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Background Following the publication of 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic.1 Gaps in prior pandemic planning were identified and require modification in the midst of ongoing surge throughout the world. Methods The Task Force for Mass Critical Care (TFMCC) adopted a modified version of established rapid guideline methodologies from the World Health Organization2 and the Guidelines International Network-McMaster Guideline Development Checklist.3 With a consensus development process incorporating expert opinion to define important questions and extract evidence, TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, “gray” evidence from lay media sources, and anecdotal experiential evidence. Results Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. Intensive care unit (ICU) surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and avoid crisis triage, with early transfer strategies to further load-balance care. We suggest intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in intensive care units (ICUs). Conclusions A subcommittee from the Task Force for Mass Critical Care offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands from COVID-19.

While brain stem involvement in multiple sclerosis (MS) is relatively common, isolated cranial nerve palsies are rare, especially when they represent the initial presenting sign of a new diagnosis of MS. This report describes a patient with no prior history of MS whose sole presenting sign was an isolated abducens palsy. An enhancing pontine lesion was found on MRI which correlated with his abducens palsy, and additional nonactive lesions on MRI led to a diagnosis of MS. This case demonstrates the importance of considering MS as part of the differential diagnosis of patients with isolated cranial nerve palsies.

The civil war in Syria has been recognized as possibly the greatest humanitarian crisis of the 21st century.1 According to the British-based Syrian Observatory for Human Rights, 511,000 people (2.33% of Syria's prewar population of 22 million) have been killed in the war from March 2011 to the present,2 and more than 1.9 million have been injured.3 The public health infrastructure has been decimated, partly because hospitals, health workers, and medical supplies have been targeted, which has rendered a large number of health care facilities nonfunctional.4 The magnitude of morbidity and mortality in this region has overwhelmed the local response system, which has made Syria dependent on foreign aid for medical care. Traditionally, responders to mass casualty events such as this one have included government/military physicians, trauma surgeons, intensivists, and emergency department physicians; however, over the past decade, there has been increasing awareness of the role of the neurologist in humanitarian assistance and disaster response (HADR) missions,5,6 as well as the significant role that neurologists can play by volunteering in low- and middle-income countries.7 The role of neurologists in both natural and man-made disasters is one that the practicing neurologist should be aware of.

Summary 1 million cases of tetanus are estimated to occur worldwide each year, with more than 200 000 deaths. Tetanus is a life-threatening but preventable disease caused by a toxin produced by Clostridium tetani —a Gram-positive bacillus found in high concentrations in soil and animal excrement. Tetanus is almost completely preventable by active immunisation, but very rarely unexpected cases can occur in individuals who have been previously vaccinated. We report a case of generalised tetanus in a 22-year-old woman that arose despite the protective antitoxin antibody in her serum. The patient received all her vaccinations in the USA; her last vaccination was 6 years ago. The case was unusual because the patient had received all standard vaccinations, had no defined port of entry at disease onset, and had symptoms lasting for 6 months. Tetanus can present with unusual clinical forms; therefore, the diagnosis and management of this rare but difficult disease should be updated. In this Grand Round, we review the clinical features, epidemiology, treatment, and prognosis of C tetani infections.

Brazilian Jiu-Jitsu (BJJ) is a rapidly growing grappling sport with a wide spectrum of participants. This cross-sectional study examined the lifetime prevalence of concussion in adult BJJ practitioners in the United States using a 17-item survey. A total of 778 (11.4% female) BJJ practitioners with a median age of 31 years completed the survey. Overall, the lifetime prevalence of the self-reported BJJ-related concussion was 25.2%. However, the prevalence was higher among females than males (43.0% versus 22.9%, X2(1,740) = 15.129, p &lt, 0.001). Factors independently associated with significantly increased odds of having sustained a BJJ-related concussion included a prior history of concussion (OR 1.76, 95% CI 1.14&ndash, 2.74, p = 0.011) and female gender (OR 1.95, 95% CI 1.04&ndash, 3.65, p = 0.037). The median return to sports time was three days, with 30.3% of participants returning on the same day as being concussed. The present study represents the first epidemiological research examining the concussions in BJJ. The results underscore the need for increased education on concussions and return to sports guidelines among BJJ coaches and practitioners.

Haiti is a country rich in revolutionaries and visionaries. It has faced countless hardships, most recently the devastating earthquake of 2010. In 2011, the population was estimated at approximately 10 million people. WHO estimates show a stark difference in the health of Haitians compared to other inhabitants of the region (table 1).1

Headlines are filled with stories of the physical disability and loss of life that results from both natural and man-made disasters. The role of a neurologist as part of the response to these tragedies has moved from a supportive role to the front line. Recent earthquakes in Haiti and Japan as well as military conflicts in Iraq and Afghanistan have demonstrated an increased need for nonsurgical neurologic care. Disaster neurology has become attractive to neurologists at many stages of their careers. Employed, academic, and private practice neurologists all have the potential to embrace this opportunity to apply their clinical skills to help others in need of care. Neurologists interested in engaging in disaster relief efforts should have the ability to respond to a situation quickly with the flexibility of devoting several weeks to the response effort.

There are few data available regarding the safety or efficacy of thrombolysis of acute ischemic stroke secondary to myxoma. We present a patient treated with intravenous recombinant tissue plasminogen activator who developed hemorrhage remote from the location of ischemic stroke. Intra-arterial local thrombolysis may be a preferable alternative because of greater risk of hemorrhage from occult tumor emboli or microaneurysms in these patients.

Summary Recent studies have provided much needed data on the probability of seizure remission among adults with chronic intractable epilepsy treated medically. Here we provide an extended follow-up to our earlier study in order to provide a more comprehensive picture of long-term prognosis in this patient population during medical treatment. The prevalence cohort was followed for two outcomes—complete seizure remission for ≥12 months and subsequent seizure relapse among those attaining a seizure remission. The study outcomes were estimated using Kaplan–Meier analysis. We found that the probability of attaining a ≥12 months of complete seizure freedom to be approximately 3–4% per year through 8 years of follow-up. By year 5 since the start of seizure remission, the cumulative probability of seizure relapse was 81%, although only half of the patients with seizure relapse went on to experience their previous seizure frequency.

On January 12, 2010, a 7.0 Richter earthquake devastated Haiti and its public health infrastructure leading to a worldwide humanitarian effort. The United States sent forces to Haiti’s assistance including the USNS Comfort, a tertiary care medical center on board a ship. Besides setting a transparent triage and medical regulating system, the leadership on the Comfort instituted a multidisciplinary Healthcare Ethics Committee to assist in delivering the highest level efficient care to the largest number of victims. Allocation of resources was based on time-honored ethics principles, the concept of mass casualty triage in the setting of resource constraints, and constructs developed by the host nation’s Ministry of Health. In offering aid in austere circumstances, healthcare practitioners must not only adhere to the basic healthcare ethics principles but also practice respect for communities, cultures, and traditions, as well as demonstrate respect for the sovereignty of the host nation. The principles outlined herein should serve as guidance for future disaster relief missions. This work is in accordance with BUMEDINST 6010.25, Establishment of Healthcare Ethics Committees.

Objective To describe a patient with an acute fulminant delirium and eventual spinal fluid block secondary to sarcoid meningitis. Design Case report. Setting Hospital and Neurology Clinic. Patient A previously healthy, 24-year-old man. Interventions Antimicrobials, corticosteroids, lumbar puncture, myelography, and lymph node biopsy. Main Outcome Measures Cerebrospinal fluid, clinical status. Results The patient improved after treatment with corticosteroids. Conclusion Sarcoid meningitis may present with delirium and spinal block.

Improved recognition and availability of noninvasive testing of autonomic disorders has prompted a better understanding of disease mechanisms of some disease forms, especially potentially treatable immune-mediated autonomic neuropathies. Development is acute, subacute, or less commonly chronic. Autonomic involvement is common and an important cause of morbidity and mortality in Guillain-Barre syndrome. Acute autonomic neuropathy can affect parasympathetic, sympathetic, and enteric nerves or neurons and is associated with antibodies to ganglionic nicotinic acetylcholine receptors. These antibodies appear to be causative based on a rabbit immunization model and serum transfer studies from patients and animals. Other important immune autonomic disorders discussed include Lambert-Eaton myasthenic syndrome, some forms of orthostatic intolerance, chronic autonomic neuropathy, and Sjogren syndrome. Paraneoplastic autonomic disorders are clinically indistinguishable and associated with various overlapping antibody associations, including anti-Hu (ANNA-1), ganglionic acetylcholine receptors, CRMP-5, and PCA-2.

As we approach the 1-year anniversary of the deadliest natural disaster in the history of the Western Hemisphere, a Haitian American neurologist reflects on his experience aboard the USNS Comfort. I walked onto the 2 Forward (Pediatrics) ward to see a young girl, hearing the familiar sounds of Haitian spirituals being sung. The girl was screaming. I had seen her the previous night in the casualty receiving area when the pediatric surgeon was discussing the need for an amputation of one of her legs. Although she was 8 years old, I thought she did not follow the discussion. In retrospect, I realize that she understood but had the stoicism that was common among the Haitian patients we were treating on the USNS Comfort after the Haitian earthquake. Her mother, though, had refused consent for amputation, largely based on strict instructions from the girl's father. When I arrived at her bedside on 2 Forward, someone from the physical therapy team was trying to work with her and she was screaming “Pa coupe jambe mwen, pa coupe jambe mwen”—“Don't cut off my leg.” It was not the first time I had seen a patient on the Comfort fear …

Objective: To characterize autonomic nervous system (ANS) abnormalities unique to active duty US service members and compare those findings to civilian counterparts. Background Autonomic dysfunction is increasingly recognized as a contributor to morbidity in patients with traumatic brain injury (TBI). The signature injury of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) is TBI so the military offers a special population to study ANS dysfunction. The purpose of this study is to analyze the difference in autonomic complaints and autonomic testing results of active duty compared to civilian patients. Design/Methods: We reviewed retrospectively the records of all patients who were evaluated at a Military Medical Treatment Facility (MTF) autonomic laboratory over a 12 month period. These patients included 56 active duty military and 49 civilians. The percentage of patients who presented with orthostatic intolerance (OI) and syncope was calculated and the distribution of diagnoses was evaluated. Tests considered included the heart rate response to deep breathing, valsalva, and tilt table testing. Results: Active duty service members were most commonly referred to the autonomic laboratory for OI (N=13, 23%) and syncope (N=23, 41%). 37 (66%) had normal studies, 13 (23%) were found to have OI and four were diagnosed with postural orthostatic tachycardia syndrome (POTS). Civilians were commonly referred to the autonomic laboratory for OI (N=10, 20%) and syncope (N=20, 40%). 27 (55%) of the studies were normal, six had orthostatic intolerance, four had POTS, and four had adrenergic failure. Conclusions: Autonomic disorders are underrecognized in the military. Active duty service members with autonomic dysfunction may be classified as unfit for duty due to the rigorous nature of work in the military. ANS disorders in service members should be recognized early so they may be properly addressed and increase the service members likelihood of returning to full duty. Disclosure: Dr. Crimmins has nothing to disclose. Dr. Etienne has nothing to disclose.

On 12 January 2010, a 7.0-magnitude earthquake devastated the island nation of Haiti, leading to the world's largest humanitarian effort in over 6 decades. The catastrophe caused massive destruction of homes and buildings and overwhelmed the Haitian health care system. The United States responded immediately with a massive relief effort, sending U.S. military forces and civilian volunteers to Haiti's aid and providing a tertiary care medical center aboard the USNS COMFORT hospital ship. The COMFORT offered sophisticated medical care to a geographically isolated population and helped to transfer resource-intensive patients from other treatment facilities. Working collaboratively with the surgical staff, ancillary services, and nursing staff, internists aboard the COMFORT were integral to supporting the mission of the hospital ship and provided high-level care to the casualties. This article provides the perspective of the U.S. Navy internists who participated in the initial response to the Haitian earthquake disaster onboard the COMFORT.

Posterior Reversible Encephalopathy Syndrome (PRES) is a syndrome comprising headache, altered mentation, and seizures, associated with neuroimaging findings characteristic of subcortical edema in the posterior regions. It is usually seen in patients treated with immunosuppressants, in renal failure, or with eclampsia. Recurrent episodes of PRES in the same patient are rarely observed. Although seizures are often seen in PRES, EEG findings are not well described and include generalized and focal slowing with epileptiform discharges; there are limited reports of Periodic Lateralized Epileptiform Discharges (PLEDs) occurring during PRES, and there are no reports of PRES associated with PLEDs with subsequent development of epilepsy. We report a patient we followed for one year with recurrent episodes of PRES associated with posteriorly dominant independent bilateral PLEDs who subsequently developed epilepsy. Patients with PRES and PLEDs should be treated aggressively with anti-hypertensive and anti-epileptic agents in order to avoid potential complications. Although PRES is typically thought of as a reversible syndrome, this case illustrates that PRES may have serious long term sequelae after the reversible syndrome has resolved. This case highlights the importance of aggressive management of PRES as well as the prevention of subsequent episodes of PRES as patients may develop permanent brain dysfunction.