed, cleaned and entered by a full-time database manager to insure accuracy and precision. The database currently contains >2000 patients.
h. Office Facilities: Each fellow is given a 100 sq. foot locked office located in the EEG Laboratory with a designated desk, bookshelves, Windows computer with high-speed internet access, and printer. Additional software includes Outlook e-mail, Excel, Access, and statistical analysis software (S-PLUS, SigmaStat). Fellows also have access to all University Library electronic databases, such as MedLine, PubMed, OMIM, etc.
i. Conference Facilities: EEG Conference is held weekly on Tuesdays and Epilepsy Fellows’ Conference is held weekly on Wednesdays in the EEG conference room. Display devices (slide, overhead, opaque projectors), whiteboards, and a computer projector linked to an EEG workstation are available for group presentations. Epilepsy Surgery Conference is held each Thursday and rotates weekly between case conference, neuropathology, and two epilepsy surgery case conferences each month.
j. Library and Reference Access: Fellows have full privileges at the Health Sciences Library. Other libraries include the Neurology Faculty library containing a broad range of neurology and neuroscience texts and journals and the EEG library containing EEG-related references. A partial listing includes multiple copies of Aminoff’s, Daly and Pedley’s, Neidemeyer’s, and Spelmann’s general EEG texts, several neonatal and pediatric atlases, sleep-scoring atlases, general EEG atlases including an original Gibbs and Gibb’s, and Chiappa’s and Haliday’s textbooks on evoked potentials. We also maintain active subscriptions to several neurophysiology journals and maintain an active reference / journal article library.

D. EDUCATIONAL PROGRAM – BASIC CURRICULUM

1. Content of subjects to be learned
A mixed experience with both children and adults is pursued. 40% of all Epilepsy Clinic visits and admissions to the Epilepsy Unit are children.

a.   Clinical epileptology
Epidemiology of epilepsy
Genetics of epilepsy
Classification of seizures and of the epilepsies
Semiology of seizures
Characteristics of onset in different cortical areas
Diagnostic principles
Treatment of new onset epilepsy
Convulsive and non-convulsive status epilepticus
Identification and treatment
General anesthesia, airway protection, cardiovascular stabilization
Refractory epilepsy
Surgery
Activation and regulation of vagus nerve stimulation Ketogenic diet
Experimental drugs
Seizures in special situations
Symptomatic seizures, febrile seizures, first seizures Neonatal seizures, pregnancy, the elderly
AED withdrawal in chronic epilepsy
b.   Antiepileptic drugs 
Principles of pharmacokinetics and pharmacodynamics: Among AEDs and with other drugs
Differential efficacy of each AED
For each seizure type and epilepsy syndrome
Side effect profiles
End organ toxicities
Dose dependent and idiosyncratic reactions
Lab monitoring of AEDs – drug levels and other surveillance tests
Risk/benefit profile for each drug
AEDs in women and in pregnancy
Pharmacoeconomics
c.   Science of epilepsy
Neuropathology of epilepsy
Neurophysiology of seizures and epilepsy
Epileptogenesis
AEDs:
Mechanisms of action
Experimental animal methods for evaluating potential AEDs
Principles of clinical trial design
Scientific validity
Regulatory requirements governing clinical trials
d.   EEG Training
Significant exposure to all facets of EEG
Concentrating on epilepsy-related issues
EEG reports
Evaluate, interpret and generate EEG reports
Routine and ambulatory EEG interpretation
Identification of artifacts simulating interictal/ictal patterns Designating and placing additional electrodes
10% electrode placement system, T1/T2, nasopharyngeal
Inserting sphenoidal electrodes
Electrodes for recording eye movements
Surface EMG/movement electrodes
Interictal and ictal epileptiform abnormalities
Normal or variant EEG patterns
Activating procedures
HV, photic stimulation
Sleep deprivation, sleep
e.   Surgical evaluation and treatment:
Evaluation methodology
Temporal and extra-temporal epilepsy
Infantile spasms
Hemispheric disorders
Symptomatic generalized epilepsy
Acquired epileptic aphasia
Adequacy of medication trials
Relative risks of surgery and refractory epilepsy
Using video/EEG monitoring
Intracranial electrode monitoring
Depth electrodes, subdural strips and grids
Neuroimaging techniques
MRI, functional MRI, MR spectroscopy
Positron emission tomography (PET)
Single photon emission computed tomography (SPECT)
Interictal and ictal
Using Wada and neuropsychological testing
Planning preoperative and post-operative management
Anterior temporal lobectomy
Lesionectomy, extratemporal resection
Multilobar resection, hemispherectomy
Repeat resection
Multiple subpial transection, corpus callosotomy
Vagus nerve stimulation
Following up surgically treated patients
Outcome assessment
Treatment of recurrent seizures
Stopping AEDs

2. Methods of Training –
A graduated increase in responsibility occurs using:

a. Bedside inpatient teaching
b. Outpatient clinic supervision
c. Attendance and presentation at conferences:
Tuesday EEG Conference, Wednesday Fellows Conference, Thursday Epilepsy Surgery Conferences
d. Independent interpretation of EEGs from clinic patients and those in the monitoring unit followed by a review with an electroencephalographer/epileptologist
e. Presenting clinical, EEG and video data at periodic multidisciplinary conferences, for surgical and out-patients
f. Preparing and giving lectures on epilepsy, especially for residents
g. Essential readings lists

3. Progression in responsibilities by PGY level

a. Year 1 – The first year of training concentrates on acquiring a knowledge base and experience in clinical neurophysiology, with emphasis on EEG, but including evoked potentials, EMG and sleep. The primary emphasis is on neurophysiological tests and performing Wada tests (intracarotid amobarbital tests), although fellows have clinic twice per week and rotate through the Epilepsy Unit where there is initial exposure to video-EEG interpretation of seizures. Fellows will supervise the neurology residents rotating through the EEG Lab and Epilepsy Unit. Neurology residents assigned to the Epilepsy Unit are the primary care providers to inpatients.
b. Year 2 – The second year expands on the knowledge base of the first year but provides didactic teaching and clinical experience in the selection and care of epilepsy patients, especially epilepsy surgery. This requires close coordination with the neurosurgeons. New and expanded methods learned include cortical mapping, intracranial evoked potentials, and lesion definition to construct surgical maps to plan resections. Increased responsibility will be in the form of providing detailed information about epilepsy surgery patients, such as cortical maps, to the neurosurgeons. The second year will have a mentored individual hypothesis driven research project.