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ObjectiveTo determine whether race is associated with the development of epilepsy after subdural hematoma (SDH), we identified adult survivors of SDH in a statewide administrative dataset and followed them up for at least 1 year for revisits associated with epilepsy.MethodsWe performed a retrospective cohort study using claims data on all discharges from emergency departments (EDs) and hospitals in California. We identified adults (age ≥18 years) admitted from 2005 to 2011 with first-time traumatic and nontraumatic SDH. We used validated diagnosis codes to identify a primary outcome of ED or inpatient revisit for epilepsy. We used multivariable Cox regression for survival analysis to identify demographic and medical risk factors for epilepsy.ResultsWe identified 29,342 survivors of SDH (mean age 71.2 [SD 16.4] years, female sex 11,954 [41.1%]). Three thousand two hundred thirty (11.0%) patients had revisits to EDs or hospitals with a diagnosis of epilepsy during the study period. Black patients (n = 1,684 [5.7%]) had significantly increased risk compared to White patients (n = 16,945 [57.7%]; hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.28–1.64, p < 0.001). Status epilepticus during the index SDH admission, although infrequent (n = 94 [0.3%]), was associated with a nearly 4-fold risk of epilepsy (HR 3.75, 95% CI 2.80–5.03, p < 0.001). Alcohol use, drug use, smoking, renal disease, and markers of injury severity (i.e., intubation, surgical intervention, length of stay, disposition other than home) were also associated with epilepsy (all p < 0.05).ConclusionsWe found an association between Black race and ED and hospital revisits for epilepsy after SDH, establishing the presence of a racial subgroup that is particularly vulnerable to post-SDH epileptogenesis.

CASE SUMMARY A 28-year-old nulliparous woman presented with rectal bleeding. Colonoscopy revealed a 4-cm malignant-appearing mass in the proximal rectum, and biopsies confirmed invasive adenocarcinoma of the rectum. Computed tomography scan showed no evidence of metastatic disease. Staging MRI found transmural extension with minimal stranding in the adjacent fat, as well as no evidence of pathological pelvic adenopathy, consistent with a T3N0 lesion. The proposed treatment plan involved neoadjuvant chemotherapy and radiation therapy before primary surgical resection. The patient desired fertility preservation and was referred immediately to Reproductive Endocrinology and Infertility. She underwent assisted reproduction with oocyte and blastocyst cryopreservation followed by laparoscopic ovarian transposition. Nine months after surgical low anterior resection of the tumor and completion of her cancer treatment, her ovaries were repositioned to their normal pelvic position during an ileostomy takedown procedure. She underwent a frozen embryo transfer but did not conceive. She resumed menses and later conceived spontaneously. Her pregnancy was complicated by cervical incompetence, requiring cervical cerclage. She delivered a live male infant via cesarean delivery at 32 weeks gestation, approximately 2 years after completion of cancer therapy. Four years after diagnosis, the patient remains in remission with undetectable CEA levels.

Background and Purpose— We evaluated the association between 2 types of predictors of delayed cerebral ischemia after nontraumatic subarachnoid hemorrhage, including biomarkers of the innate immune response and neurophysiologic changes on continuous electroencephalography. Methods— We studied subarachnoid hemorrhage patients that had at least 72 hours of continuous electroencephalography and blood samples collected within the first 5 days of symptom onset. We measured inflammatory biomarkers previously associated with delayed cerebral ischemia and functional outcome, including soluble ST2 (sST2), IL-6 (interleukin-6), and CRP (C-reactive protein). Serial plasma samples and cerebrospinal fluid sST2 levels were available in a subgroup of patients. Neurophysiologic changes were categorized into new or worsening epileptiform abnormalities (EAs) or new background deterioration. The association of biomarkers with neurophysiologic changes were evaluated using the Wilcoxon rank-sum test. Plasma and cerebrospinal fluid sST2 were further examined longitudinally using repeated measures mixed-effects models. Results— Forty-six patients met inclusion criteria. Seventeen (37%) patients developed new or worsening EAs, 21 (46%) developed new background deterioration, and 8 (17%) developed neither. Early (day, 0–5) plasma sST2 levels were higher among patients with new or worsening EAs (median 115 ng/mL [interquartile range, 73.8–197]) versus those without (74.7 ng/mL [interquartile range, 44.8–102]; P =0.024). Plasma sST2 levels were similar between patients with or without new background deterioration. Repeated measures mixed-effects modeling that adjusted for admission risk factors showed that the association with new or worsening EAs remained independent for both plasma sST2 (β=0.41 [95% CI, 0.09–0.73]; P =0.01) and cerebrospinal fluid sST2 (β=0.97 [95% CI, 0.14–1.8]; P =0.021). IL-6 and CRP were not associated with new background deterioration or with new or worsening EAs. Conclusions— In patients admitted with subarachnoid hemorrhage, sST2 level was associated with new or worsening EAs but not new background deterioration. This association may identify a link between a specific innate immune response pathway and continuous electroencephalography abnormalities in the pathogenesis of secondary brain injury after subarachnoid hemorrhage.

Introduction: Delayed cerebral ischemia (DCI) is the leading complication of subarachnoid hemorrhage (SAH). Because DCI was traditionally thought to be caused by large vessel vasospasm, transcranial Doppler ultrasounds (TCDs) have been the standard of care. Continuous EEG has emerged as a promising complementary monitoring modality and predicts increased DCI risk. Clinical variables have also been used in DCI prediction. We hypothesize integrating these diagnostic modalities improves DCI prediction. Methods: We assessed 107 patients with moderate-severe SAH (2011-2015) who had both TCD and EEG monitoring during hospitalization. Clinical demographics, including Hunt-Hess and aneurysm treatment (clipping/coiling), were collected via retrospective chart review. Middle cerebral artery (MCA) peak systolic velocities (PSV) and the presence or absence of epileptiform abnormalities (EA), defined as seizures, epileptiform discharges, and rhythmic/periodic activity, were recorded daily. Logistic regressions were used to identify EEG, TCD, and clinical variables associated with DCI. Group-Based Trajectory Modeling (GBTM) was used to account for changes over time by identifying distinct group trajectories of MCA and EA associated with DCI risk. Results: Independent predictors of DCI in logistic regressions are: presence of high MCA velocity (PSV≥200cm/s) and presence of EA on or before day 3. There are 2 univariate GBTM trajectories of EA (%DCI in group 1=32.1, group 2=70.4) significantly associated with DCI, but MCA velocity trajectories are not significant. Logistic regression and GBTM models using both TCD and EEG monitoring improve upon models using either modality alone. Hunt-Hess score at admission and aneurysm treatment as covariates further improved model performance. The best models used both TCD and EEG monitoring modalities and clinical variables as predictors (logistic regression: Se=90%, Sp=70%; GBTM: Se=89%, Sp=67%). Conclusions: EEG and TCD biomarkers combined provide the best prediction of DCI, compared to either alone. Models that considered the timing of EA and high MCA velocities plus clinical variables improved model performance.

Background and Aims: Advances in low-field MRI have enabled image acquisition at the point-of-care (POC). We aim to characterize ischemic lesions in low-field, POC MRI and assess its relationship with stroke severity in ischemic stroke patients. Methods: We performed POC MRI exams on ischemic stroke patients. T2-weighted (T2W), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI) exams were acquired with a 64mT, portable bedside MRI system. Three raters computed signal intensity ratios (SIR) for each sequence. For every slice showing an infarct, an SIR was generated by dividing the mean signal intensity of the lesion by the mean signal intensity of the contralateral hemisphere. Infarct volumes were obtained by multiplying the lesion area of each slice by the slice thickness (5mm) and summing the cross-sectional areas. Volumes were correlated with National Institutes of Health Stroke Scale (NIHSS) scores at the time of scan. Results: We studied 18 ischemic stroke patients (50% women; ages 30-95 years). Two patients were studied at two and three serial timepoints, respectively. POC exams were obtained 2.7 ± 2.2 days after symptom onset. A total of 18 T2W, 17 FLAIR, and 18 DWI exams were obtained. Three exams (1 T2W; 1 FLAIR; 1 DWI) were excluded due to motion degradation. High field MRI exams (19 ± 16 hours from POC exams) demonstrated ischemic infarcts in 15 of the 18 patients. All POC T2W and FLAIR exams revealed infarcts in these patients, and 14 of the 17 DWI exams showed infarcts. Ischemic infarcts were seen as hyperintense lesions (SIR: T2W = 1.19 ± 0.10, FLAIR = 1.15 ± 0.08, DWI = 1.36 ± 0.17). Infarct volume significantly correlated with NIHSS scores (T2W: r = 0.71, p < 0.01; FLAIR: r = 0.65, p < 0.05; DWI: r = 0.65, p < 0.05). Conclusions: These preliminary data suggest that low-field, POC MRI may be useful in the clinical evaluation of ischemic stroke. Further work in larger cohorts is needed to elucidate the appearance of infarction on low-field imaging.

Objective: Worsening epileptiform abnormalities (EAs) and deteriorating background activity are common continuous electroencephalography (cEEG) patterns that predict subsequent clinical deterioration following subarachnoid hemorrhage (SAH). While worsening EAs and background deterioration both imply cortical dysfunction, we sought to clarify if these patterns have a different association with clinical outcomes. Methods: We enrolled patients with SAH undergoing > 3 days of cEEG monitoring enrolled in a prospective outcome study with a modified Rankin Scale (mRS) assessment at 3 months. Worsening EAs included new or increasing burden of sporadic epileptiform discharges, lateralized rhythmic delta activity (LRDA), lateralized periodic discharges (LPD), or generalized periodic discharges (GPD). Background deterioration was defined as decreasing Alpha Delta Ratio (ADR), Relative Alpha Variability (RAV) or worsening focal slowing. We evaluated the association between these cEEG patterns and 3-month mRS >3 and examined whether the influence on outcome was independent of delayed cerebral ischemia (DCI). Results: Of 59 patients meeting inclusion criteria (3-month mRS median 3 [IQR 1-5]), worsening EAs developed in 23 (39%) and new background deterioration in 24 (41%), whereas 24 patients (41%) developed neither finding and 12 (20%) developed both. Patients with worsening EAs were more likely to have a poor 3-month mRS compared to those without worsening EAs (OR 6.44; 95%CI 1.99-20.9; p=0.001). Developing new background deterioration was not significantly associated with poor 3-month outcome (OR 1.56, 95%CI 0.53-4.59; p=0.42). There was no additive effect on poor outcome of developing both findings. In a multivariate logistic regression, the effect of worsening EAs on 3-month mRS was independent of DCI. Interpretation: While both worsening EAs and new background deterioration have previously been associated with DCI, only worsening EAs influences poor long-term outcome. Further investigation may clarify if distinct mechanisms underlie these differences.

BACKGROUND Postoperative psychosocial distress is a critical aspect of surgery, particularly in aesthetically sensitive areas. In this study, the authors assess the level of psychosocial distress associated with nasal reconstruction. The authors also compare postoperative distress levels associated with different reconstructive techniques throughout the healing process. METHODS The authors conducted a prospective study of patients undergoing nasal reconstruction following excision of cutaneous malignancy. The main outcome measure was the Derriford Appearance Scale 24, a measure of psychosocial distress. The Derriford Appearance Scale was administered at preoperative assessment, 1 < x < 4 weeks, 4 ≤ x < 12 weeks, and x ≥ 12 weeks. The entire cohort was analyzed with respect to distress levels before and after surgery. Reconstructions were categorized as interpolated, local tissue, or full-thickness skin graft. Analyses were performed for reconstruction type, patient, and defect data. RESULTS Fifty-nine patients were enrolled. Reconstructions included 14 interpolated flaps, 17 local tissue flaps, and 28 full-thickness skin grafts. For the entire cohort, distress levels were significantly higher at the first postoperative visit (p < 0.05), with normalization at subsequent follow-up evaluations. At the first assessment, the interpolated flap group had significantly higher levels of distress in comparison with the full-thickness skin graft group (p < 0.05). At late follow-up, levels of distress were equivalent. CONCLUSIONS Nasal reconstruction is associated with short-term increases in psychosocial distress that corrects by approximately 12 weeks after surgery. Interpolated flaps cause significantly higher distress at early assessment. Distress levels at late follow-up appear to be equivalent to those following a full-thickness skin graft despite larger and deeper initial defects. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.

To discuss whether strict allergen avoidance is the most appropriate strategy for managing or preventing food allergy.The standard of care for the management of food allergy has been strict allergen avoidance. This advice is based upon the suppositions that exposure could result in allergic reactions and avoidance may speed recovery. Recent studies challenge these assumptions. Studies now demonstrate that most children with milk and egg allergy tolerate extensively heated forms of these foods. Moreover, clinical trials of oral immunotherapy show that oral exposure can lead to desensitization. Additionally, recent epidemiologic studies fail to support the notion that delaying introduction of highly allergenic foods to infants and young children prevents the development of food allergy. In fact, the data suggest that delays may increase risks.Recent data indicate that strict allergen avoidance is not always necessary for treatment, exposure may be therapeutic, and extended delay in introduction of food allergens to the diet of young children may increase allergy risks. However, in many circumstances strict avoidance is clearly necessary for treatment. Additional studies are needed to determine the risks and benefits of exposure to tolerated allergen, including identification of biomarkers to identify patients who may benefit.