Correlation between ED symptoms and clinical outcomes in the patient with aneurysmal subarachnoid hemorrhage

The combined signatures of telomere and immune cell landscape provide a prognostic and therapeutic biomarker in glioma

Background

Gliomas, the most prevalent primary malignant tumors of the central nervous system in adults, exhibit slow growth in lower-grade gliomas (LGG). However, the majority of LGG cases progress to high-grade gliomas, posing challenges for prognostication. The tumor microenvironment (TME), characterized by telomere-related genes and immune cell infiltration, strongly influences glioma growth and therapeutic response. Therefore, our objective was to develop a Telomere-TME (TM-TME) classifier that integrates telomere-related genes and immune cell landscape to assess prognosis and therapeutic response in glioma.

Methods

This study encompassed LGG patients from the TCGA and CCGA databases. TM score and TME score were derived from the expression signatures of telomere-related genes and the presence of immune cells in LGG, respectively. The TM-TME classifier was established by combining TM and TME scores to effectively predict prognosis. Subsequently, we conducted Kaplan-Meier survival estimation, univariate Cox regression analysis, and receiver operating characteristic curves to validate the prognostic prediction capacity of the TM-TME classifier across multiple cohorts. Gene Ontology (GO) analysis, biological processes, and proteomaps were performed to annotate the functional aspects of each subgroup and visualize the cellular signaling pathways.

Results

The TM_low+TME_high subgroup exhibited superior prognosis and therapeutic response compared to other subgroups (P<0.001). This finding could be attributed to distinct tumor somatic mutations and cancer cellular signaling pathways. GO analysis indicated that the TM_low+TME_high subgroup is associated with the neuronal system and modulation of chemical synaptic transmission. Conversely, the TM_high+TME_low subgroup showed a strong association with cell cycle and DNA metabolic processes. Furthermore, the classifier significantly differentiated overall survival in the TCGA LGG cohort and served as an independent prognostic factor for LGG patients in both the TCGA cohort (P<0.001) and the CGGA cohort (P<0.001).

Conclusion

Overall, our findings underscore the significance of the TM-TME classifier in predicting prognosis and immune therapeutic response in glioma, shedding light on the complex immune landscape within each subgroup. Additionally, our results suggest the potential of integrating risk stratification with precision therapy for LGG.

Medical malpractice and intracranial hemorrhages in the U.S.: An analysis of 121 cases over 35 years

Introduction

Though all physicians are at risk for medical malpractice litigation, those in surgical specialties, particularly neurosurgeons, are at increased risk. Because intracranial hemorrhages are a life-threatening and commonly misdiagnosed condition, the aim of this study is to identify and increase awareness of factors associated with litigation in cases of intracranial hemorrhages.

Methods

The online legal database Westlaw was utilized to query public litigation cases related to the management of intracranial hemorrhages between 1985 and 2020. Various search terms were used to identify cases, and the following variables were extracted: plaintiff demographics, defendant specialty, trial year, court type, location, reason for litigation, plaintiff medical complaints, trial outcomes, and payouts for both verdicts and settlements. Comparative analysis was performed between cases decided in favor of the plaintiff and in favor of the defendant.

Results

A total of 121 cases met inclusion criteria. The most common type of hemorrhage was subarachnoid (65.3%), and the most common cause of hemorrhage was cerebral aneurysm/vascular malformation (37.2%). Most cases were brought against a hospital or healthcare system (60.3%), followed by emergency medicine physicians (33.1%), family medicine physicians (10.7%), and neurosurgeons (6.6%). Failure to diagnose was the most common reason for litigation (84.3%). Cases most frequently resulted in verdicts favoring the defense (48.8%), followed by settlements (35.5%). Plaintiffs were found to be significantly younger in cases ruled in favor of the plaintiff than in cases ruled in favor of the defense (p = 0.014). Cases ruled in favor of the plaintiff were also significantly more likely to involve a neurologist (p = 0.029).

Conclusions

Most cases of intracranial hemorrhage resulting in malpractice litigation were classified as subarachnoid hemorrhages and caused by aneurysm/vascular malformation. Most cases were brought against hospital systems, and failure to diagnose was the most common reason for litigation. Cases resulting in verdicts in favor of the plaintiff were significantly more likely to involve younger plaintiffs and neurologists.

Symptoms presented during emergency telephone calls for patients with spontaneous subarachnoid haemorrhage

Background

A spontaneous subarachnoid haemorrhage (SAH) is one of the most critical neurological emergencies a dispatcher can face in an emergency telephone call. No study has yet investigated which symptoms are presented in emergency telephone calls for these patients. We aimed to identify symptoms indicative of SAH and to determine the sensitivity of these and their association (odds ratio, OR) with SAH.

Methods

This was a nested case–control study based on all telephone calls to the medical dispatch center of Copenhagen Emergency Medical Services in a 4-year time period. Patients with SAH were identified in the Danish National Patient Register; diagnoses were verified by medical record review and their emergency telephone call audio files were extracted. Audio files were replayed, and symptoms extracted in a standardized manner. Audio files of a control group were replayed and assessed as well.

Results

We included 224 SAH patients and 609 controls. Cardiac arrest and persisting unconsciousness were reported in 5.8% and 14.7% of SAH patients, respectively. The highest sensitivity was found for headache (58.9%), nausea/vomiting (46.9%) and neck pain (32.6%). Among conscious SAH patients these symptoms were found to have the strongest association with SAH (OR 27.0, 8.41 and 34.0, respectively). Inability to stand up, speech difficulty, or sweating were reported in 24.6%, 24.2%, and 22.8%. The most frequent combination of symptoms was headache and nausea/vomiting, which was reported in 41.6% of SAH patients. More than 90% of headaches were severe, but headache was not reported in 29.7% of conscious SAH patients. In these, syncope was described by 49.1% and nausea/vomiting by 37.7%.

Conclusion

Headache, nausea/vomiting, and neck pain had the highest sensitivity and strongest association with SAH in emergency telephone calls. Unspecific symptoms such as inability to stand up, speech difficulty or sweating were reported in 1 out of 5 calls. Interestingly, 1 in 3 conscious SAH patients did not report headache.

Trial registration NCT03980613 (www.clinicaltrials.gov).

The positive predictive value of spontaneous subarachnoid hemorrhage diagnoses in the Danish National Patient Register

Introduction: Spontaneous (non-traumatic) subarachnoid hemorrhage (ntSAH) is frequently suspected in the emergency department, but the incidence rate is low. Diagnosis registers can provide valuable data for research in uncommon conditions like ntSAH. Unfortunately, validity vary in the registers. We aimed to assess the validity of the ntSAH diagnosis in the Danish National Patient Register (DNPR) and secondly to describe patients misclassified as ntSAH and to calculate the incidence rate of ntSAH. Methods: From the DNPR we extracted information on patients at least 18 years of age on admission registered with a diagnosis of ntSAH and admitted to a hospital in the Capital Region of Denmark between January 1, 2008 and December 31, 2014. Two independent investigators reviewed the medical records to assess if the diagnosis could be confirmed. Those not confirmed were categorized according to a predeveloped case report form. Results: We identified 1101 patients with a diagnosis of ntSAH; medical records were accessible for 1069 (97.7%) and 842 (78.8%) met the inclusion criteria. The diagnosis was confirmed in 537 patients (63.8% (95% confidence interval: 60.5-67.0%)). Among patients where ntSAH was not confirmed, 122 (40.0%) had a traumatic subarachnoid hemorrhage (tSAH), ntSAH had been suspected in 57 (18.9%) patients but was not substantiated during admission, while parenchymal hemorrhages were identified in 45 (14.5%) patients. The incidence rate was 5.5 (95% CI: 4.9-6.1) per 100,000 persons per year. Conclusion: We found a positive predictive value (PPV) of 63.8% for the diagnosis of non-traumatic subarachnoid hemorrhage in the Danish National Patient Register. The low PPV suggests that care should be taken if unvalidated data are used for research and that results of previous studies should be interpreted with caution.

Improved survival after non-traumatic subarachnoid haemorrhage with structured care pathways and modern intensive care

OBJECTIVE

Patients with subarachnoid haemorrhage (SAH) often require multidisciplinary management and their treatment is difficult to standardize. The aim was to describe baseline characteristics, care pathways and discharge status in an unselected group of patients with first ever non-traumatic SAH, and to examine whether their care pathways and outcomes vary.

METHODS

Patients admitted with first ever non-traumatic SAH to a neurosurgical unit (NSU) in Sweden during a period of 18 months in 2009-2010 were included. The data was retrospectively collected from patient charts.

RESULTS

A total of 131 patients were admitted with first ever non-traumatic SAH. Forty-nine (37%) patients initially sought medical care nearby the NSU and 82 (63%) in other parts of the catchment area. The average age was 55.5 years and 79 (60%) were female. In 98 (75%) cases, a ruptured aneurysm was found to be the cause of SAH. There was a significant correlation between poor clinical grade at admission and poor patient outcome (p<0.0005). No significant correlation between early aneurysm treatment and improved clinical outcome were seen. No significant differences in outcome were seen between patients who initially sought medical care nearby the NSU and those in other parts of the catchment area. There was no difference seen in the number of patients who had follow-up at the NSU depending on where they initially sought help.

CONCLUSION

This study shows an improvement in survival after SAH compared to earlier studies in Sweden. The results are indicative of effective management of all patients with SAH in the catchment area that are treated at the NSU. A nationwide registry to assess the overall management of patients treated for SAH would be useful to further investigate patients with SAH.