34 results on '"Barry M. Czeisler"'
Search Results
2. Life stressors significantly impact long-term outcomes and post-acute symptoms 12-months after COVID-19 hospitalization
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Jennifer A. Frontera, Sakinah Sabadia, Dixon Yang, Adam de Havenon, Shadi Yaghi, Ariane Lewis, Aaron S. Lord, Kara Melmed, Sujata Thawani, Laura J. Balcer, Thomas Wisniewski, Steven L. Galetta, Shashank Agarwal, Andres Andino, Vito Arena, Samuel Baskharoun, Kristie Bauman, Lena Bell, Stephen Berger, Dhristie Bhagat, Matthew Bokhari, Steven Bondi, Melanie Canizares, Alexander Chervinsky, Barry M. Czeisler, Levi Dygert, Taolin Fang, Brent Flusty, Daniel Friedman, David Friedman, Benjamin Fuchs, Andre Granger, Daniel Gratch, Lindsey Gurin, Josef Gutman, Lisena Hasanaj, Manisha Holmes, Jennifer Horng, Joshua Huang, Haruki Ishii, Ruben Jauregui, Yuan Ji, D. Ethan Kahn, Ethan Koch, Penina Krieger, Alexandra Kvernland, Rebecca Lalchan, Kaitlyn Lillemoe, Jessica Lin, Susan B. Liu, Maya Madhavan, Chaitanya Medicherla, Patricio Millar-Vernetti, Nicole Morgan, Anlys Olivera, Mirza Omari, George Park, Palak Patel, Milan Ristic, Jonathan Rosenthal, Michael Sonson, Thomas Snyder, Rebecca S. Stainman, Brian Sunwoo, Daniel Talmasov, Michael Tamimi, Betsy Thomas, Eduard Valdes, Ting Zhou, and Yingrong Zhu
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Hospitalization ,Neurology ,Activities of Daily Living ,Quality of Life ,Humans ,COVID-19 ,Female ,Neurology (clinical) ,Prospective Studies ,Longitudinal Studies ,Fatigue - Abstract
Limited data exists evaluating predictors of long-term outcomes after hospitalization for COVID-19.We conducted a prospective, longitudinal cohort study of patients hospitalized for COVID-19. The following outcomes were collected at 6 and 12-months post-diagnosis: disability using the modified Rankin Scale (mRS), activities of daily living assessed with the Barthel Index, cognition assessed with the telephone Montreal Cognitive Assessment (t-MoCA), Neuro-QoL batteries for anxiety, depression, fatigue and sleep, and post-acute symptoms of COVID-19. Predictors of these outcomes, including demographics, pre-COVID-19 comorbidities, index COVID-19 hospitalization metrics, and life stressors, were evaluated using multivariable logistic regression.Of 790 COVID-19 patients who survived hospitalization, 451(57%) completed 6-month (N = 383) and/or 12-month (N = 242) follow-up, and 77/451 (17%) died between discharge and 12-month follow-up. Significant life stressors were reported in 121/239 (51%) at 12-months. In multivariable analyses, life stressors including financial insecurity, food insecurity, death of a close contact and new disability were the strongest independent predictors of worse mRS, Barthel Index, depression, fatigue, and sleep scores, and prolonged symptoms, with adjusted odds ratios ranging from 2.5 to 20.8. Other predictors of poor outcome included older age (associated with worse mRS, Barthel, t-MoCA, depression scores), baseline disability (associated with worse mRS, fatigue, Barthel scores), female sex (associated with worse Barthel, anxiety scores) and index COVID-19 severity (associated with worse Barthel index, prolonged symptoms).Life stressors contribute substantially to worse functional, cognitive and neuropsychiatric outcomes 12-months after COVID-19 hospitalization. Other predictors of poor outcome include older age, female sex, baseline disability and severity of index COVID-19.
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- 2022
3. Toxic Metabolic Encephalopathy in Hospitalized Patients with COVID-19
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Barry M. Czeisler, Shadi Yaghi, Steven L. Galetta, Kara Melmed, Ting Zhou, Ariane Lewis, Aaron Lord, Sharon B. Meropol, D. Ethan Kahn, Laura J. Balcer, Andrea B. Troxel, Taolin Fang, Joshua Huang, Thomas Wisniewski, Sebastian Kurz, Jessica Lin, Adam de Havenon, Andre Granger, and Jennifer A. Frontera
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medicine.medical_specialty ,Sedation ,Encephalopathy ,Critical Care and Intensive Care Medicine ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,law ,Internal medicine ,medicine ,Humans ,Hospital Mortality ,Confusion ,Retrospective Studies ,Brain Diseases ,Brain Diseases, Metabolic ,SARS-CoV-2 ,Proportional hazards model ,business.industry ,Mortality rate ,Hazard ratio ,COVID-19 ,Delirium ,030208 emergency & critical care medicine ,Mental status ,medicine.disease ,Intensive care unit ,Hospitalization ,Etiology ,sense organs ,Neurology (clinical) ,medicine.symptom ,business ,Original Work ,030217 neurology & neurosurgery ,Cohort study - Abstract
Background Toxic metabolic encephalopathy (TME) has been reported in 7–31% of hospitalized patients with coronavirus disease 2019 (COVID-19); however, some reports include sedation-related delirium and few data exist on the etiology of TME. We aimed to identify the prevalence, etiologies, and mortality rates associated with TME in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients. Methods We conducted a retrospective, multicenter, observational cohort study among patients with reverse transcriptase–polymerase chain reaction-confirmed SARS-CoV-2 infection hospitalized at four New York City hospitals in the same health network between March 1, 2020, and May 20, 2020. TME was diagnosed in patients with altered mental status off sedation or after an adequate sedation washout. Patients with structural brain disease, seizures, or primary neurological diagnoses were excluded. The coprimary outcomes were the prevalence of TME stratified by etiology and in-hospital mortality (excluding comfort care only patients) assessed by using a multivariable time-dependent Cox proportional hazards models with adjustment for age, race, sex, intubation, intensive care unit requirement, Sequential Organ Failure Assessment scores, hospital location, and date of admission. Results Among 4491 patients with COVID-19, 559 (12%) were diagnosed with TME, of whom 435 of 559 (78%) developed encephalopathy immediately prior to hospital admission. The most common etiologies were septic encephalopathy (n = 247 of 559 [62%]), hypoxic-ischemic encephalopathy (HIE) (n = 331 of 559 [59%]), and uremia (n = 156 of 559 [28%]). Multiple etiologies were present in 435 (78%) patients. Compared with those without TME (n = 3932), patients with TME were older (76 vs. 62 years), had dementia (27% vs. 3%) or psychiatric history (20% vs. 10%), were more often intubated (37% vs. 20%), had a longer hospital length of stay (7.9 vs. 6.0 days), and were less often discharged home (25% vs. 66% [all P
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- 2021
4. Abstract TP99: Hemorrhagic Conversion Of Ischemic Stroke Is Associated With Hematoma Expansion
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Natalie Palaychuk, Abhinav Changa, Siddhant Dogra, Jason Wei, Ariane Lewis, Aaron Lord, Koto Ishida, Cen Zhang, Barry M Czeisler, Jose L Torres, Jennifer Frontera, Seena Dehkharghani, and Kara R Melmed
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Advanced and Specialized Nursing ,cardiovascular diseases ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine - Abstract
Objectives: Hemorrhagic conversion of ischemic stroke (HCIS) is a common complication of cerebral ischemia and is associated with worse stroke outcomes. Differentiation between HCIS and other causes of intracerebral hemorrhage (ICH) can be challenging in practice. We sought to determine whether imaging features of hematoma expansion (HE) can be used to discriminate HCIS from other etiologies of ICH. Materials and Methods: We performed a retrospective review of patients admitted to two large urban hospitals between 2015-2020 with non-traumatic ICH and at least two head CTs within the initial 24 hours and brain MRI prior to discharge to assist with etiology identification. ICH etiology was determined by expert consensus. HE was defined as ≥6 mL and/or ≥33% growth between the first and second scan. Clinical and imaging covariates were studied using univariable and multivariable regression to assess the relationship between cause of intracerebral hemorrhage and HE. We evaluated whether HE was associated with functional status on discharge. Results: 258 patients (median age 66 [51-76], 43% female) met our inclusion criteria including 37 (14%) with HCIS as the presumed cause of hemorrhage. Etiology for ICH was hypertensive in 29%, vascular in 27%, and cerebral amyloid angiopathy in 13%. HE occurred in 11/37 (30%) patients with HCIS, and in 33/221(15%) patients with other causes (p= 0.04). History of anticoagulation use was more frequent in patients with HCIS (24% vs 11%, p= 0.04), although there was no significant difference in admission INR or platelet count. There was no difference in age, admission systolic blood pressure, admission hematoma size or ICH score between groups. HCIS was significantly associated with HE (OR 2.4, CI 1.08-5.34, p=0.03) on univariable analysis. When controlling for hematoma size and anticoagulant use, the relationship between HCIS and HE remained significant (aOR 2.68, CI 1.17-6.13, p=0.02). Patients with HCIS had a higher modified Rankin scale on discharge when compared to those with ICH due to other causes ((mRS 5 [4-5.5] vs. mRS 4 [2-4], p Conclusion: HE within the first 24 hours is more common in HCIS than in other etiologies of ICH. Imaging signatures of HE may be contributory towards determining ICH etiology.
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- 2022
5. A Prospective Study of Neurologic Disorders in Hospitalized Patients With COVID-19 in New York City
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Brent Flusty, Mirza Omari, Erica Scher, Palak Patel, Koto Ishida, Courtney L. Robertson, Nicole Morgan, D. Ethan Kahn, Sujata Thawani, Mengling Liu, Patricio Millar-Vernetti, Jennifer A. Frontera, Ting Zhou, Molly McNett, Manisha Holmes, Dixon Yang, Taolin Fang, Adam de Havenon, Penina Krieger, Nada Abou-Fayssal, David Friedman, Jose Torres, Raimund Helbok, Matthew Bokhari, Kara Melmed, Sakinah Sabadia, Barry M. Czeisler, Rebecca Lalchan, David K. Menon, Dimitris G. Placantonakis, Andres Andino, Sherry H.-Y. Chou, Steven L. Galetta, Laura J. Balcer, Jose I. Suarez, Thomas Wisniewski, Andre Granger, Michelle E. Schober, Eduard Valdes, Alexandra Kvernland, Joshua Huang, Jonathan Howard, Wendy C. Ziai, Ericka L. Fink, Aaron Lord, Kaitlyn Lillemoe, Stephen Berger, Shraddha Mainali, Josef Gutman, Andrea B. Troxel, Shashank Agarwal, Thomas Snyder, Shadi Yaghi, Daniel Friedman, and Ariane Lewis
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Adult ,Male ,Pediatrics ,medicine.medical_specialty ,Organ Dysfunction Scores ,Myelitis ,Spinal Cord Diseases ,Young Adult ,03 medical and health sciences ,Myelopathy ,Sex Factors ,0302 clinical medicine ,Intubation, Intratracheal ,medicine ,Humans ,Hospital Mortality ,Prospective Studies ,030212 general & internal medicine ,Young adult ,Prospective cohort study ,Stroke ,Aged ,Brain Diseases ,business.industry ,Hazard ratio ,Age Factors ,COVID-19 ,Middle Aged ,medicine.disease ,Patient Discharge ,Hospitalization ,Female ,Neurotoxicity Syndromes ,New York City ,Neurology (clinical) ,Nervous System Diseases ,business ,Meningitis ,030217 neurology & neurosurgery ,Encephalitis - Abstract
ObjectiveTo determine the prevalence and associated mortality of well-defined neurologic diagnoses among patients with coronavirus disease 2019 (COVID-19), we prospectively followed hospitalized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–positive patients and recorded new neurologic disorders and hospital outcomes.MethodsWe conducted a prospective, multicenter, observational study of consecutive hospitalized adults in the New York City metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between patients with COVID-19 with and without neurologic disorders.ResultsOf 4,491 patients with COVID-19 hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were reverse transcriptase PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all p < 0.05). After adjusting for age, sex, SOFA scores, intubation, history, medical complications, medications, and comfort care status, patients with COVID-19 with neurologic disorders had increased risk of in-hospital mortality (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.17–1.62, p < 0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63–0.85, p < 0.001).ConclusionsNeurologic disorders were detected in 13.5% of patients with COVID-19 and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.
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- 2020
6. How Does Preexisting Hypertension Affect Patients with Intracerebral Hemorrhage?
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Jose Torres, Jonathan Rosenthal, Jennifer A. Frontera, Ariane Lewis, Thomas Calahan, Fred Lee, David Valentine, Barry M. Czeisler, Koto Ishida, and Aaron Lord
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Male ,medicine.medical_specialty ,genetic structures ,Blood Pressure ,Affect (psychology) ,Severity of Illness Index ,Disability Evaluation ,Electrocardiography ,03 medical and health sciences ,Patient Admission ,0302 clinical medicine ,Risk Factors ,Internal medicine ,medicine ,Humans ,In patient ,Antihypertensive Agents ,Aged ,Cerebral Hemorrhage ,Ohio ,Retrospective Studies ,Intracerebral hemorrhage ,business.industry ,Rehabilitation ,Middle Aged ,Bleed ,Prognosis ,medicine.disease ,Blood pressure ,Echocardiography ,Hypertension ,Cardiology ,Female ,Hypertrophy, Left Ventricular ,New York City ,Surgery ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery - Abstract
Patients with intracerebral hemorrhage (ICH) frequently present with hypertension, but it is unclear if this is due to pre-existing hypertension (prHTN) or to the bleed itself or associated pain. We sought to assess the relationship between prHTN and admission systolic blood pressure (aBP) and bleed severity.We retrospectively assessed the relationship between prHTN and aBP and NIHSS in patients with ICH at 3 institutions.Of 251 patients, 170 (68%) had prHTN based on history of hypertension/antihypertensive use. Median aBP was significantly higher in those with prHTN (155 mm Hg (IQR 135-181) versus 139 mm Hg (IQR 124-158), P.001). Patients with left ventricular hypertrophy (LVH) on electrocardiogram (ECG) or transthoracic echocardiogram (TTE) had significantly higher aBP than those without LVH (median aBP 195 mm Hg (IQR 155-216) for patients with LVH on ECG versus 147 mm Hg (IQR 129-163) for patients with no LVH on ECG, P.001; median aBP 181 mm Hg (IQR 153-214) for patients with LVH on TTE versus 152 mm Hg (IQR 137-169) for patients with no LVH on TTE, P = .01). prHTN was associated with a higher median NIHSS (11 (IQR 3-20) for patients with history of hypertension/antihypertensive use versus 6 (IQR 1-14) for patients without this history (P = .02); 9 (IQR 3-19) versus 5 (IQR 2-13) for patients with/without LVH on ECG (P = .085); and 10 (IQR 5-18) versus 5 (IQR 1-13) for patients with/without LVH on TTE (P = .046).Patients with ICH who have prHTN have higher aBP and NIHSS, suggesting that prHTN may worsen reactive hypertension in the setting of ICH.
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- 2019
7. Abstract P100: Hemorrhagic Stroke in the Setting of COVID-19 is Associated With Anticoagulation Use
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Peter Kim Nelson, Jennifer A. Frontera, Alexandra Kvernland, Seena Dehkharghani, Barry M. Czeisler, David L. Gordon, Aaron Lord, Ariane Lewis, Kara Melmed, D. E. Kahn, Jose Torres, A. de Havenon, Nils Henninger, Ting Zhou, E. Raz, Koto Ishida, Howard A. Riina, B. Mac Grory, Arooshi Kumar, Maksim Shapiro, Omar Tanweer, Shadi Yaghi, Erez Nossek, and Rajan Jain
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Advanced and Specialized Nursing ,Intracerebral hemorrhage ,2019-20 coronavirus outbreak ,medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,business.industry ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,medicine.disease ,Emergency medicine ,medicine ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,Stroke ,Thrombotic complication - Abstract
Introduction: While the thrombotic complications of COVID-19 have been described, there are limited data on its implications in hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this group of patients are especially salient as empiric therapeutic anticoagulation becomes increasingly common in the treatment and prevention of thrombotic complications of COVID-19. Methods: We conducted a retrospective cohort study of patients with hemorrhagic stroke (both non-traumatic intracerebral hemorrhage and spontaneous non-aneurysmal subarachnoid hemorrhage) who were hospitalized between 3/1/20-5/15/20 at a NYC hospital system, during the coronavirus pandemic. We compared the demographic and clinical characteristics of patients with hemorrhagic stroke and COVID-19 to those without COVID-19 admitted to our hospital between 3/1/20-5/15/20 (contemporary controls) and 3/1/19-5/15/19 (historical controls), using Fischer’s exact test and non-parametric testing. We adjusted for multiple comparisons using the Bonferroni method. Results: During the study period, 19 out of 4071 (0.5%) patients who were hospitalized with COVID-19 had hemorrhagic stroke on imaging. Of all COVID-19 with hemorrhagic stroke, only 3 had non-aneurysmal SAH without intraparenchymal hemorrhage. Among hemorrhagic stroke and COVID-19 patients, coagulopathy was the most common etiology (73.7%); empiric anticoagulation was started in 89.5% vs 4.2% of contemporary and 10.0% of historical controls (both with p = Conclusion: We observed an overall low rate of imaging-confirmed hemorrhagic stroke among patients hospitalized with COVID-19. Most hemorrhages in COVID-19 patients occurred in the setting of therapeutic anticoagulation and were associated with increased mortality. Further studies are needed to evaluate the safety and efficacy of therapeutic anticoagulation in COVID-19 patients.
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- 2021
8. Abstract P458: Systemic Inflammatory Response Syndrome is Associated With Hematoma Expansion in Intracerebral Hemorrhage
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Cen Zhang, Elizabeth Carroll, Koto Ishida, Jose Torres, Aaron Lord, Kara Melmed, Barry M. Czeisler, and Ariane Lewis
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Advanced and Specialized Nursing ,Systemic inflammatory response syndrome ,Intracerebral hemorrhage ,medicine.medical_specialty ,Hematoma ,business.industry ,Internal medicine ,medicine ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,medicine.disease ,business ,Gastroenterology - Abstract
Objective: Systemic inflammatory response syndrome (SIRS) and hematoma expansion are both associated with worse outcomes after intracerebral hemorrhage (ICH), but their relationship remains unclear. We sought to determine the association between SIRS and hematoma expansion after ICH. Methods: We performed a retrospective cohort study of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. Patients were excluded if they had a decompressive craniectomy, intracranial vascular lesions or malignancy, or coagulopathy. Hematoma volume was measured using the ABC/2 method; hematoma expansion was defined as 6mL or 33% growth between the first and second scan. We compared patients with and without SIRS using Pearson’s χ2, students T and Wilcoxon rank sum tests. The relationship between admission SIRS and hematoma expansion was assessed using univariate and multivariate regression analysis. Results: Of 187 patients with ICH, 73 (39%; mean age 6617, 40% female) met inclusion criteria. Of those, 38 (52%) had SIRS on admission. Admission systolic blood pressure (SBP) was significantly higher in patients with SIRS compared to those without (169 [IQR 133- 205] vs 152 [125- 179] mm Hg, p= 0.02). There was no difference in mean days to first antibiotic administration (6.3 vs 5.6, p=0.78), admission platelets (227 vs 243, p= 0.38) or initial hematoma volume (23 vs 15, p=0.16). Hematoma expansion occurred in 14 patients, 11 (79%) of whom also had SIRS. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (87 vs 67%, p=0.05). SIRS was significantly associated with hematoma expansion (OR 4.35, 95% CI 1.10-17.20, p= 0.04) on univariate analysis. The association remained statistically significant after adjusting for admission SBP, platelets, and initial hematoma volume (OR 4.54, 95% CI 1.01-20.60, p= 0.05). Conclusion: Presence of SIRS on admission is associated with hematoma expansion within the first 24 hours. Further research is needed to better understand this association, which may enable us to identify early on and treat those patients at highest risk for decompensation.
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- 2021
9. Risk factors for intracerebral hemorrhage in patients with COVID-19
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Eytan Raz, Shadi Yaghi, Siddhant Dogra, Meng Cao, Kara Melmed, Jeffrey S. Berger, Ji Chen, Jennifer A. Frontera, Ruina Zhang, Aaron Lord, Ariane Lewis, Rajan Jain, Barry M. Czeisler, and Seda Bilaloglu
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Male ,medicine.medical_specialty ,Population ,Neuroimaging ,030204 cardiovascular system & hematology ,Risk Assessment ,Article ,Cohort Studies ,03 medical and health sciences ,Anticoagulation ,0302 clinical medicine ,Mechanical ventilation ,Risk Factors ,Internal medicine ,Medicine ,Humans ,030212 general & internal medicine ,cardiovascular diseases ,education ,Aged ,Cerebral Hemorrhage ,Ischemic Stroke ,Intracerebral hemorrhage ,Univariate analysis ,education.field_of_study ,business.industry ,SARS-CoV-2 ,Anticoagulants ,COVID-19 ,Retrospective cohort study ,Odds ratio ,Hematology ,medicine.disease ,Respiration, Artificial ,United States ,Respiratory failure ,Female ,Complication ,business ,Hemorrhagic stroke ,Cardiology and Cardiovascular Medicine ,Respiratory Insufficiency ,Cohort study - Abstract
Intracerebral hemorrhage (ICH) can be a devastating complication of coronavirus disease (COVID-19). We aimed to assess risk factors associated with ICH in this population. We performed a retrospective cohort study of adult patients admitted to NYU Langone Health system between March 1 and April 27 2020 with a positive nasopharyngeal swab polymerase chain reaction test result and presence of primary nontraumatic intracranial hemorrhage or hemorrhagic conversion of ischemic stroke on neuroimaging. Patients with intracranial procedures, malignancy, or vascular malformation were excluded. We used regression models to estimate odds ratios and 95% confidence intervals (OR, 95% CI) of the association between ICH and covariates. We also used regression models to determine association between ICH and mortality. Among 3824 patients admitted with COVID-19, 755 patients had neuroimaging and 416 patients were identified after exclusion criteria were applied. The mean (standard deviation) age was 69.3 (16.2), 35.8% were women, and 34.9% were on therapeutic anticoagulation. ICH occurred in 33 (7.9%) patients. Older age, non-Caucasian race, respiratory failure requiring mechanical ventilation, and therapeutic anticoagulation were associated with ICH on univariate analysis (p < 0.01 for each variable). In adjusted regression models, anticoagulation use was associated with a five-fold increased risk of ICH (OR 5.26, 95% CI 2.33–12.24, p < 0.001). ICH was associated with increased mortality (adjusted OR 2.6, 95 % CI 1.2–5.9). Anticoagulation use is associated with increased risk of ICH in patients with COVID-19. Further investigation is required to elucidate underlying mechanisms and prevention strategies in this population. Electronic supplementary material The online version of this article (10.1007/s11239-020-02288-0) contains supplementary material, which is available to authorized users.
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- 2020
10. Prevalence and Impact of Hyponatremia in Patients With Coronavirus Disease 2019 in New York City
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D. Ethan Kahn, Kara Melmed, Jennifer A. Frontera, Elizabeth Hammer, Thomas Wisniewski, Erica Scher, Shadi Yaghi, Eduard Valdes, Barry M. Czeisler, Ariane Lewis, Laura J. Balcer, Ting Zhou, Aaron Lord, and Joshua Huang
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Adult ,Male ,medicine.medical_specialty ,Adolescent ,medicine.medical_treatment ,Encephalopathy ,Online Clinical Investigation ,Kaplan-Meier Estimate ,Critical Care and Intensive Care Medicine ,Severity of Illness Index ,Body Mass Index ,coronavirus disease 2019 ,Young Adult ,Sex Factors ,Internal medicine ,Severity of illness ,medicine ,Prevalence ,pneumonia ,Humans ,Hospital Mortality ,Pandemics ,Aged ,Retrospective Studies ,Mechanical ventilation ,Aged, 80 and over ,business.industry ,Interleukin-6 ,Age Factors ,nutritional and metabolic diseases ,COVID-19 ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Respiration, Artificial ,Patient Discharge ,Pneumonia ,Logistic Models ,ComputingMethodologies_DOCUMENTANDTEXTPROCESSING ,Female ,New York City ,Hyponatremia ,business ,Body mass index ,severe acute respiratory syndrome coronavirus 2 ,Cohort study - Abstract
Supplemental Digital Content is available in the text., Objectives: Hyponatremia occurs in up to 30% of patients with pneumonia and is associated with increased morbidity and mortality. The prevalence of hyponatremia associated with coronavirus disease 2019 and the impact on outcome is unknown. We aimed to identify the prevalence, predictors, and impact on outcome of mild, moderate, and severe admission hyponatremia compared with normonatremia among coronavirus disease 2019 patients. Design: Retrospective, multicenter, observational cohort study. Setting: Four New York City hospitals that are part of the same health network. Patients: Hospitalized, laboratory-confirmed adult coronavirus disease 2019 patients admitted between March 1, 2020, and May 13, 2020. Interventions: None. Measurements and Main Results: Hyponatremia was categorized as mild (sodium: 130–134 mmol/L), moderate (sodium: 121–129 mmol/L), or severe (sodium: ≤ 120 mmol/L) versus normonatremia (135–145 mmol/L). The primary outcome was the association of increasing severity of hyponatremia and in-hospital mortality assessed using multivariable logistic regression analysis. Secondary outcomes included encephalopathy, acute renal failure, mechanical ventilation, and discharge home compared across sodium levels using Kruskal-Wallis and chi-square tests. In exploratory analysis, the association of sodium levels and interleukin-6 levels (which has been linked to nonosmotic release of vasopressin) was assessed. Among 4,645 patient encounters, hyponatremia (sodium < 135 mmol/L) occurred in 1,373 (30%) and 374 of 1,373 (27%) required invasive mechanical ventilation. Mild, moderate, and severe hyponatremia occurred in 1,032 (22%), 305 (7%), and 36 (1%) patients, respectively. Each level of worsening hyponatremia conferred 43% increased odds of in-hospital death after adjusting for age, gender, race, body mass index, past medical history, admission laboratory abnormalities, admission Sequential Organ Failure Assessment score, renal failure, encephalopathy, and mechanical ventilation (adjusted odds ratio, 1.43; 95% CI, 1.08–1.88; p = 0.012). Increasing severity of hyponatremia was associated with encephalopathy, mechanical ventilation, and decreased probability of discharge home (all p < 0.001). Higher interleukin-6 levels correlated with lower sodium levels (p = 0.017). Conclusions: Hyponatremia occurred in nearly a third of coronavirus disease 2019 patients, was an independent predictor of in-hospital mortality, and was associated with increased risk of encephalopathy and mechanical ventilation.
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- 2020
11. Intra-arterial thrombolytic therapy for acute anterior spinal artery stroke
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Maksim Shapiro, Erez Nossek, Joseph Haynes, Barry M. Czeisler, and Eytan Raz
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Male ,Cord ,medicine.medical_treatment ,Anterior spinal artery ,Ischemia ,Eptifibatide ,03 medical and health sciences ,0302 clinical medicine ,Lumbar ,Fibrinolytic Agents ,Physiology (medical) ,medicine.artery ,medicine ,Humans ,Thrombolytic Therapy ,Stroke ,business.industry ,Spinal Cord Ischemia ,General Medicine ,Thrombolysis ,Middle Aged ,medicine.disease ,Treatment Outcome ,Neurology ,Injections, Intra-Arterial ,Verapamil ,030220 oncology & carcinogenesis ,Anesthesia ,Tissue Plasminogen Activator ,Surgery ,Neurology (clinical) ,business ,Paraplegia ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Background and importance Spinal cord infarction is rare but can be extremely disabling. Prompt diagnosis and treatment of these infarcts is important for patient outcomes. While intravenous thrombolytic therapy is a well-established form of treatment in circumstances of cerebral stroke, it has only recently been successfully used in a few incidents of spinal cord ischemia. We present a case of anterior spinal artery (ASA) territory ischemia treated with ASA intra-arterial thrombolytic therapy. Clinical presentation A 52-year-old male presented with acute onset of severe lumbar pain, rapidly progressing paraplegia and loss of pain and temperature sensation, with preservation of proprioception and vibratory sensation at the L1 level and below on the right and at the L3 level and below on the left. MRI showed restricted diffusion involving the cord at and below L1 level, with normal cord T2 signal. Digital subtraction spinal angiography showed ASA cutoff in the descending limb at the level of L1. Intra-arterial tissue plasminogen activator (t-PA) combined with verapamil and eptifibatide was administered within the ASA and the patient had significant neurological improvement immediately postoperatively and at 8-month clinical follow-up. Conclusion Direct ASA intra-arterial thrombolysis is feasible, and this drug combination might be an effective therapy for spinal stroke.
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- 2020
12. Abstract WP381: Modafinil in Recovery After Stroke: A Retrospective Study
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Danielle B. Cross, Cen Zhang, Amabel Karoub, Koto Ishida, Danielle Golub, Ariane Lewis, Jose Torres, Shadi Yaghi, Jonathan Tiu, Christopher Hernandez, Chaitanya Medicherla, Aaron Lord, Barry M. Czeisler, and Christopher Wu
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Advanced and Specialized Nursing ,medicine.medical_specialty ,Rehabilitation ,business.industry ,medicine.medical_treatment ,Modafinil ,Retrospective cohort study ,medicine.disease ,Lethargy ,mental disorders ,medicine ,Physical therapy ,In patient ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,Stroke recovery ,business ,Stroke ,medicine.drug - Abstract
Background: Acute rehabilitation is known to enhance stroke recovery. However, post-stroke lethargy and fatigue can hinder participation in rehabilitation therapies. We hypothesized that in patients with moderate to severe stroke, early stimulant therapy with modafinil increases favorable discharge disposition defined as transfer to acute rehabilitation. Methods: We retrospectively reviewed a cohort of patients with acute stroke admitted over a 3 year period. Patients were excluded for low NIH Stroke Scale score (below 5) or absence of confirmed stroke on brain imaging. We compared patients that were treated with modafinil 50-200mg to those managed with standard care. The primary outcome measure was discharge disposition. Secondary outcome was modified Rankin Score after discharge. Statistical significance was determined using chi-square test for association and logistic regression models. Results: The study cohort included 199 patients (145 ischemic, 54 hemorrhagic). 72 (36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute rehab. Median NIHSS for modafinil patients vs standard care patients was higher but did not reach statistical significance (median (IQR): 13.5 (15) vs 11 (10), p=0.059). In adjusted models, modafinil was associated with higher odds of favorable discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days (mRS ≤ 2) occurred more frequently with modafinil (5.6% vs. 3.3%) but this did not achieve statistical significance (p>0.1). The benefit of modafinil was seen across all subgroups of patients, except those with severe stroke (NIHSS > 15). There were no significant complications clearly linked to modafinil administration. Conclusions: Modafinil use in acute stroke patients with moderate to severe stroke was associated with improved discharge disposition. Randomized controlled trials are needed to further study the safety, efficacy, and long-term effects of modafinil in this population.
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- 2020
13. Simulation in Neurocritical Care: Past, Present, and Future
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Aarti Sarwal, Barry M. Czeisler, and Nicholas A. Morris
- Subjects
Medical education ,Health professionals ,business.industry ,Critically ill ,Foundation (evidence) ,Neurointensive care ,030208 emergency & critical care medicine ,Critical Care and Intensive Care Medicine ,Nature versus nurture ,03 medical and health sciences ,0302 clinical medicine ,Teaching tool ,ComputingMilieux_COMPUTERSANDEDUCATION ,Medicine ,The Conceptual Framework ,Neurology (clinical) ,business ,Adult Learning ,030217 neurology & neurosurgery - Abstract
Simulation-based medical education is a technique that leverages adult learning theory to train healthcare professionals by recreating real-world scenarios in an interactive way. It allows learners to emotionally engage in the assessment and management of critically ill patients without putting patients at risk. Learners are encouraged to work at the edge of their expertise to promote growth and are provided with feedback to nurture development. Thus, the training is targeted to the learner, not the patient. Despite its origins as a teaching tool for neurological diseases, simulation-based medical education has been historically abandoned by neurocritical care educators. In contrast, other critical care educators have embraced the technique and built an impressive foundation of literature supporting its use. Slowly, neurocritical care educators have started experimenting with simulation-based medical education and sharing their results. In this review, we will investigate the historical origins of simulation in the neurosciences, the conceptual framework supporting the technique, current applications, and future directions.
- Published
- 2018
14. Highest In-Hospital Glucose Measurements are Associated With Neurological Outcomes After Intracerebral Hemorrhage
- Author
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Aaron Lord, Koto Ishida, Ariane Lewis, Jonathan Rosenthal, Barry M. Czeisler, and Jose Torres
- Subjects
Blood Glucose ,Male ,Time Factors ,Databases, Factual ,Glucose control ,030204 cardiovascular system & hematology ,Disability Evaluation ,03 medical and health sciences ,Patient Admission ,0302 clinical medicine ,Risk Factors ,Modified Rankin Scale ,Humans ,Medicine ,Glasgow Coma Scale ,Prospective Studies ,cardiovascular diseases ,Aged ,Cerebral Hemorrhage ,Retrospective Studies ,Aged, 80 and over ,Intracerebral hemorrhage ,business.industry ,Rehabilitation ,Glucose Measurement ,Recovery of Function ,Length of Stay ,Middle Aged ,Prognosis ,medicine.disease ,Patient Discharge ,nervous system diseases ,Hyperglycemia ,Anesthesia ,Cohort ,Female ,Surgery ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,Biomarkers ,030217 neurology & neurosurgery - Abstract
The relationship between in-hospital hyperglycemia and neurological outcome after intracerebral hemorrhage (ICH) is not well studied.We analyzed the relationships between pre-hospital and hospital variables including highest in-hospital glucose (HIHGLC) and discharge Glasgow Coma Scale (GCS), discharge Modified Rankin Scale (MRS) and 3-month MRS using a single-institution cohort of ICH patients between 2013 and 2015.There were 106 patients in our sample. Mean HIHGLC was 154 ± 58 mg/dL for patients with discharge GCS of 15 and 180 ± 57 mg/dL for patients with GCS15; 146 ± 55 mg/dL for patients with discharge MRS 0-3 and 175 ± 58 mg/dL for patients with discharge MRS 4-6; and 149 ± 52 mg/dL for patients with 3-month MRS of 0-3 and 166 ± 61 mg/dL for patients with 3-month MRS of 4-6. On univariate analysis, discharge GCS was associated with HIHGLC (P = .01), age (P = .006), ICH volume (P = .008), and length of stay (LOS) (P = .01); discharge MRS was associated with HIHGLC (P.001), age (P.001), premorbid MRS (P = .046), ICH volume (P.001), and LOS (P.001); and 3-month MRS was associated with HIHGLC (P = .006), discharge MRS (P.001), age (P = .001), sex (P = .002), ICH volume (P = .03), and length of stay (P = .004). On multivariate analysis, discharge GCS only had a significant relationship with ICH volume (odds ratio [OR] .949, .927-.971); discharge MRS had a significant relationship with age (OR 1.043, 1.009-1.079), premorbid MRS (OR 2.622, 1.144-6.011), and ICH volume (OR 1.047, 1.003-1.093); and 3-month MRS only had a significant relationship with age (OR 1.039, 1.010-1.069).The relationship between in-hospital hyperglycemia and neurological outcomes in ICH patients was meaningful on univariate, but not multivariate, analysis. Glucose control after ICH is important.
- Published
- 2018
15. Management of Elevated Intracranial Pressure: a Review
- Author
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Abhinav R Changa, Barry M. Czeisler, and Aaron Lord
- Subjects
0301 basic medicine ,medicine.medical_specialty ,Neurology ,Intracranial Pressure ,03 medical and health sciences ,0302 clinical medicine ,Intensive care ,medicine ,Humans ,Elevated Intracranial Pressure ,Multiple modalities ,Clinical care ,Intensive care medicine ,Intracranial pressure ,Modalities ,business.industry ,General Neuroscience ,Disease Management ,Electroencephalography ,Optic Nerve ,Intensive Care Units ,030104 developmental biology ,Pharmacological interventions ,Neurology (clinical) ,Intracranial Hypertension ,business ,030217 neurology & neurosurgery - Abstract
Principles of intracranial pressure (ICP) management continue to be an essential part of the neurointensivist’s skillset as appropriate treatment decisions can prevent secondary injury to the central nervous system. This review of the literature aims to: discuss commonly encountered pathologies associated with increased ICP, summarize diagnostic approaches used in evaluating ICP, and present evidence-based treatment paradigms that drive clinical care in intensive care units. Recent topics of discussion include invasive and non-invasive modalities of diagnosis and monitoring, recent developments in hypothermia, hyperosmolar therapy, pharmacological interventions, and surgical therapies. The authors also present an example of an algorithm used within our system of hospitals for managing patients with elevated ICP. Recent advances have shown the mortality benefits in appropriately recognizing and treating increased ICP. Multiple modalities of treatment have been explored, and evidence has shown benefit in some. Further work continues to provide clarity in the appropriate management of intracranial hypertension.
- Published
- 2019
16. Systemic Inflammatory Response Syndrome is Associated with Hematoma Expansion in Intracerebral Hemorrhage
- Author
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Kara Melmed, Jose Torres, Cen Zhang, Jennifer A. Frontera, Shadi Yaghi, Amelia K. Boehme, Aaron Lord, Elizabeth Carroll, Koto Ishida, Ariane Lewis, and Barry M. Czeisler
- Subjects
Male ,Risk Assessment ,Disability Evaluation ,03 medical and health sciences ,Patient Admission ,0302 clinical medicine ,Hematoma ,Risk Factors ,Humans ,Medicine ,cardiovascular diseases ,Aged ,Cerebral Hemorrhage ,Retrospective Studies ,Aged, 80 and over ,Intracerebral hemorrhage ,Retrospective review ,Multivariable regression analysis ,business.industry ,Rehabilitation ,Mean age ,Middle Aged ,Prognosis ,medicine.disease ,Systemic Inflammatory Response Syndrome ,body regions ,Systemic inflammatory response syndrome ,Functional Status ,Blood pressure ,Anesthesia ,Disease Progression ,Female ,Surgery ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery - Abstract
Objectives Systemic inflammatory response syndrome (SIRS) and hematoma expansion are independently associated with worse outcomes after intracerebral hemorrhage (ICH), but the relationship between SIRS and hematoma expansion remains unclear. Materials and methods We performed a retrospective review of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. The relationship between SIRS and hematoma expansion, defined as ≥6 mL or ≥33% growth between the first and second scan, was assessed using univariable and multivariable regression analysis. We assessed the relationship of hematoma expansion and SIRS on discharge mRS using mediation analysis. Results Of 149 patients with ICH, 83 (56%; mean age 67±16; 41% female) met inclusion criteria. Of those, 44 (53%) had SIRS. Admission systolic blood pressure (SBP), temperature, antiplatelet use, platelet count, initial hematoma volume and rates of infection did not differ between groups (all p>0.05). Hematoma expansion occurred in 15/83 (18%) patients, 12 (80%) of whom also had SIRS. SIRS was significantly associated with hematoma expansion (OR 4.5, 95% CI 1.16 - 17.39, p= 0.02) on univariable analysis. The association remained statistically significant after adjusting for admission SBP and initial hematoma volume (OR 5.72, 95% CI 1.40 – 23.41, p= 0.02). There was a significant indirect effect of SIRS on discharge mRS through hematoma expansion. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (59 vs 33%, p=0.02). Conclusion SIRS is associated with hematoma expansion of ICH within the first 24 hours, and hematoma expansion mediates the effect of SIRS on poor outcome.
- Published
- 2021
17. Teaching NeuroImages: Hippocampal sclerosis in cerebral malaria
- Author
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Danielle Brewington, Aaron Lord, Arielle Kurzweil, Kaitlyn Lillemoe, Ariane Lewis, and Barry M. Czeisler
- Subjects
Adult ,Pathology ,medicine.medical_specialty ,Primaquine ,Malaria, Cerebral ,Parasitemia ,Hippocampal formation ,Hippocampus ,Malaise ,White matter ,Diagnosis, Differential ,03 medical and health sciences ,0302 clinical medicine ,parasitic diseases ,medicine ,Humans ,030212 general & internal medicine ,Hippocampal sclerosis ,Sclerosis ,biology ,business.industry ,medicine.disease ,Plasmodium ovale ,biology.organism_classification ,Magnetic Resonance Imaging ,medicine.anatomical_structure ,Cerebral Malaria ,Female ,Neurology (clinical) ,medicine.symptom ,business ,030217 neurology & neurosurgery ,medicine.drug - Abstract
A 39-year-old woman presented with fever, malaise, and headache after visiting Tanzania. Peripheral smear showed Plasmodium falciparum and Plasmodium ovale with parasitemia >14%. Within hours, she became unresponsive. MRI demonstrated punctate foci of microhemorrhage throughout the deep white matter, and hippocampal restricted diffusion (figure). Five days of video-EEG were negative for seizure. She was discharged after 3 weeks of quinidine, doxycycline, and primaquine. Repeat MRI showed bilateral hippocampal sclerosis; repeat EEG was normal. Follow-up examination was only notable for short-term memory impairment.
- Published
- 2019
18. Attracting neurology's next generation: A qualitative study of specialty choice and perceptions
- Author
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Barry M. Czeisler, Rujuta B. Wilson, Rana R. Said, Madhu Soni, Carolyn Cahill, Justin T. Jordan, Tasha Ostendorf, Veronica Santini, Anita Navarro, Imran Ali, Charlene E. Gamaldo, A. Gordon Smith, Laurie Gutmann, and Maggie Rock
- Subjects
Male ,medicine.medical_specialty ,Neurology ,Students, Medical ,media_common.quotation_subject ,Specialty ,Affect (psychology) ,Interviews as Topic ,03 medical and health sciences ,0302 clinical medicine ,Perception ,medicine ,Humans ,030212 general & internal medicine ,Curriculum ,media_common ,Medical education ,Career Choice ,Internship and Residency ,Focus Groups ,Focus group ,Harm ,Female ,Neurology (clinical) ,Psychology ,030217 neurology & neurosurgery ,Qualitative research ,Education, Medical, Undergraduate - Abstract
ObjectivesTo better understand the reasons medical students select or avoid a career in neurology by using a qualitative methodology to explore these factors, with the long-term objective of attracting more graduates to the field.MethodsIn 2017, 27 medical students and 15 residents participated in 5 focus groups, and 33 fourth-year medical students participated in semistructured individual interviews. Participants were asked predefined open-ended questions about specialty choice, experiences in their basic neuroscience course and neurology clerkship, and perceptions about the field. Interviews were audio recorded and transcribed. We used a flexible coding methodology to generate themes across groups and interviews.ResultsFour main analytical themes emerged: (1) early and broad clinical exposure allows students to “try on” neurology and experience the variety of career options; (2) preclerkship experiences and a strong neuroscience curriculum lay the foundation for interest in the field; (3) personal interactions with neurology providers may attract or deter students from considering the specialty; and (4) persistent stereotypes about neurologists, neurology patients, and treatment options harm student perceptions of neurology.ConclusionEfforts to draw more students to neurology may benefit from focusing on clinical correlations during preclerkship neuroscience courses and offering earlier and more diverse clinical experiences, including hands-on responsibilities whenever possible. Finally, optimizing student interactions with faculty and residents and reinforcing the many positive aspects of neurology are likely to favorably affect student perceptions.
- Published
- 2019
19. Variations in Strategies to Prevent Ventriculostomy-Related Infections
- Author
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Ariane Lewis, Barry M. Czeisler, and Aaron Lord
- Subjects
Ventriculostomy ,medicine.medical_specialty ,Ideal (set theory) ,business.industry ,medicine.medical_treatment ,Original Articles ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Ventriculitis ,Medicine ,In patient ,030212 general & internal medicine ,Neurology (clinical) ,business ,Intensive care medicine ,030217 neurology & neurosurgery ,External ventricular drain - Abstract
Background and Purpose: The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. Methods: We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. Results: The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents’ institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. Conclusion: Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.
- Published
- 2016
20. Modafinil in Recovery after Stroke (MIRAS): A Retrospective Study
- Author
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Danielle Golub, Aaron Lord, Jose Torres, Barry M. Czeisler, Jonathan Tiu, Danielle B. Cross, Shadi Yaghi, Amabel Karoub, Chaitanya Medicherla, Koto Ishida, Christopher Wu, and Christopher Hernandez
- Subjects
Lethargy ,Male ,medicine.medical_specialty ,Time Factors ,Health Status ,medicine.medical_treatment ,Modafinil ,law.invention ,Disability Evaluation ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,mental disorders ,Humans ,Medicine ,Adverse effect ,Stroke ,Fatigue ,Aged ,Retrospective Studies ,Aged, 80 and over ,Rehabilitation ,business.industry ,Stroke Rehabilitation ,Retrospective cohort study ,Recovery of Function ,Middle Aged ,medicine.disease ,Treatment Outcome ,Central Nervous System Stimulants ,Female ,Surgery ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,Stroke recovery ,030217 neurology & neurosurgery ,medicine.drug - Abstract
Background and Purpose: Acute rehabilitation is known to enhance stroke recovery. However, poststroke lethargy and fatigue can hinder participation in rehabilitation therapies. We hypothesized that in patients with moderate to severe stroke complicated by poststroke fatigue and lethargy early stimulant therapy with modafinil increases favorable discharge disposition defined as transfer to acute inpatient rehabilitation or home. Methods: We retrospectively reviewed a cohort of patients with acute stroke admitted to the stroke service over a 3-year period. All patients 18 years or older with confirmed ischemic or hemorrhagic stroke, an NIHSS greater than or equal to 5 and documentation of fatigue/lethargy in clinical documentation were included. We compared patients that were treated with modafinil 50-200 mg to those managed with standard care. The primary outcome measure was discharge disposition. Secondary outcome was 90 day modified Rankin score (mRS). Statistical significance was determined using chi-square test for association and logistic regression models. Logistic regression models were derived in 2 ways with both raw data and an adjusted model that accounted for age, sex, and NIHSS score to account for the lack of randomization. Results: This study included 199 stroke patients (145 ischemic, 54 hemorrhagic). Seventy-two (36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute inpatient rehabilitation, while none were recommended for discharge home. Median NIHSS for modafinil patients was 13.5 versus 11 for standard care patients (P = .059). In adjusted models, modafinil was associated with higher odds of favorable discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days defined as mRS less than or equal to 2 occurred more frequently with modafinil (5.6% versus 3.3%) but this did not achieve statistical significance (P > .1). These results occurred despite the modafinil group requiring longer ICU stays and having more in-hospital complications such as infections and need for percutaneous gastrostomy tubes. The benefit of modafinil was seen across all subgroups except those with severe stroke (NIHSS ≥ 15). There were no significant adverse events associated with modafinil administration. Conclusions: Modafinil use in acute in-hospital stroke patients with moderate stroke complicated by lethargy and fatigue was associated with improved discharge disposition. Randomized controlled trials are needed to further study the safety, efficacy, and long-term effects of modafinil in this patient population.
- Published
- 2020
21. Simulation in Neurocritical Care: Past, Present, and Future
- Author
-
Nicholas A, Morris, Barry M, Czeisler, and Aarti, Sarwal
- Subjects
Critical Care ,Education, Medical ,Neurology ,Humans ,History, 20th Century ,History, 21st Century ,Simulation Training - Abstract
Simulation-based medical education is a technique that leverages adult learning theory to train healthcare professionals by recreating real-world scenarios in an interactive way. It allows learners to emotionally engage in the assessment and management of critically ill patients without putting patients at risk. Learners are encouraged to work at the edge of their expertise to promote growth and are provided with feedback to nurture development. Thus, the training is targeted to the learner, not the patient. Despite its origins as a teaching tool for neurological diseases, simulation-based medical education has been historically abandoned by neurocritical care educators. In contrast, other critical care educators have embraced the technique and built an impressive foundation of literature supporting its use. Slowly, neurocritical care educators have started experimenting with simulation-based medical education and sharing their results. In this review, we will investigate the historical origins of simulation in the neurosciences, the conceptual framework supporting the technique, current applications, and future directions.
- Published
- 2018
22. Characteristics of graduating US allopathic medical students pursuing a career in neurology
- Author
-
Laurie Gutmann, Carolyn Cahill, Barry M. Czeisler, Imran Ali, Justin T. Jordan, Veronica Santini, Rana R. Said, Madhu Soni, Charlene E. Gamaldo, Rujuta B. Wilson, and A. Gordon Smith
- Subjects
Adult ,Male ,medicine.medical_specialty ,Neurology ,Students, Medical ,education ,Specialty ,MEDLINE ,Logistic regression ,03 medical and health sciences ,0302 clinical medicine ,Surveys and Questionnaires ,medicine ,Humans ,030212 general & internal medicine ,Salary ,Medical education ,Career Choice ,Specialty choice ,Internship and Residency ,Female ,Neurology (clinical) ,Psychology ,030217 neurology & neurosurgery ,Career choice ,Graduation - Abstract
ObjectivesTo identify factors associated with medical students becoming neurologists because, despite the increasing burden of neurologic disorders, there is a growing neurologist shortage.MethodsDeidentified data from the Association of American Medical Colleges Matriculating Student Questionnaire (MSQ) and Graduation Questionnaire (GQ) were obtained for the graduation years 2013 to 2014 through 2016 to 2017. Logistic regression was used to assess demographic characteristics and responses to training and career-related questions in association with specialty choice (intent to enter neurology).ResultsOf the 51,816 students with complete data, 1,456 (2.8%) indicated an intent to enter a neurology residency. Factors associated with an increased likelihood of entering neurology were a student's rating of excellent for their basic neuroscience course and neurology clerkship, participation in an MD/PhD program, majoring in neuroscience or psychology as an undergraduate, a selection response of “content of the specialty was a strong influence on career choice,” and indicating interest in neurology on the MSQ. Factors associated with a decreased likelihood of entering neurology were a higher-priority response on the GQ for salary, work/life balance, and personal fit of the specialty.ConclusionData from surveys at the entry into and graduation from medical school suggest several approaches to increase the number of medical students entering neurology, including a focus on the student-reported quality of the basic neuroscience course and neurology clerkships, targeted engagement with MD/PhD students, and mentoring programs for students interested in neurology. Efforts to improve salaries for neurologists, to reduce medical school debt, and to improve work/life balance may also help to attract more students.
- Published
- 2018
23. Ventriculostomy-related infections: The performance of different definitions for diagnosing infection
- Author
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W. Taylor Kimberly, Sarah J. Karinja, Aaron Lord, Barry M. Czeisler, Ariane Lewis, and Sarah Wahlster
- Subjects
Ventriculostomy ,medicine.medical_specialty ,medicine.medical_treatment ,Concordance ,030501 epidemiology ,Article ,03 medical and health sciences ,Catheters, Indwelling ,0302 clinical medicine ,Standard definition ,Interquartile range ,Internal medicine ,medicine ,Ventriculitis ,Humans ,Surgical Wound Infection ,Retrospective Studies ,Csf shunt ,business.industry ,Retrospective cohort study ,General Medicine ,medicine.disease ,Hospitals ,Anti-Bacterial Agents ,Surgery ,Cohort ,Neurology (clinical) ,0305 other medical science ,business ,030217 neurology & neurosurgery - Abstract
Introduction. Comparison of rates of ventriculostomy-related infections (VRIs) across institutions is difficult due to the lack of a standard definition. We sought to review published definitions of VRI and apply them to a test cohort to determine the degree of variability in VRI diagnosis. Materials and methods. We conducted a PubMed search for definitions of VRI using the search strings “ventriculostomy-related infection” and “ventriculostomy-associated infection.” We applied these definitions to a test cohort of 18 positive cerebrospinal fluid (CSF) cultures taken from ventriculostomies at two institutions to compare the frequency of infection using each definition. Results. We found 16 unique definitions of VRI. When the definitions were applied to the test cohort, the frequency of infection ranged from 22 to 94% (median 61% with interquartile range (IQR) 56–74%). The concordance between VRI diagnosis and treatment with VRI-directed antibiotics for at least seven days ranged from 56 to 89% (median: 72%, IQR: 71–78%). Conclusions. The myriad of definitions in the literature produce widely different frequencies of infection. In order to compare rates of VRI between institutions for the purposes of qualitative metrics and research, a consistent definition of VRI is needed.
- Published
- 2015
24. Public education and misinformation on brain death in mainstream media
- Author
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Arthur L. Caplan, Ariane Lewis, Aaron Lord, and Barry M. Czeisler
- Subjects
medicine.medical_specialty ,Brain Death ,Tissue and Organ Procurement ,Declaration ,Poison control ,Public opinion ,03 medical and health sciences ,0302 clinical medicine ,Injury prevention ,Medicine ,Mainstream ,Humans ,030212 general & internal medicine ,Organ donation ,Misinformation ,Mass Media ,Mass media ,Transplantation ,business.industry ,Communication ,Surgery ,Life Support Care ,Family medicine ,Public Opinion ,Tissue and Organ Harvesting ,business ,030217 neurology & neurosurgery - Abstract
INTRODUCTION: We sought to evaluate the caliber of education mainstream media provides the public about brain death. METHODS: We reviewed articles published prior to July 31, 2015 on the most shared/heavily trafficked mainstream media websites of 2014 using the names of patients from two highly publicized brain death cases, "Jahi McMath" and "Marlise Munoz." RESULTS: We reviewed 208 unique articles. The subject was referred to as being "alive" or on "life support" in 72% (149) of the articles, 97% (144) of which also described the subject as being brain dead. A definition of brain death was provided in 4% (9) of the articles. Only 7% (14) of the articles noted that organ support should be discontinued after brain death declaration unless a family has agreed to organ donation. Reference was made to well-known cases of patients in persistent vegetative states in 16% (34) of articles and 47% (16) of these implied both patients were in the same clinical state. CONCLUSIONS: Mainstream media provides poor education to the public on brain death. Because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved. Language: en
- Published
- 2016
25. Prolonged prophylactic antibiotics with neurosurgical drains and devices: Are we using them? Do we need them?
- Author
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Barry M. Czeisler, Ariane Lewis, and Aaron Lord
- Subjects
medicine.medical_specialty ,Epidemiology ,medicine.drug_class ,business.industry ,Extramural ,Health Policy ,Antibiotics ,Public Health, Environmental and Occupational Health ,MEDLINE ,Neurosurgery ,Antibiotic Prophylaxis ,Anti-Bacterial Agents ,03 medical and health sciences ,0302 clinical medicine ,Infectious Diseases ,Surveys and Questionnaires ,medicine ,Drainage ,Humans ,Surgical Wound Infection ,030212 general & internal medicine ,business ,Intensive care medicine ,030217 neurology & neurosurgery - Published
- 2016
26. Predicting Large Vessel Occlusion in Acute Ischemic Stroke: Less is More
- Author
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Stephan A. Mayer and Barry M. Czeisler
- Subjects
medicine.medical_specialty ,business.industry ,Critical Care and Intensive Care Medicine ,Brain Ischemia ,Stroke ,03 medical and health sciences ,0302 clinical medicine ,Text mining ,Internal medicine ,medicine ,Cardiology ,Humans ,030212 general & internal medicine ,business ,Acute ischemic stroke ,030217 neurology & neurosurgery ,Large vessel occlusion - Published
- 2016
27. Majority of 30-Day Readmissions After Intracerebral Hemorrhage Are Related to Infections
- Author
-
Koto Ishida, Mitchell S.V. Elkind, Hooman Kamel, Daniel Woo, Barry M. Czeisler, Bernadette Boden-Albala, Jose Torres, Aaron Lord, and Ariane Lewis
- Subjects
Male ,medicine.medical_specialty ,Aspiration pneumonia ,Pneumonia, Aspiration ,Patient Readmission ,California ,Article ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Acute care ,Sepsis ,Epidemiology ,Medicine ,Humans ,030212 general & internal medicine ,Hospital Mortality ,Stroke ,Aged ,Cerebral Hemorrhage ,Retrospective Studies ,Advanced and Specialized Nursing ,Intracerebral hemorrhage ,business.industry ,Retrospective cohort study ,Pneumonia ,Middle Aged ,medicine.disease ,Patient Discharge ,Surgery ,Relative risk ,Urinary Tract Infections ,Female ,Neurology (clinical) ,Diagnosis code ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery - Abstract
Background and Purpose— Infections are common after intracerebral hemorrhage, but little is known about the risk of serious infection requiring readmission after hospital discharge. Methods— To determine if infections are prevalent in patients readmitted within 30 days of discharge, we performed a retrospective cohort study of patients discharged from nonfederal acute care hospitals in California with a primary diagnosis of intracerebral hemorrhage between 2006 and 2010. We excluded patients who died during the index admission, were discharged against medical advice, or were not California residents. Our main outcome was 30-day unplanned readmission with primary infection–related International Classification of Diseases , Ninth Revision, Clinical Modification code. Results— There were 24 540 index intracerebral hemorrhage visits from 2006 to 2010. Unplanned readmissions occurred in 14.5% (n=3550) of index patients. Of 3550 readmissions, 777 (22%) had an infection-related primary diagnosis code. When evaluating primary and all secondary diagnosis codes, infection was associated with 1826 (51%) of readmissions. Other common diagnoses associated with readmission included stroke-related codes (n=840, 23.7%) and aspiration pneumonitis (n=154, 4.3%). The most common infection-related primary diagnosis codes were septicemia (n=420, 11.8%), pneumonia (n=124, 3.5%), urinary tract infection (n=141, 4.0%), and gastrointestinal infection (n=42, 1.2%). Patients with a primary infection–related International Classification of Diseases , Ninth Revision, Clinical Modification code on readmission had higher in-hospital mortality compared with other types of readmission (15.6% versus 8.0%, P Conclusions— Infections are associated with a majority of 30-day readmissions after intracerebral hemorrhage and increased mortality. Efforts should be made to reduce infection-related complications after hospital discharge.
- Published
- 2016
28. Establishment of an External Ventricular Drain Best Practice Guideline: The Quest for a Comprehensive, Universal Standard for External Ventricular Drain Care
- Author
-
Barry M. Czeisler, Marina Spektor, Millie Hepburn-Smith, Aaron Lord, Irina Dynkevich, and Ariane Lewis
- Subjects
medicine.medical_specialty ,MEDLINE ,CINAHL ,Asepsis ,Ventriculostomy ,03 medical and health sciences ,0302 clinical medicine ,Catheters, Indwelling ,Nursing ,Medicine ,Humans ,030212 general & internal medicine ,Intensive care medicine ,Device Removal ,Nursing literature ,Infection Control ,Catheter insertion ,Endocrine and Autonomic Systems ,business.industry ,Guideline ,Medical–Surgical Nursing ,Catheter ,Practice Guidelines as Topic ,Drainage ,Surgery ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,External ventricular drain ,Hydrocephalus - Abstract
External ventricular drains (EVDs) are commonly used to facilitate removal of cerebrospinal fluid in patients with neurologic dysfunction. Despite a high risk for infection (upward of 45%), many hospitals lack strict protocols for EVD placement and maintenance. In addition, EVD infections are typically not tracked with the same diligence as central-line catheter infections, because there are no widely accepted standards for routine management of EVDs. The purpose of this review is to provide a guide for the development of a standardized, best practice EVD protocol for catheter insertion, care, and maintenance to reduce ventriculostomy-related infections. A secondary goal of this review is to provide support for the future development of guidelines for the consistent tracking of EVD insertion and maintenance practices.At an academic medical center, an interdisciplinary team of nurses, advanced practice nurses, and neurointensivists reviewed recent medical and nursing literature as well as research-based institutional protocols on EVD insertion and maintenance from the United States and abroad to determine global best practices. The goal of this literature review was to identify key areas of focus in EVD insertion and maintenance as well as to identify recent studies that have shown success in managing EVDs with low rates of infection. The following terms were used in this search: EVD, externalized ventricular drains, EVD infections, EVD insertion, EVD Care and Maintenance, Nursing and EVDS. The following databases were utilized by each member of the interdisciplinary team to establish a state of the science on EVD management: American Association of Neurosurgical Surgeons, CINAHL, Cochrane, National Guidelines Clearinghouse, and PubMed. The following common EVD themes were identified: preinsertion hair removal and skin preparation, aseptic technique, catheter selection, monitoring of EVD insertion technique using a "bundle" approach, postinsertion dressing type and frequency of dressing changes, techniques for maintenance and cerebrospinal fluid sampling, duration of catheter placement, staff education/competence, and surveillance.
- Published
- 2016
29. A Novel Clinical Score to Assess Seizure Risk
- Author
-
Barry M. Czeisler and Jan Claassen
- Subjects
medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,MEDLINE ,030208 emergency & critical care medicine ,Electroencephalography ,03 medical and health sciences ,0302 clinical medicine ,Text mining ,Critical illness ,Medicine ,Neurology (clinical) ,business ,Psychiatry ,030217 neurology & neurosurgery - Published
- 2017
30. Reading and writing the blood-brain barrier: relevance to therapeutics
- Author
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Damir Janigro and Barry M. Czeisler
- Subjects
business.industry ,Central nervous system ,S100 Proteins ,Stimulation ,Plasma levels ,Parasympathetic nerve ,Blood–brain barrier ,Permeability ,Tight Junctions ,Psychiatry and Mental health ,medicine.anatomical_structure ,Drug conjugation ,Blood-Brain Barrier ,Osmotic Pressure ,Drug Discovery ,medicine ,Animals ,Humans ,Pharmacology (medical) ,business ,Neuroscience ,Bbb permeability ,Multidrug transporter ,Central Nervous System Agents - Abstract
The blood-brain barrier (BBB) serves to protect the central nervous system (CNS) from damage by exogenous molecules. In doing so, it also can prevent some drugs from reaching their sites of action. Accordingly, a variety of methods for bypassing the BBB have been developed. Ekwuribe et al. recently patented a method for drug conjugation in order to increase lipophilicity, and therefore BBB permeability. Shalev developed a device for opening the barrier via parasympathetic nerve fiber stimulation and Gudkov et al. produced compounds that modulate the activity of multidrug transporter proteins, by either increasing or decreasing the selective permeability of the BBB. A variety of CNS disorders contribute to barrier disruption, and detection of this opening can be used for both diagnostic purposes and for determining time periods when drugs can more easily enter the CNS. While expensive and time-consuming imaging techniques are currently used for this purpose, Janigro et al. have devised a method for detecting plasma levels of S100beta, a peripheral protein marker for BBB disruption. These techniques for both "reading" and "writing" the BBB will help new and old medications to reach their pharmacological targets in the CNS.
- Published
- 2008
31. Neuroprotective effects of olanzapine in a rat model of neurodevelopmental injury
- Author
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Maureen V. Martin, Mitchell A. Meltzer, John G. Csernansky, Barry M. Czeisler, Zulfiqar Ali, and Hongxin Dong
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Olanzapine ,Kainic acid ,medicine.drug_class ,medicine.medical_treatment ,Clinical Biochemistry ,Atypical antipsychotic ,Pharmacology ,Toxicology ,Biochemistry ,Neuroprotection ,Melatonin ,Rats, Sprague-Dawley ,Behavioral Neuroscience ,chemistry.chemical_compound ,Benzodiazepines ,medicine ,Haloperidol ,Animals ,Antipsychotic ,Biological Psychiatry ,Injections, Intraventricular ,Kainic Acid ,business.industry ,Dentate gyrus ,Rats ,Disease Models, Animal ,Neuroprotective Agents ,nervous system ,chemistry ,Anesthesia ,Female ,business ,medicine.drug ,Antipsychotic Agents - Abstract
Recent clinical studies have suggested that treatment with atypical antipsychotic drugs, such as olanzapine, may slow progressive changes in brain structure in patients with schizophrenia. To investigate the possible neural basis of this effect, we sought to determine whether treatment with olanzapine would inhibit the loss of hippocampal neurons associated with the administration of the excitotoxin, kainic acid, in neonatal rats. At post-natal day 7 (P7), rats were exposed to kainic acid via intracerebroventricular administration. Neuronal loss within the CA2 and CA3 subfields of the hippocampus and neurogenesis within the dentate gyrus of the hippocampus were then assessed at P14 by Fluoro-Jade B and BrdU labeling, respectively. Daily doses of olanzapine (2, 6, or 12 mg/day), haloperidol (1.2 mg/kg), melatonin (10 mg/kg), or saline were administered between P7 and P14. Melatonin is an anti-oxidant drug and was included in this study as a positive control, since it has been observed to have neuroprotective effects in a variety of animal models. The highest dose of olanzapine and melatonin, but not haloperidol, ameliorated the hippocampal neuronal loss triggered by kainic acid administration. However, drug administration did not have a significant effect on the rate of neurogenesis. These results suggest that olanzapine has neuroprotective effects in a rat model of neurodevelopmental insult, and may be relevant to the observed effects of atypical antipsychotic drugs on brain structure in patients with schizophrenia.
- Published
- 2005
32. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study
- Author
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Gian Marco De Marchis, Christine Lesch, Stephan A. Mayer, Andres Fernandez, Barry M. Czeisler, Jan Claassen, J. Michael Schmidt, Sachin Agarwal, Hector Lantigua, Brandon Foreman, and Deborah Pugin
- Subjects
Adult ,Male ,medicine.medical_specialty ,Status epilepticus ,Critical Care and Intensive Care Medicine ,Cohort Studies ,Epilepsy ,Status Epilepticus ,Interquartile range ,Internal medicine ,medicine ,Humans ,Infusions, Intravenous ,Pentobarbital ,Aged ,Retrospective Studies ,business.industry ,FOS: Clinical medicine ,Research ,Glasgow Outcome Scale ,Neurosciences ,Electroencephalography ,Symptomatic seizures ,Retrospective cohort study ,Pneumonia ,Middle Aged ,medicine.disease ,Treatment Outcome ,Anesthesia ,Female ,Hypotension ,medicine.symptom ,Complication ,business ,Cohort study - Abstract
Introduction: Seizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE. Methods: We retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year. Results: Thirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5) severely disabled, and 10% (N = 3) had no or minimal disability. Death or unresponsive wakefulness was associated with catastrophic etiology (p = 0.03), but none of the other collected variables. Conclusions: cIV-PTB effectively aborts SRSE and complications are infrequent; outcome in this highly refractory cohort of patients with devastating underlying etiologies remains poor. Phenobarbital may be particularly helpful when weaning cIV-PTB.
- Published
- 2014
33. Comparison between Institutionally-Defined Clinical Criteria and CDC-Criteria for the Diagnosis of Ventriculostomy-Related Infection (P02.220)
- Author
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J. Michael Schmidt, Neeraj Badjatia, Amanda M. Carpenter, E. Sander Connolly, Hector Lantigua, Mary Presciutti, Stephan A. Mayer, KuangHa Guo, John H. Zhang, Kiwon Lee, Jan Claassen, Sang-Bae Ko, Barry M. Czeisler, Paul Bernstein, and H. Alex Choi
- Subjects
Ventriculostomy ,Intracerebral hemorrhage ,medicine.medical_specialty ,Subarachnoid hemorrhage ,CSF glucose ,business.industry ,medicine.medical_treatment ,medicine.disease ,Internal medicine ,medicine ,Ventriculitis ,Observational study ,Neurology (clinical) ,Medical diagnosis ,business ,Medical systems - Abstract
Objective: To compare our clinical criteria for ventriculostomy-related infections (VRIs) to the Centers for Disease Control (CDC) criteria. Background The diagnosis of VRI is commonly made based upon clinical impression rather than utilizing specific criteria, which may result in misdiagnoses and overutilization of antibiotics. Design/Methods: A prospective observational study of VRI was conducted between August 2009 and April 2011. Patients were excluded due to death within three days of EVD insertion, EVD insertion at an outside hospital >1 day before transfer, or pre-insertion CNS infection. CSF was sampled every other day and additionally for clinical suspicion of VRI. Clinical criteria for VRI was fever (T≥38.3C) accompanied by an increase in CSF white blood cells (WBCs) and/or decrease in CSF glucose. CDC-defined VRI was concurrently diagnosed by an infectious disease epidemiologist. Both the epidemiologist and treating team were blinded to the other9s diagnosis. Results: A total of 133 patients met criteria. Mean age was 57 years and 52% were female. The majority of diagnoses were subarachnoid hemorrhage (n=63, 47%) and intracerebral hemorrhage (n=44, 33%). There were 31 (23%) patients diagnosed and treated for VRI using clinical criteria. Of all treated patients, 13 (42%) had CDC-defined VRI and only one (3%) had positive CSF cultures. There was no difference in maximum daily temperature or CSF WBCs, protein, or glucose between those with CDC-defined VRI and those treated who did not meet CDC criteria. In addition, two patients not empirically treated developed culture-positive ventriculitis. The positive predictive value of our clinical diagnosis as compared to CDC criteria was only 42%; negative predictive value was 98%. Conclusions: The majority (58%) of patients diagnosed with VRI by clinical criteria did not meet CDC criteria, raising concern for antibiotic overuse. Improved clinical parameters for defining VRI must be developed for more precise management. Disclosure: Dr. Czeisler has nothing to disclose. Dr. Choi has nothing to disclose. Dr. Guo has nothing to disclose. Dr. Bernstein has nothing to disclose. Dr. Presciutti has nothing to disclose. Dr. Lantigua has nothing to disclose. Dr. Carpenter has nothing to disclose. Dr. Zhang has nothing to disclose. Dr. Ko has nothing to disclose. Dr. Schmidt has nothing to disclose. Dr. Claassen has nothing to disclose. Dr. Mayer has received personal compensation for activities with Astellas Pharmaceuticals, General Electric, Medivance, Inc., Acorda Therapeutics, Actelion, the Medicines Company, Sanofi-Aventis Pharmaceuticals, Inc., Edge Therapeutics, Novartis, Codman, Baxter, and Orsan. Dr. Mayer has received research support from Non-Invasive Medical Systems, Inc. Dr. Lee has received personal compensation for activities with UCB Pharmaceuticals, EKR Therapeutics, Boehringer-Ingelheim, Edwards Lifesciences, Medivance, Innercool, and Astellas as a speaker. Dr. Connolly has nothing to disclose. Dr. Badjatia has nothing to disclose.
- Published
- 2012
34. Corrigendum to 'Neuroprotective effects of olanzapine in a rat model of neurodevelopmental injury' [Pharmacol Biochem Behav 83 (2006) 208–213]
- Author
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John G. Csernansky, Maureen V. Martin, Barry M. Czeisler, Zulfiqar Ali, Hongxin Dong, and Mitchell A. Meltzer
- Subjects
Pharmacology ,Olanzapine ,Behavioral Neuroscience ,Clinical Biochemistry ,Rat model ,medicine ,Toxicology ,Psychology ,Biochemistry ,Neuroscience ,Neuroprotection ,Biological Psychiatry ,medicine.drug - Published
- 2006
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