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Durand NC, Kim HG, Patel VN, Turnbull MT, Siegel JL, Hodge DO, Tawk RG, Meschia JF, Freeman WD, Zubair AC. Mesenchymal Stem Cell Therapy in Acute Intracerebral Hemorrhage: A Dose-Escalation Safety and Tolerability Trial. Neurocrit Care 2024; 41:59-69. [PMID: 38114796 PMCID: PMC11335835 DOI: 10.1007/s12028-023-01897-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/15/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND We conducted a preliminary phase I, dose-escalating, safety, and tolerability trial in the population of patients with acute intracerebral hemorrhage (ICH) by using human allogeneic bone marrow-derived mesenchymal stem/stromal cells. METHODS Eligibility criteria included nontraumatic supratentorial hematoma less than 60 mL and Glasgow Coma Scale score greater than 5. All patients were monitored in the neurosciences intensive care unit for safety and tolerability of mesenchymal stem/stromal cell infusion and adverse events. We also explored the use of cytokines as biomarkers to assess responsiveness to the cell therapy. We screened 140 patients, enrolling 9 who met eligibility criteria into three dose groups: 0.5 million cells/kg, 1 million cells/kg, and 2 million cells/kg. RESULTS Intravenous administration of allogeneic bone marrow-derived mesenchymal stem/stromal cells to treat patients with acute ICH is feasible and safe. CONCLUSIONS Future larger randomized, placebo-controlled ICH studies are necessary to validate this study and establish the effectiveness of this therapeutic approach in the treatment of patients with ICH.
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Affiliation(s)
- Nisha C Durand
- Center for Regenerative Biotherapeutics, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
- Human Cellular Therapy Laboratory, Mayo Clinic, Jacksonville, FL, USA.
| | - H G Kim
- Clinical Research Intern Scholar Program, Mayo Clinic, Jacksonville, FL, USA
| | - Vishal N Patel
- Division of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA
| | - Marion T Turnbull
- Research Collaborator in the Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Jason L Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - David O Hodge
- Biostatistics Unit, Mayo Clinic, Jacksonville, FL, USA
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - W David Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Abba C Zubair
- Center for Regenerative Biotherapeutics, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Department of Laboratory Medicine and Pathology, Center for Regenerative Biotherapeutics, Mayo Clinic, Jacksonville, FL, USA
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Samarasekera N, Ferguson K, Parry-Jones AR, Rodrigues M, Loan J, Moullaali TJ, Hughes J, Shoveller L, Wardlaw J, McColl B, Allan SM, Selim M, Norrie J, Smith C, Al-Shahi Salman R. Perihaematomal Oedema Evolution over 2 Weeks after Spontaneous Intracerebral Haemorrhage and Association with Outcome: A Prospective Cohort Study. Cerebrovasc Dis 2024:1-10. [PMID: 38952101 DOI: 10.1159/000540099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/21/2024] [Indexed: 07/03/2024] Open
Abstract
INTRODUCTION We know little about the evolution of perihaematomal oedema (PHO) >24 h after ICH onset. We aimed to determine the trajectory of PHO after ICH onset and its association with outcome. METHODS We did a prospective cohort study using a pre-specified scanning protocol in adults with first-ever spontaneous ICH and measured absolute PHO volumes on CT head scans at ICH diagnosis and 3 ± 2, 7 ± 2, and 14 ± 2 days after ICH onset. We used the largest ICH if ICHs were multiple. The primary outcomes were (a) the trajectory of PHO after ICH onset and (b) the association between PHO (absolute volume at the time when most repeat CT head scans were obtained, and change in PHO volume at this time compared with the first CT head scan) and poor functional outcome (modified Rankin scale 3-6 at 90 days). We pre-specified multivariable logistic regression models of this association adjusting analyses for potential confounders: age, GCS, infratentorial ICH location, and intraventricular extension. RESULTS In 106 participants of whom 49 (46%) were female, with a median ICH volume 7 mL (interquartile range [IQR] 2-22 mL), the trajectory of median PHO volume increased from 14 mL (IQR: 7-26 mL) at diagnosis to 18 mL (IQR: 8-40 mL) at 3 ± 2 days (n = 87), 20 mL (IQR: 8-48 mL) at 7 ± 2 days (n = 93) and 21 mL (IQR: 10-54 mL) at 14 ± 2 days (n = 78) (p = <0.001). PHO volume at each time point was collinear with ICH volume at diagnosis (│r│ >0.7), but the change in PHO volume between diagnosis and each time point was not. Given collinearity, we used total lesion (i.e., ICH + PHO) volume instead of PHO volume in a logistic regression model of its association at each time point with outcome. Increasing total lesion (ICH + PHO) volume at day 7 ± 2 was associated with poor functional outcome (adjusted OR per mL 1.02, 95% CI: 1.00-1.03; p = 0.036), but the increase in PHO volume between diagnosis and day 7 ± 2 was not associated with poor functional outcome (adjusted OR per mL 1.03, 95% CI: 0.99-1.07; p = 0.132). CONCLUSION PHO volume increases throughout the first 2 weeks after onset of mild to moderate ICH. Total lesion (ICH + PHO) volume at day 7 ± 2 was associated with poor functional outcome, but the change in PHO volume between diagnosis and day 7 ± 2 was not. Prospective cohort studies with larger sample sizes are needed to investigate these associations and their modifiers.
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Affiliation(s)
| | - Karen Ferguson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Adrian Robert Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal National Health Service Foundation Trust, University of Manchester, Manchester, UK
| | - Mark Rodrigues
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - James Loan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jeremy Hughes
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Laura Shoveller
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Barry McColl
- UK Dementia Research Institute Centre, Centre for Discovery Brain Sciences University of Edinburgh, Edinburgh, UK
| | - Stuart M Allan
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Colin Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Muehlschlegel S. Prognostication in Neurocritical Care. Continuum (Minneap Minn) 2024; 30:878-903. [PMID: 38830074 DOI: 10.1212/con.0000000000001433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication. LATEST DEVELOPMENTS Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care. ESSENTIAL POINTS This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.
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Schwiddessen R, Brelie CVD, Mielke D, Rohde V, Malinova V. Establishing reliable selection criteria for performing fibrinolytic therapy in patients with intracerebral haemorrhage based on prognostic tools. J Stroke Cerebrovasc Dis 2024; 33:107804. [PMID: 38821191 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/19/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024] Open
Abstract
OBJECTIVES Minimally invasive surgery combined with fibrinolytic therapy is a promising treatment option for patients with intracerebral haemorrhage (ICH), but a meticulous patient selection is required, because not every patient benefits from it. The ICH score facilitates a reliable patient selection for fibrinolytic therapy except for ICH-4. This study evaluated whether an additional use of other prognostic tools can overcome this limitation. MATERIALS AND METHODS A consecutive ICH patient cohort treated with fibrinolytic therapy between 2010 and 2020 was retrospectively analysed. The following prognostic tools were calculated: APACHE II, ICH-GS, ICH-FUNC, and ICH score. The discrimination power of every score was determined by ROC-analysis. Primary outcome parameters regarding the benefit of fibrinolytic therapy were the in-hospital mortality and a poor outcome defined as modified Rankin scale (mRS) > 4. RESULTS A total of 280 patients with a median age of 72 years were included. The mortality rates according to the ICH score were ICH-0 = 0 % (0/0), ICH-1 = 0 % (0/22), ICH-2 = 7.1 % (5/70), ICH-3 = 17.3 % (19/110), ICH-4 = 67.2 % (45/67), ICH-5 = 100 % (11/11). The APACHE II showed the best discrimination power for in-hospital mortality (AUC = 0.87, p < 0.0001) and for poor outcome (AUC = 0.79, p < 0.0001). In the subgroup with ICH-4, APACHE II with a cut-off of 24.5 showed a good discriminating power for in-hospital mortality (AUC = 0.83, p < 0.001) and for poor outcome (AUC = 0.87, p < 0.001). CONCLUSIONS An additional application of APACHE II score increases the discriminating power of ICH score 4 enabling a more precise appraisal of in-hospital mortality and of functional outcome, which could support the patient selection for fibrinolytic therapy.
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Affiliation(s)
| | - Christian von der Brelie
- Department of Neurosurgery, University Medical Center, Göttingen, Germany; Department of Neurosurgery and Spine Surgery, Johanniter-Kliniken Bonn, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center, Göttingen, Germany; Department of Neurosurgery, University Medical Center Augsburg, Augsburg, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center, Göttingen, Germany.
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Lernon SM, Frings D, Terry L, Simister R, Browning S, Burgess H, Chua J, Reddy U, Werring DJ. Doctors and nurses subjective predictions of 6-month outcome compared to actual 6-month outcome for adult patients with spontaneous intracerebral haemorrhage (ICH) in neurocritical care: An observational study. eNeurologicalSci 2024; 34:100491. [PMID: 38274038 PMCID: PMC10809071 DOI: 10.1016/j.ensci.2023.100491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
Background Acute spontaneous intracerebral haemorrhage is a devastating form of stroke. Prognostication after ICH may be influenced by clinicians' subjective opinions. Purpose To evaluate subjective predictions of 6-month outcome by clinicians' for ICH patients in a neurocritical care using the modified Rankin Scale (mRS) and compare these to actual 6-month outcome. Method We included clinicians' predictions of 6-month outcome in the first 48 h for 52 adults with ICH and compared to actual 6-month outcome using descriptive statistics and multilevel binomial logistic regression. Results 35/52 patients (66%) had a poor 6-month outcome (mRS 4-6); 19/52 (36%) had died. 324 predictions were included. For good (mRS 0-3) versus poor (mRS 4-6), outcome, accuracy of predictions was 68% and exact agreement 29%. mRS 6 and mRS 4 received the most correct predictions. Comparing job roles, predictions of death were underestimated, by doctors (12%) and nurses (13%) compared with actual mortality (36%). Predictions of vital status showed no significant difference between doctors and nurses: OR = 1.24 {CI; 0.50-3.05}; (p = 0.64) or good versus poor outcome: OR = 1.65 {CI; 0.98-2.79}; (p = 0.06). When predicted and actual 6-month outcome were compared, job role did not significantly relate to correct predictions of good versus poor outcome: OR = 1.13 {CI;0.67-1.90}; (p = 0.65) or for vital status: OR = 1.11 {CI; 0.47-2.61}; p = 0.81). Conclusions Early prognostication is challenging. Doctors and nurses were most likely to correctly predict poor outcome but tended to err on the side of optimism for mortality, suggesting an absence of clinical nihilism in relation to ICH.
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Affiliation(s)
- Siobhan Mc Lernon
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
- London South Bank University, School of Health and Social Care, London, UK
| | - Daniel Frings
- London South Bank University, School of Applied Sciences, London, UK
| | - Louise Terry
- London South Bank University, School of Health and Social Care, London, UK
| | - Rob Simister
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation, Queen Square, London, UK
- University College London Hospital NHS Foundation Trust, Hyper Acute Stroke Unit, National Hospital for Neurology and Neurosurgery, UK
| | - Simone Browning
- University College London Hospital NHS Foundation Trust, Hyper Acute Stroke Unit, National Hospital for Neurology and Neurosurgery, UK
| | - Helen Burgess
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation, Queen Square, London, UK
| | - Josenile Chua
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation, Queen Square, London, UK
| | - Ugan Reddy
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation, Queen Square, London, UK
| | - David J. Werring
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation, Queen Square, London, UK
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Yeh HL, Hsieh FI, Lien LM, Kuo WH, Jeng JS, Sun Y, Wei CY, Yeh PY, Yip HT, Lin CL, Huang N, Hsu KC. Patient and hospital characteristics associated with do-not-resuscitate/do-not-intubate orders: a cross-sectional study based on the Taiwan stroke registry. BMC Palliat Care 2023; 22:138. [PMID: 37715158 PMCID: PMC10503153 DOI: 10.1186/s12904-023-01257-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Previous studies of do-not-resuscitate (DNR) or do-not-intubate (DNI) orders in stroke patients have primarily been conducted in North America or Europe. However, characteristics associated with DNR/DNI orders in stroke patients in Asia have not been reported. METHODS Based on the Taiwan Stroke Registry, this nationwide cross-sectional study enrolled hospitalized stroke patients from 64 hospitals between 2006 and 2020. We identified characteristics associated with DNR/DNI orders using a two-level random effects model. RESULTS Among the 114,825 patients, 5531 (4.82%) had DNR/DNI orders. Patients with acute ischemic stroke (AIS) had the highest likelihood of having DNR/DNI orders (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.61-1.93), followed by patients with intracerebral hemorrhage (ICH), and patients with subarachnoid hemorrhage (SAH) had the lowest likelihood (aOR 0.53, 95% CI 0.43-0.66). From 2006 to 2020, DNR/DNI orders increased in all three types of stroke. In patients with AIS, women were significantly more likely to have DNR/DNI orders (aOR 1.23, 95% CI 1.15-1.32), while patients who received intravenous alteplase had a lower likelihood (aOR 0.74, 95% CI 0.65-0.84). Patients with AIS who were cared for by religious hospitals (aOR 0.55, 95% CI 0.35-0.87) and patients with SAH who were cared for by medical centers (aOR 0.40, 95% CI 0.17-0.96) were significantly less likely to have DNR/DNI orders. CONCLUSIONS In Taiwan, DNR/DNI orders increased in stroke patients between 2006 and 2020. Hospital characteristics were found to play a significant role in the use of DNR/DNI orders.
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Affiliation(s)
- Hsu-Ling Yeh
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Fang-I Hsieh
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Wen-Hua Kuo
- Institute of Science, Technology, and Society, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center, Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan
| | - Cheng-Yu Wei
- Department of Exercise and Health Promotion, College of Kinesiology and Health, Chinese Culture University, Taipei, Taiwan
| | - Po-Yen Yeh
- Department of Neurology, St. Martin de Porres Hospital, Chiayi City, Taiwan
| | - Hei-Tung Yip
- Management office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No. 155, Section 2, Li-Nong Street, Taipei 112, Taipei, Taiwan.
| | - Kai-Cheng Hsu
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
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Comer AR, Fettig L, Bartlett S, Sinha S, D'Cruz L, Odgers A, Waite C, Slaven JE, White R, Schmidt A, Petras L, Torke AM. Code status orders in hospitalized patients with COVID-19. Resusc Plus 2023; 15:100452. [PMID: 37662642 PMCID: PMC10470381 DOI: 10.1016/j.resplu.2023.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Background The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19. Methods A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020). Results Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80. Conclusions There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.
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Affiliation(s)
- Amber R. Comer
- Indiana University School of Health and Human Science, United States
- Indiana University School of Medicine, United States
- American Medical Association, United States
| | - Lyle Fettig
- Indiana University School of Medicine, United States
| | | | - Shilpee Sinha
- Indiana University School of Medicine, United States
| | - Lynn D'Cruz
- Indiana University School of Health and Human Science, United States
| | - Aubrey Odgers
- Indiana University School of Health and Human Science, United States
| | - Carly Waite
- Indiana University School of Health and Human Science, United States
| | | | - Ryan White
- Indiana University School of Medicine, United States
| | | | - Laura Petras
- Indiana University School of Medicine, United States
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Kalasapudi L, Williamson S, Shipper AG, Motta M, Esenwa C, Otite FO, Chaturvedi S, Morris NA. Scoping Review of Racial, Ethnic, and Sex Disparities in the Diagnosis and Management of Hemorrhagic Stroke. Neurology 2023; 101:e267-e276. [PMID: 37202159 PMCID: PMC10382273 DOI: 10.1212/wnl.0000000000207406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/28/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the United States, Black, Hispanic, and Asian Americans experience excessively high incidence rates of hemorrhagic stroke compared with White Americans. Women experience higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity. METHODS We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients aged 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke. RESULTS After reviewing 6,161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control after intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care. DISCUSSION Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.
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Affiliation(s)
- Lakshman Kalasapudi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Stacey Williamson
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Andrea G Shipper
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Melissa Motta
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Charles Esenwa
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Fadar Oliver Otite
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Seemant Chaturvedi
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse
| | - Nicholas A Morris
- From the Department of Neurology (L.K., M.M., S.C., N.M.) and Health Sciences and Human Services Library (A.S.), University of Maryland School of Medicine, Baltimore; Department of Neurology (S.W.), Henry Ford Health System, Detroit, MI; Program in Trauma (M.M., N.M.), Shock Trauma Hospital, Baltimore, MD; Department of Neurology (C.E.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Department of Neurology (F.O.O.), State University of New York Upstate Medical University, Syracuse.
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Mark DG, Huang J, Sonne DC, Rauchwerger AS, Reed ME. Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated "Hub-and-Spoke" Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation? Neurocrit Care 2023; 38:761-770. [PMID: 36600074 DOI: 10.1007/s12028-022-01667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization. METHODS This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a "hub-and-spoke" model of neuroscience care in which two centers service as neuroscience "hubs" and the remaining 19 centers service as referral "spokes." Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less]. RESULTS A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44). CONCLUSIONS Within an integrated "hub-and-spoke" neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a "hub-and-spoke" care model for patients with nontraumatic ICH, although additional investigations are warranted.
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Affiliation(s)
- Dustin G Mark
- Departments of Emergency Medicine and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
| | - Jie Huang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - D Chris Sonne
- Division of Neuroradiology, Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
| | - Adina S Rauchwerger
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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10
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Abstract
Differences exist between genders in intracerebral hemorrhage cause, epidemiology, and outcomes. These gender differences are in part attributable to physiologic differences; however, demographic, social/behavioral risk factors, along with health care system variation and potential family and/or clinician bias play a role as well. These factors vary from region to region and interact, making comprehensive and definitive conclusions regarding sex differences a challenging task. Differences between the genders in intracerebral hemorrhage epidemiology and extensive differences in underlying pathophysiology, intervention, risk factors, and outcome are all discussed.
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Affiliation(s)
- Nicholas Dykman Osteraas
- Department of Neurological Sciences, Division of Cerebrovascular Diseases, Rush University Medical Center, 1725 West Harrison Street Suite 118, Chicago, IL 60612, USA.
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11
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De-Arteaga M, Elmer J. Self-fulfilling prophecies and machine learning in resuscitation science. Resuscitation 2023; 183:109622. [PMID: 36306959 PMCID: PMC10687765 DOI: 10.1016/j.resuscitation.2022.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/22/2022] [Accepted: 10/17/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Growth of machine learning (ML) in healthcare has increased potential for observational data to guide clinical practice systematically. This can create self-fulfilling prophecies (SFPs), which arise when prediction of an outcome increases the chance that the outcome occurs. METHODS We performed a scoping review, searching PubMed and ArXiv using terms related to machine learning, algorithmic fairness and bias. We reviewed results and selected manuscripts for inclusion based on expert opinion of well-designed or key studies and review articles. We summarized these articles to explore how use of ML can create, perpetuate or compound SFPs, and offer recommendations to mitigate these risks. RESULTS We identify-four key mechanisms through which SFPs may be reproduced or compounded by ML. First, imperfect human beliefs and behavior may be encoded as SFPs when treatment decisions are not accounted for. Since patient outcomes are influenced by a myriad of clinical actions, many of which are not collected in data, this is common. Second, human-machine interaction may compound SFPs through a cycle of mutual reinforcement. Third, ML may introduce new SFPs stemming from incorrect predictions. Finally, historically correct clinical choices may become SFPs in the face of medical progress. CONCLUSION There is a need for broad recognition of SFPs as ML is increasingly applied in resuscitation science and across medicine. Acknowledging this challenge is crucial to inform research and practice that can transform ML from a tool that risks obfuscating and compounding SFPs into one that sheds light on and mitigates SFPs.
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Affiliation(s)
- Maria De-Arteaga
- Information, Risk and Operations Management Department, McCombs School of Business, University of Texas at Austin, Austin, TX, USA
| | - Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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12
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Soomägi A, Viktorisson A, Sunnerhagen KS. Predictors of do-not-attempt-resuscitation decisions in patients with infratentorial or large supratentorial intracerebral hemorrhages and consequences thereafter: a register-based, longitudinal study in Sweden. BMC Neurol 2023; 23:19. [PMID: 36647055 PMCID: PMC9841725 DOI: 10.1186/s12883-023-03056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/06/2023] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Do-not-attempt-resuscitation (DNAR) decisions for patients with infratentorial or large supratentorial intracerebral hemorrhages (ICHs) pose clinical and ethical challenges. We aimed to investigate factors associated with DNAR decisions in patients with infratentorial or large (≥30 mL) supratentorial ICH, and differences in complications, treatment, and mortality. MATERIALS & METHODS This longitudinal, observational study comprised all patients treated for ICH at three stroke units in Gothenburg, Sweden, between November 2014 and June 2019. Patients were identified in the local stroke register, and additional data were collected from medical records and national registries. Mortality rates were followed 1 year after incident ICHs. Factors associated with DNAR decisions, and one-year mortality were explored. RESULTS Of 307 included patients, 164 received a DNAR decision. Most (75%) decisions were made within 24 h. DNAR decisions were associated with higher age, pre-stroke dependency, stroke severity, and intraventricular hemorrhage. Patients without DNAR decisions received thrombosis prophylaxis, oral antibiotics, and rehabilitative evaluations more frequently. The one-year survival probability was 0.16 (95% confidence interval [CI] 0.11-0.23) in patients with DNAR decisions, and 0.87 (95% CI 0.81-0.92) in patients without DNAR decision. DNAR decisions, higher age, stroke severity, hematoma volume, and comorbidities were associated with increased one-year mortality. Thrombosis prophylaxis and living alone were associated with a lower hazard. CONCLUSION The majority of DNAR decisions for patients with infratentorial or large supratentorial ICH were made within 48 h. Higher age, pre-stroke dependency, high stroke severity, and intraventricular hemorrhage predicted receiving a DNAR decision. DNAR decisions were strongly associated with increased short- and long-term mortality.
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Affiliation(s)
- Amanda Soomägi
- grid.8761.80000 0000 9919 9582Institute of Neuroscience and Physiology, Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, and the Sahlgrenska University Hospital, PO Box 430, Per Dubbsgatan 14, 3rd floor, SE 405 30 Gothenburg, Sweden
| | - Adam Viktorisson
- grid.8761.80000 0000 9919 9582Institute of Neuroscience and Physiology, Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, and the Sahlgrenska University Hospital, PO Box 430, Per Dubbsgatan 14, 3rd floor, SE 405 30 Gothenburg, Sweden
| | - Katharina S. Sunnerhagen
- grid.8761.80000 0000 9919 9582Institute of Neuroscience and Physiology, Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, and the Sahlgrenska University Hospital, PO Box 430, Per Dubbsgatan 14, 3rd floor, SE 405 30 Gothenburg, Sweden
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13
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Brizzi K. Outpatient neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:29-48. [PMID: 36599513 DOI: 10.1016/b978-0-12-824535-4.00002-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Palliative care is an approach to patient care that focuses on enhancing quality of life through relief of physical, emotional, and spiritual sources of distress and patient-tailored discussions about goals of care. The palliative care approach can be delivered by any provider, and can occur alongside disease-modifying therapies. For patients with a serious neurologic illness or a neurodegenerative disease, neuropalliative care is a growing field focused on providing high-quality palliative care to neurology patients. There are three models of neuropalliative care delivery in the outpatient setting: a consultative model with a palliative care specialist, an integrated model with an embedded palliative care provider, and a primary palliative care model with the patient's neurology provider. The main components of an outpatient palliative care visit include symptom assessment and treatment, communication about serious illness, advance care planning, and assessment of caregiver needs. For patients with advanced illness, palliative care can help facilitate timely referral to hospice. Through a palliative care approach, outpatient care for patients with serious neurologic disease or neurodegenerative disease can focus on the issues most important to the patient, promote improved illness understanding and planning, and can improve the overall quality of care.
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Affiliation(s)
- Kate Brizzi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Boston, MA, United States.
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14
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Lin V, Lele AV, Fong CT, Jannotta GE, Livesay S, Sharma M, Bonow RH, Town JA, Chou SH, Creutzfeldt CJ, Wahlster S. Impact of COVID-19 on neurocritical care delivery and outcomes in patients with severe acute brain injury - Assessing the initial response in the first US epicenter. J Clin Neurosci 2022; 106:135-140. [PMID: 36308868 PMCID: PMC9556940 DOI: 10.1016/j.jocn.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/06/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022]
Abstract
To investigate the pandemic’s impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, ‘PUI’). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies.
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Affiliation(s)
- Victor Lin
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA.
| | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Christine T Fong
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Gemi E Jannotta
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA; College of Nursing, Rush University, Chicago, IL, USA
| | - Monisha Sharma
- Department of Global Health, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Robert H Bonow
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - James A Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Sherry H Chou
- Ken and Ruth Davee Dept of Neurology, Northwestern University Feinberg School of Medicine, Chicago IL, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
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15
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DeHoff G, Lau W. Medical management of cerebral edema in large hemispheric infarcts. Front Neurol 2022; 13:857640. [PMID: 36408500 PMCID: PMC9672377 DOI: 10.3389/fneur.2022.857640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/26/2022] [Indexed: 09/08/2024] Open
Abstract
Acute ischemic stroke confers a high burden of morbidity and mortality globally. Occlusion of large vessels of the anterior circulation, namely the intracranial carotid artery and middle cerebral artery, can result in large hemispheric stroke in ~8% of these patients. Edema from stroke can result in a cascade effect leading to local compression of capillary perfusion, increased stroke burden, elevated intracranial pressure, herniation and death. Mortality from large hemispheric stroke is generally high and surgical intervention may reduce mortality and improve good outcomes in select patients. For those patients who are not eligible candidates for surgical decompression either due timing, medical co-morbidities, or patient and family preferences, the mainstay of medical management for cerebral edema is hyperosmolar therapy. Other neuroprotectants for cerebral edema such as glibenclamide are under investigation. This review will discuss current guidelines and evidence for medical management of cerebral edema in large hemispheric stroke as well as discuss important neuromonitoring and critical care management targeted at reducing morbidity and mortality for these patients.
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Affiliation(s)
- Grace DeHoff
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
| | - Winnie Lau
- Department of Neurology, University of North Carolina, Chapel Hill, NC, United States
- Department of Neurosurgery, University of North Carolina, Chapel Hill, NC, United States
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16
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McHugh DC, George BP, Bender MT, Horowitz RK, Kaufman DC, Holloway RG, Roberts DE. Reversal of Advanced Directives in Neurologic Emergencies. Neurohospitalist 2022; 12:651-658. [PMID: 36147771 PMCID: PMC9485691 DOI: 10.1177/19418744221097348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Objective Patients with advanced directives or Medical Orders for Life-Sustaining Treatment (MOLST), including "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI), may be candidates for procedural interventions when presenting with acute neurologic emergencies. Such interventions may limit morbidity and mortality, but typically they require MOLST reversal. We investigated outcomes of patients with MOLST reversal for treatment of neurologic emergencies. Methods We conducted a retrospective chart review from July 1, 2019 to April 30, 2021 of patients with MOLST reversal treated in our NeuroMedicine Intensive Care Unit. Variables collected include neurologic disease, MOLST reversal decision maker, procedural interventions, and outcomes. Results Twenty-seven patients (18 female, median age 78 years (IQR 73-85 years), median baseline modified Rankin score 1 [IQR 0-2.5] were identified with MOLST reversal. The most common pre-procedural MOLST was DNR/DNI (n=22, 81%), and 93% (n=25) pre-procedural MOLSTs were completed by the patient. MOLSTs were reversed by surrogates in n=23 cases (85%). The median time from MOLST completion to MOLST reversal was 603 days (IQR 45 days to 4 years). The most common neurologic emergency was ischemic stroke (n=14, 52%). Most patients died (n=14, 52%), 26% (n=7) were discharged to skilled nursing, and 22% (n=6) returned to home or assisted living. Conclusions In neurologic emergencies, urgent shared decision making is needed to ensure goal-concordant care, which may result in reversal of existing advanced directives. Outcomes of patients with MOLST reversal were heterogeneous, emphasizing the importance of deliberate patient-centered care weighing the risks and benefits of each intervention.
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Affiliation(s)
- Daryl C. McHugh
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin P. George
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert K. Horowitz
- Department of Medicine, Division of Palliative Care, University of Rochester Medical Center, Rochester, NY, USA
| | - David C. Kaufman
- Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Debra E. Roberts
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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17
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Smeds M, Skrifvars MB, Reinikainen M, Bendel S, Hoppu S, Laitio R, Ala-Kokko T, Curtze S, Sibolt G, Martinez-Majander N, Raj R. One-year healthcare costs of patients with spontaneous intracerebral hemorrhage treated in the intensive care unit. Eur Stroke J 2022; 7:267-279. [PMID: 36082247 PMCID: PMC9446333 DOI: 10.1177/23969873221094705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background Spontaneous intracerebral hemorrhage (ICH) entails significant mortality and morbidity. Severely ill ICH patients are treated in intensive care units (ICUs), but data on 1-year healthcare costs and patient care cost-effectiveness are lacking. Methods Retrospective multi-center study of 959 adult patients treated for spontaneous ICH from 2003 to 2013. The primary outcomes were 12-month mortality or permanent disability, defined as being granted a permanent disability allowance or pension by the Social Insurance Institution by 2016. Total healthcare costs were hospital, rehabilitation, and social security costs within 12 months. A multivariable linear regression of log transformed cost data, adjusting for case mix, was used to assess independent factors associated with costs. Results Twelve-month mortality was 45% and 51% of the survivors were disabled at the end of follow-up. The mean 12-month total cost was €49,754, of which rehabilitation, tertiary hospital and social security costs accounted for 45%, 39%, and 16%, respectively. The highest effective cost per independent survivor (ECPIS) was noted among patients aged >70 years with brainstem ICHs, low Glasgow Coma Scale (GCS) scores, larger hematoma volumes, intraventricular hemorrhages, and ICH scores of 3. In multivariable analysis, age, GCS score, and severity of illness were associated independently with 1-year healthcare costs. Conclusions Costs associated with ICHs vary between patient groups, and the ECPIS appears highest among patients older than 70 years and those with brainstem ICHs and higher ICH scores. One-third of financial resources were used for patients with favorable outcomes. Further detailed cost-analysis studies for patients with an ICH are required.
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Affiliation(s)
- Marika Smeds
- Department of Emergency Care and
Services, Helsinki University Hospital and University of Helsinki, Helsinki,
Finland
| | - Markus B Skrifvars
- Department of Emergency Care and
Services, Helsinki University Hospital and University of Helsinki, Helsinki,
Finland
| | - Matti Reinikainen
- Department of Intensive Care, Kuopio
University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Stepani Bendel
- Department of Intensive Care, Kuopio
University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Sanna Hoppu
- Department of Intensive Care, Tampere
University Hospital and University of Tampere, Tampere, Finland
| | - Ruut Laitio
- Department of Department of
Perioperative Services, Intensive Care and Pain Management, Turku University
Hospital and University of Turku, Turku, Finland
| | - Tero Ala-Kokko
- Department of Intensive Care, Oulu
University Hospital and University of Oulu, Oulu, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki
University Hospital and University of Helsinki, Helsinki, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki
University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Rahul Raj
- Department of Neurosurgery, Helsinki
University Hospital and University of Helsinki, Helsinki, Finland
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18
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Shlobin NA, Garcia RM, Bernstein M. Neuropalliative care for the neurosurgeon: a primer. J Neurosurg 2022; 137:850-858. [PMID: 34920433 DOI: 10.3171/2021.9.jns211872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
Many neurosurgical conditions are incurable, leading to disability or severe symptoms, poor quality of life, and distress for patients and families. The field of neuropalliative care (NPC) addresses the palliative care (PC) needs of individuals living with neurological conditions. Neurosurgeons play an important role within multidisciplinary NPC teams because of their understanding of the natural history of and treatment strategies for neurosurgical conditions, longitudinal patient-physician relationships, and responsibility for neurosurgical emergencies. Moreover, patients with neurosurgical conditions have unique PC needs given the trajectories of neurosurgical diseases, the realities of prognostication, psychosocial factors, communication strategies, and human behavior. PC improves outcomes among neurosurgical patients. Despite the importance of NPC, neurosurgeons often lack formal training in PC skills, which include identifying patients who require PC, assessing a patient's understanding and preferences regarding illness, educating patients, building trust, managing symptoms, addressing family and caregiver needs, discussing end-of-life care, and recognizing when to refer patients to specialists. The future of NPC involves increasing awareness of the approach's importance, delineating priorities for neurosurgeons with regard to NPC, increasing emphasis on PC skills during training and practice, expanding research efforts, and adjusting reimbursement structures to incentivize the provision of NPC by neurosurgeons.
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Affiliation(s)
- Nathan A Shlobin
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Roxanna M Garcia
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark Bernstein
- 2Division of Neurosurgery, Toronto Western Hospital, University of Toronto; and
- 3Temmy Latner Center for Palliative Care, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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19
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Gil-Garcia CA, Alvarez EF, Garcia RC, Mendoza-Lopez AC, Gonzalez-Hermosillo LM, Garcia-Blanco MDC, Valadez ER. Essential topics about the imaging diagnosis and treatment of Hemorrhagic Stroke: a comprehensive review of the 2022 AHA guidelines. Curr Probl Cardiol 2022; 47:101328. [PMID: 35870549 DOI: 10.1016/j.cpcardiol.2022.101328] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Intracerebral hemorrhage (ICH) is a severe stroke with a high death rate (40 % mortality). The prevalence of hemorrhagic stroke has increased globally, with changes in the underlying cause over time as anticoagulant use and hypertension treatment have improved. The fundamental etiology of ICH and the mechanisms of harm from ICH, particularly the complex interaction between edema, inflammation, and blood product toxicity, have been thoroughly revised by the American Heart Association (AHA) in 2022. Although numerous trials have investigated the best medicinal and surgical management of ICH, there is still no discernible improvement in survival and functional tests. Small vessel diseases, such as cerebral amyloid angiopathy (CAA) or deep perforator arteriopathy (hypertensive arteriopathy), are the most common causes of spontaneous non-traumatic intracerebral hemorrhage (ICH). Even though ICH only causes 10-15% of all strokes, it contributes significantly to morbidity and mortality, with few acute or preventive treatments proven effective. Current AHA guidelines acknowledge up to 89% sensitivity for unenhanced brain CT and 81% for brain MRI. The imaging findings of both methods are helpful for initial diagnosis and follow-up, sometimes necessary a few hours after admission, especially for detecting hemorrhagic transformation or hematoma expansion. This review summarized the essential topics on hemorrhagic stroke epidemiology, risk factors, physiopathology, mechanisms of injury, current management approaches, findings in neuroimaging, goals and outcomes, recommendations for lifestyle modifications, and future research directions ICH. A list of updated references is included for each topic.
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Affiliation(s)
| | | | | | | | | | | | - Ernesto-Roldan Valadez
- Directorado de investigación, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, CDMX, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
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20
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 404] [Impact Index Per Article: 202.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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21
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Fang XL, Ding SY, Du XZ, Wang JH, Li XL. Ferroptosis—A Novel Mechanism With Multifaceted Actions on Stroke. Front Neurol 2022; 13:881809. [PMID: 35481263 PMCID: PMC9035991 DOI: 10.3389/fneur.2022.881809] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022] Open
Abstract
As a neurological disease with high morbidity, disability, and mortality, the pathological mechanism underlying stroke involves complex processes such as neuroinflammation, oxidative stress, apoptosis, autophagy, and excitotoxicity; but the related research on these molecular mechanisms has not been effectively applied in clinical practice. As a form of iron-dependent regulated cell death, ferroptosis was first discovered in the pathological process of cancer, but recent studies have shown that ferroptosis is closely related to the onset and development of stroke. Therefore, a deeper understanding of the relationship between ferroptosis and stroke may lead to more effective treatment strategies. Herein, we reviewed the mechanism(s) underlying the onset of ferroptosis in stroke, the potential role of ferroptosis in stroke, and the crosstalk between ferroptosis and other pathological mechanisms. This will further deepen our understanding of ferroptosis and provide new approaches to the treatment of stroke.
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Affiliation(s)
- Xiao-Ling Fang
- College of Acupuncture and Massage, Gansu University of Traditional Chinese Medicine, Lanzhou, China
| | - Shao-Yun Ding
- College of Acupuncture and Massage, Gansu University of Traditional Chinese Medicine, Lanzhou, China
| | - Xiao-Zheng Du
- College of Acupuncture and Massage, Gansu University of Traditional Chinese Medicine, Lanzhou, China
- *Correspondence: Xiao-Zheng Du
| | - Jin-Hai Wang
- Department of Traditional Chinese Medicine, The Second Hospital of Lanzhou University, Lanzhou, China
- Jin-Hai Wang
| | - Xing-Lan Li
- College of Acupuncture and Massage, Gansu University of Traditional Chinese Medicine, Lanzhou, China
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22
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Goostrey K, Muehlschlegel S. Prognostication and shared decision making in neurocritical care. BMJ 2022; 377:e060154. [PMID: 35696329 DOI: 10.1136/bmj-2021-060154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient's behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.
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Affiliation(s)
- Kelsey Goostrey
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Susanne Muehlschlegel
- Department of neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of anesthesiology/critical care, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Finley Caulfield A, Mlynash M, Eyngorn I, Lansberg MG, Afjei A, Venkatasubramanian C, Buckwalter MS, Hirsch KG. Prognostication of ICU Patients by Providers with and without Neurocritical Care Training. Neurocrit Care 2022; 37:190-199. [PMID: 35314970 DOI: 10.1007/s12028-022-01467-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 02/04/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training. METHODS Consecutive patients who were intubated for ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction. RESULTS Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]). CONCLUSIONS Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA.
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Irina Eyngorn
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Anousheh Afjei
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Chitra Venkatasubramanian
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
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De Georgia M. The intersection of prognostication and code status in patients with severe brain injury. J Crit Care 2022; 69:153997. [PMID: 35114602 DOI: 10.1016/j.jcrc.2022.153997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.
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Affiliation(s)
- Michael De Georgia
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America.
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25
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Berthaud JV, Morgenstern LB, Zahuranec DB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Alkhachroum A, Bustillo AJ, Asdaghi N, Marulanda-Londono E, Gutierrez CM, Samano D, Sobczak E, Foster D, Kottapally M, Merenda A, Koch S, Romano JG, O’Phelan K, Claassen J, Sacco RL, Rundek T. Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness. Stroke 2021; 52:3891-3898. [PMID: 34583530 PMCID: PMC8608746 DOI: 10.1161/strokeaha.121.035233] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). METHODS Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. RESULTS Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. CONCLUSIONS In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Antonio J Bustillo
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Erika Marulanda-Londono
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Carolina M Gutierrez
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Daniel Samano
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Evie Sobczak
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, USA
| | - Mohan Kottapally
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Kristine O’Phelan
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
| | - Ralph L. Sacco
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
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27
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Morris NA, Mazzeffi M, McArdle P, May TL, Burke JF, Bradley SM, Agarwal S, Badjatia N, Perman SM. Women receive less targeted temperature management than men following out-of-hospital cardiac arrest due to early care limitations - A study from the CARES Investigators. Resuscitation 2021; 169:97-104. [PMID: 34756958 DOI: 10.1016/j.resuscitation.2021.10.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Women experience worse neurological outcomes following out-of-hospital cardiac arrest (OHCA). It is unknown whether sex disparities exist in the use of targeted temperature management (TTM), a standard of care treatment to improve neurological outcomes. METHODS We performed a retrospective study of prospectively collected patients who survived to hospital admission following OHCA from the Cardiac Arrest Registry to Enhance Survival from 2013 through 2019. We compared receipt of TTM by sex in a mixed-effects model adjusted for patient, arrest, neighborhood, and hospital factors, with the admitting hospital modeled as a random intercept. RESULTS Among 123,419 patients, women had lower rates of shockable rhythms (24.4 % vs. 39.2%, P < .001) and lower rates of presumed cardiac aetiologies for arrest (74.3% vs. 81.1%, P < .001). Despite receiving a similar rate of TTM in the field (12.1% vs. 12.6%, P = .02), women received less TTM than men upon admission to the hospital (41.6% vs. 46.4%, P < .001). In an adjusted mixed-effects model, women were less likely than men to receive TTM (Odds Ratio 0.91, 95% Confidence Interval 0.89 to 0.94). Among the 27,729 patients with data indicating the reason for not using TTM, a higher percentage of women did not receive TTM due to Do-Not-Resuscitate orders/family requests (15.1% vs. 11.4%, p < .001) and non-shockable rhythms (11.1% vs. 8.4%, p < .001). CONCLUSIONS We found that women received less TTM than men, likely due to early care limitations and a preponderance of non-shockable rhythms.
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Affiliation(s)
- Nicholas A Morris
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Michael Mazzeffi
- Department of Anesthesia, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Patrick McArdle
- Departments of Medicine and Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME, United States
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, United States
| | - Sachin Agarwal
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Neeraj Badjatia
- Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Sarah M Perman
- Department of Emergency Medicine, Department of Medicine, Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO, United States
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28
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Sadan O. Quantitative Pupillometry Following Cardiac Arrest: Is It Time to Throw Away Our Penlight? Crit Care Med 2021; 49:1840-1842. [PMID: 34529617 DOI: 10.1097/ccm.0000000000005050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Emory University School of Medicine and Emory University Hospital, Atlanta, GA
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29
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CAEP Position Statement - Management of devastating brain injuries in the emergency department: Enhancing neuroprognostication and maintaining the opportunity for organ and tissue donation. CAN J EMERG MED 2021; 22:658-660. [PMID: 32618532 PMCID: PMC7509745 DOI: 10.1017/cem.2020.357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The primary purpose of this statement is to improve neuroprognostication after devastating brain injury (DBI), with a secondary benefit of potential organ and tissue donation.
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30
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Masomi-Bornwasser J, Fabrig O, Krenzlin H, König J, Tanyildizi Y, Kempski O, Ringel F, Keric N. Systematic Analysis of Combined Thrombolysis Using Ultrasound and Different Fibrinolytic Drugs in an in Vitro Clot Model of Intracerebral Hemorrhage. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1334-1342. [PMID: 33549380 DOI: 10.1016/j.ultrasmedbio.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
Adequate removal of blood clots by minimally invasive surgery seems to correlate with a better clinical outcome in patients with intracerebral hemorrhages (ICHs). Moreover, neurotoxic effects of recombinant tissue plasminogen activator have been reported. The aim of this study was to improve fibrinolysis using an intra-clot ultrasound application with tenecteplase and urokinase in our established ICH clot model. One hundred thirty clots were produced from 25 or 50 mL of human blood, incubated for different periods and equipped with drainage, through which an ultrasound catheter was placed in 65 treatment clots for 1 h, randomly allocated into three groups: administration of ultrasound, administration of 60 IU of tenecteplase or administration of 30,000 IU urokinase. Relative end weights were compared. This study found a significant increase in thrombolysis caused by a combination of ultrasound and fibrinolytic drugs, whereas ultrasound and tenecteplase are significantly more effective in the treatment of larger and aged clots.
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Affiliation(s)
- Julia Masomi-Bornwasser
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Oliver Fabrig
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Harald Krenzlin
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Yasemin Tanyildizi
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Oliver Kempski
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Dwyer M, Francis K, Peterson GM, Ford K, Gall S, Phan H, Castley H, Wong L, White R, Ryan F, Arthurson L, Kim J, Cadilhac DA, Lannin NA. Regional differences in the care and outcomes of acute stroke patients in Australia: an observational study using evidence from the Australian Stroke Clinical Registry (AuSCR). BMJ Open 2021; 11:e040418. [PMID: 33795291 PMCID: PMC8021749 DOI: 10.1136/bmjopen-2020-040418] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To compare the processes and outcomes of care in patients who had a stroke treated in urban versus rural hospitals in Australia. DESIGN Observational study using data from a multicentre national registry. SETTING Data from 50 acute care hospitals in Australia (25 urban, 25 rural) which participated in the Australian Stroke Clinical Registry during the period 2010-2015. PARTICIPANTS Patients were divided into two groups (urban, rural) according to the Australian Standard Geographical Classification Remoteness Area classification. Data pertaining to 28 115 patients who had a stroke were analysed, of whom 8159 (29%) were admitted to hospitals located within rural areas. PRIMARY AND SECONDARY OUTCOME MEASURES Regional differences in processes of care (admission to a stroke unit, thrombolysis for ischaemic stroke, discharge on antihypertensive medication and provision of a care plan), and survival analyses up to 180 days and health-related quality of life at 90-180 days. RESULTS Compared with those admitted to urban hospitals, patients in rural hospitals less often received thrombolysis (urban 12.7% vs rural 7.5%, p<0.001) or received treatment in stroke units (urban 82.2% vs rural 76.5%, p<0.001), and fewer were discharged with a care plan (urban 61.3% vs rural 44.7%, p<0.001). No significant differences were found in terms of survival or overall self-reported quality of life. CONCLUSIONS Rural access to recommended components of acute stroke care was comparatively poorer; however, this did not appear to impact health outcomes at approximately 6 months.
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Affiliation(s)
- Mitchell Dwyer
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Karen Francis
- School of Nursing, College of Health and Medicine, University of Tasmania, Launceston, Tasmania, Australia
| | - Gregory M Peterson
- School of Pharmacy and Pharmacology, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Karen Ford
- Centre of Education and Research Nursing and Midwifery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Hoang Phan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Department of Public Health Management, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
| | - Helen Castley
- Neurology Department, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Lillian Wong
- Princess Alexandra Hospital, QLD Health, Woolloongabba, Queensland, Australia
| | - Richard White
- Townsville Hospital, QLD Health, Townsville, Queensland, Australia
| | - Fiona Ryan
- Orange and Bathurst Health Services, NSW Health, North Sydney, New South Wales, Australia
| | - Lauren Arthurson
- Inpatient Rehabilitation, Echuca Regional Health, Echuca, Victoria, Australia
| | - Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Occupational Therapy Department, Alfred Hospital, Melbourne, Victoria, Australia
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Rodrigues MA, E. Samarasekera N, Lerpiniere C, Perry LA, Moullaali TJ, J.M. Loan J, Wardlaw JM, Al‐Shahi Salman R. Association between Computed Tomographic Biomarkers of Cerebral Small Vessel Diseases and Long-Term Outcome after Spontaneous Intracerebral Hemorrhage. Ann Neurol 2021; 89:266-279. [PMID: 33145789 PMCID: PMC7894327 DOI: 10.1002/ana.25949] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 12/03/2022]
Abstract
OBJECTIVE A study was undertaken to assess whether cerebral small vessel disease (SVD) computed tomographic (CT) biomarkers are associated with long-term outcome after intracerebral hemorrhage. METHODS We performed a prospective, community-based cohort study of adults diagnosed with spontaneous intracerebral hemorrhage between June 1, 2010 and May 31, 2013. A neuroradiologist rated the diagnostic brain CT for acute intracerebral hemorrhage features and SVD biomarkers. We used severity of white matter lucencies and cerebral atrophy, and the number of lacunes to calculate the CT SVD score. We assessed the association between CT SVD biomarkers and either death, or death or dependence (modified Rankin Scale scores = 4-6) 1 year after first-ever intracerebral hemorrhage using logistic regression, adjusting for known predictors of outcome. RESULTS Within 1 year of intracerebral hemorrhage, 224 (56%) of 402 patients died. In separate models, 1-year death was associated with severe atrophy (adjusted odds ratio [aOR] = 2.54, 95% confidence interval [CI] = 1.44-4.49, p = 0.001) but not lacunes or severe white matter lucencies, and CT SVD sum score ≥ 1 (aOR = 2.50, 95% CI = 1.40-4.45, p = 0.002). Two hundred seventy-seven (73%) of 378 patients with modified Rankin Scale data were dead or dependent at 1 year. In separate models, 1-year death or dependence was associated with severe atrophy (aOR = 3.67, 95% CI = 1.71-7.89, p = 0.001) and severe white matter lucencies (aOR = 2.18, 95% CI = 1.06-4.51, p = 0.035) but not lacunes, and CT SVD sum score ≥ 1 (aOR = 2.81, 95% CI = 1.45-5.46, p = 0.002). INTERPRETATION SVD biomarkers on the diagnostic brain CT are associated with 1-year death and dependence after intracerebral hemorrhage, independent of known predictors of outcome. ANN NEUROL 2021;89:266-279.
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Affiliation(s)
- Mark A. Rodrigues
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- Department of NeuroradiologyNHS LothianEdinburghUK
| | | | | | - Luke A. Perry
- Department of Anaesthesia and Pain ManagementRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Tom J. Moullaali
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - James J.M. Loan
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- Department of Clinical NeurosciencesNHS LothianEdinburghUK
- Centre for Discovery Brain SciencesUniversity of EdinburghEdinburghUK
| | - Joanna M. Wardlaw
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- UK Dementia Research Institute at the University of EdinburghEdinburghUK
- Row Fogo Centre for Research into Ageing and the BrainUniversity of EdinburghEdinburghUK
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Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031028. [PMID: 33503811 PMCID: PMC7908360 DOI: 10.3390/ijerph18031028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 11/27/2022]
Abstract
Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age >85 years (adjusted odd ratios (AOR) 1.700, 1.027–2.814), living in long-term care facilities (AOR 1.880, 1.066–3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039–4.358), “medical staff would not be surprised if the patient died within 12 months” (AOR 1.725, 1.193–2.496), and patients’ family requesting palliative care (AOR 2.420, 1.187–4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p < 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p < 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.
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Nam TM, Jang JH, Kim SH, Kim KH, Kim YZ. Comparative Analysis of the Patients with Spontaneous Thalamic Hemorrhage with Concurrent Intraventricular Hemorrhage and Those without Intraventricular Hemorrhage. J Korean Med Sci 2021; 36:e4. [PMID: 33398941 PMCID: PMC7781848 DOI: 10.3346/jkms.2021.36.e4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/22/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND This study aimed to compare the characteristics of patients with spontaneous thalamic hemorrhage (STH) accompanied by intraventricular hemorrhage (IVH) with those of patients without IVH. METHODS The medical records of consecutive patients with STH admitted to our institute between January 2000 and December 2018 were reviewed retrospectively. The laboratory and radiological results, mortality, and functional recovery were compared between the STH patients with IVH and those without IVH. RESULTS Among 2,389 patients with spontaneous intracerebral hemorrhage, 233 (9.8%) patients were included in this study. Concurrent IVH was detected in 159 (68.2%) patients with STH, and more frequently in those with body mass index ≥ 25, Glasgow Coma Scale score of 3-8, underlying disease, family history of stoke, posterior/medial/global location of hematoma, ventriculomegaly, large volume of hemorrhage, and midline shift ≥ 5 mm. The 3-month mortality was 25.8% and 8.1% (P = 0.039), the rate of good functional recovery at 6 months was 52.2% and 31.0% (P = 0.040), and incidence of delayed normal pressure hydrocephalus (NPH) at 12 months was 10.8% and 24.5% (P = 0.062) in the STH patients with IVH and those without IVH, respectively. At 12 months, delayed NPH developed in 28 of 47 (59.6%) patients who received external ventricular drainage (EVD)-based treatment, 5 of 45 (11.1%) patients who underwent endoscopic evacuation-based treatment, and 8 of 45 (17.8%) patients who underwent other surgeries. CONCLUSION Concurrent IVH is strongly associated with mortality in patients with STH. Delayed NPH may develop more frequently in STH patients with IVH who were treated with EVD.
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Affiliation(s)
- Taek Min Nam
- Department of Neurosurgery and Center for Cerebrovascular Disease, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ji Hwan Jang
- Department of Neurosurgery and Center for Cerebrovascular Disease, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Seung Hwan Kim
- Department of Neurosurgery and Center for Cerebrovascular Disease, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyu Hong Kim
- Department of Neurosurgery and Center for Cerebrovascular Disease, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Young Zoon Kim
- Department of Neurosurgery and Center for Cerebrovascular Disease, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
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Abstract
Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.
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Affiliation(s)
- Arturo Montaño
- Departments of Neurology and Neurosurgery, University of Colorado, Aurora, CO, United States
| | - Daniel F Hanley
- Departments of Neurology and Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - J Claude Hemphill
- Departments of Neurology and Neurosurgery, University of California San Francisco, San Francisco, CA, United States.
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Parry-Jones AR, Moullaali TJ, Ziai WC. Treatment of intracerebral hemorrhage: From specific interventions to bundles of care. Int J Stroke 2020; 15:945-953. [PMID: 33059547 PMCID: PMC7739136 DOI: 10.1177/1747493020964663] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/17/2020] [Indexed: 12/17/2022]
Abstract
Intracerebral hemorrhage (ICH) represents a major, global, unmet health need with few treatments. A significant minority of ICH patients present taking an anticoagulant; both vitamin-K antagonists and increasingly direct oral anticoagulants. Anticoagulants are associated with an increased risk of hematoma expansion, and rapid reversal reduces this risk and may improve outcome. Vitamin-K antagonists are reversed with prothrombin complex concentrate, dabigatran with idarucizumab, and anti-Xa agents with PCC or andexanet alfa, where available. Blood pressure lowering may reduce hematoma growth and improve clinical outcomes and careful (avoiding reductions ≥60 mm Hg within 1 h), targeted (as low as 120-130 mm Hg), and sustained (minimizing variability) treatment during the first 24 h may be optimal for achieving better functional outcomes in mild-to-moderate severity acute ICH. Surgery for ICH may include hematoma evacuation and external ventricular drainage to treat hydrocephalus. No large, well-conducted phase III trial of surgery in ICH has so far shown overall benefit, but meta-analyses report an increased likelihood of good functional outcome and lower risk of death with surgery, compared to medical treatment only. Expert supportive care on a stroke unit or critical care unit improves outcomes. Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24-48 h of care. Implementation of acute ICH care can be challenging, and using a care bundle approach, with regular monitoring of data and improvement of care processes can ensure consistent and optimal care for all patients.
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Affiliation(s)
- Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, UK
- George Institute for Global Health, Sydney, Australia
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Cacic K, Bonomo J. NeuroEthics and End of Life Care. Emerg Med Clin North Am 2020; 39:217-225. [PMID: 33218659 DOI: 10.1016/j.emc.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability. The emergency department physician must take these ethical quandaries into account to provide standard of care treatment.
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Affiliation(s)
- Kelsey Cacic
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Mail Location 0525, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, USA.
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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Hiraoka E, Arai J, Kojima S, Norisue Y, Suzuki T, Homma Y, Takahashi O, Obunai K, Watanabe H. Early DNR Order and Long-Term Prognosis Among Patients Hospitalized for Acute Heart Failure: Single-Center Cohort Study in Japan. Int J Gen Med 2020; 13:721-728. [PMID: 33061541 PMCID: PMC7532062 DOI: 10.2147/ijgm.s252651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/18/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose An early do-not-resuscitate (DNR) order is classified as such when it occurs within 24 hours of admission. Early DNR has been previously associated with in-hospital mortality among acute heart failure (AHF) patients and one-year mortality among patients discharged from ICU. Here, we investigate whether early DNR is associated with long-term mortality in AHF Japanese patients, by performing a retrospective cohort study. Patients and Methods We retrospectively investigated all patients with AHF, admitted to our hospital between April 2013 and March 2015, and survived to discharge. We obtained data on demographics, comorbidities, laboratory and echocardiography results, social background, DNR status, and outcomes (one-year death). The association of early DNR with one-year death was analyzed by multivariate logistic regression analysis. Results Among 370 survive to discharge patients, 48 (12%) were lost to follow up. We analyzed 322 patients. The median age was 74 years, and 80 (25%) had an early DNR order. Patients with a DNR order were older and displayed more activities of daily living (ADL)-dependence. Early DNR was associated with higher one-year mortality. Conclusion Early DNR was associated with one-year mortality among AHF patients. Further studies are necessary to investigate unmeasured factors associated with a worse prognosis related to early DNR among AHF patients.
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Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
| | - Junya Arai
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
| | - Shunsuke Kojima
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
| | - Yasuhiro Norisue
- Department of Critical Care and Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
| | - Toshihiko Suzuki
- Department of Nephrology, Endocrinology, and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
| | - Yosuke Homma
- Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
| | - Osamu Takahashi
- Department of Internal Medicine, St Luke's International Hospital, Chuo-ku, Tokyo 104-8560, Japan
| | - Kotaro Obunai
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
| | - Hiroyuki Watanabe
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan
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Mc Lernon S, Schwarz G, Wilson D, Ambler G, Goodwin R, Shakeshaft C, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Houlden H, Brown MM, Muir KW, Jäger HR, Terry L, Werring DJ. Association between critical care admission and 6-month functional outcome after spontaneous intracerebral haemorrhage. J Neurol Sci 2020; 418:117141. [PMID: 32977232 DOI: 10.1016/j.jns.2020.117141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is uncertainty about the clinical benefit of admission to critical care after spontaneous intracerebral haemorrhage (ICH). PURPOSE We investigated factors associated with critical care admission after spontaneous ICH and evaluated associations between critical care and 6-month functional outcome. METHODS We included 825 patients with acute spontaneous non-traumatic ICH, recruited to a prospective multicenter observational study. We evaluated the characteristics associated with critical care admission and poor 6-month functional outcome (modified Rankin Scale, mRS > 3) using univariable (chi-square test and Wilcoxon rank-sum test, as appropriate) and multivariable analysis. RESULTS 286 patients (38.2%) had poor 6-month functional outcome. Seventy-seven (9.3%) patients were admitted to critical care. Patients admitted to critical care were younger (p < 0.001), had lower GCS score (p < 0.001), larger ICH volume (p < 0.001), more often had intraventricular extension (p = 0.008) and underwent neurosurgery (p < 0.001). Critical care admission was associated with poor functional outcome at 6 months (39/77 [50.7%] vs 286/748 [38.2%]; p = 0.034); adjusted OR 2.43 [95%CI 1.36-4.35], p = 0.003), but not with death (OR 1.29 [95%CI 0.71-2.35; p = 0.4). In ordinal logistic regression, patients admitted to critical care showed an OR 1.47 (95% CI 0.98-2.20; p = 0.07) for a shift in the 6-month modified Rankin Scale. CONCLUSIONS Admission to critical care is associated with poor 6-month functional outcome after spontaneous ICH but not with death. Patients admitted to critical care were a priori more severely affected. Although adjusted for main known predictors of poor outcome, our findings could still be confounded by unmeasured factors. Establishing the true effectiveness of critical care after ICH requires a randomised trial with clinical outcomes and quality of life assessments.
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Affiliation(s)
- Siobhan Mc Lernon
- Stroke Research Centre, University College London, Institute of Neurology, London, UK; London South Bank University, School of Health and Social Care, London, UK.
| | - Ghil Schwarz
- Stroke Research Centre, University College London, Institute of Neurology, London, UK; Department of Neurology, Stroke Unit San Raffaele Hospital, Milan, Italy
| | - Duncan Wilson
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK
| | - Russell Goodwin
- London South Bank University, School of Health and Social Care, London, UK
| | - Clare Shakeshaft
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, 51 Chenies Mews, London, UK
| | - Tarek Yousry
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Henry Houlden
- Department of Molecular Neuroscience, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Martin M Brown
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Hans Rolf Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Louise Terry
- London South Bank University, School of Health and Social Care, London, UK
| | - David J Werring
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
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Azizi K, Waheed S, Barolia R, Ahmed N, Ismail M. Understanding perceptions and factors involved in do not resuscitate (DNR) decision making in the emergency department of a low-resource country: a mixed-methods study protocol. BMJ Open 2020; 10:e038915. [PMID: 32928865 PMCID: PMC7490947 DOI: 10.1136/bmjopen-2020-038915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/20/2020] [Accepted: 07/31/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Do not resuscitate (DNR) decision making is an integral component of emergency medicine practice. There is a paucity of data, protocols and guidelines regarding the perceptions and barriers that are involved in the interactions among healthcare professionals, patients and their caregivers regarding DNR decision making. The aim of this study is, therefore, to explore the perceptions and factors influencing DNR decision making in the emergency department and to evaluate the use of a context-based protocol for DNR decision making. METHODS AND ANALYSIS This will be a sequential mixed method study beginning with qualitative research involving in-depth interviews (IDIs) with patient family members and focus group discussion with healthcare professionals. The consensual qualitative approach will be used to perform a thematic analysis to the point of saturation. The expected outcome will be to identify key themes that suggest perceptions and factors involved in DNR decision making. After piloting, the derived protocol will then be used with a different group of individuals (150 healthcare professionals) who meet the eligibility criteria in a quantitative cross-sectional study with universal sampling. Data will be analysed using NVIVO in the qualitative phase and SPSS V.19 in the quantitative phase. The study findings will support the development of a standardised protocol for DNR decision making for healthcare professionals in the emergency department. ETHICS AND DISSEMINATION The proposal was reviewed by the ethics review committee (ERC) of the institution (ERC # 2020-1551-7193). The project is an institution SEED grant recipient PF139/0719. The results will be disseminated among participants, patient communities and healthcare professionals in the institution through seminars, presentations, brochures and emails. The findings will be published in a highly accessed peer-reviewed medical journal and will be presented at international conferences.
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Affiliation(s)
- Kiran Azizi
- Emergency Department, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Shahan Waheed
- Emergency Department, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Rubina Barolia
- School of Nursing, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Naveed Ahmed
- Emergency Medicine, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Madiha Ismail
- Emergency Medicine, Aga Khan University Hospital, Karachi, Sindh, Pakistan
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Reinink H, Konya B, Geurts M, Kappelle LJ, van der Worp HB. Treatment Restrictions and the Risk of Death in Patients With Ischemic Stroke or Intracerebral Hemorrhage. Stroke 2020; 51:2683-2689. [PMID: 32757755 DOI: 10.1161/strokeaha.120.029788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Do-not-resuscitate (DNR) orders in the first 24 hours after intracerebral hemorrhage have been associated with an increased risk of early death. This relationship is less certain for ischemic stroke. We assessed the relation between treatment restrictions and mortality in patients with ischemic stroke and in patients with intracerebral hemorrhage. We focused on the timing of treatment restrictions after admission and the type of treatment restriction (DNR order versus more restrictive care). METHODS We retrospectively assessed demographic and clinical data, timing and type of treatment restrictions, and vital status at 3 months for 622 consecutive stroke patients primarily admitted to a Dutch university hospital. We used a Cox regression model, with adjustment for age, sex, comorbidities, and stroke type and severity. RESULTS Treatment restrictions were installed in 226 (36%) patients, more frequently after intracerebral hemorrhage (51%) than after ischemic stroke (32%). In 187 patients (83%), these were installed in the first 24 hours. Treatment restrictions installed within the first 24 hours after hospital admission and those installed later were independently associated with death at 90 days (adjusted hazard ratios, 5.41 [95% CI, 3.17-9.22] and 5.36 [95% CI, 2.20-13.05], respectively). Statistically significant associations were also found in patients with ischemic stroke and in patients with just an early DNR order. In those who died, the median time between a DNR order and death was 520 hours (interquartile range, 53-737). CONCLUSIONS The strong relation between treatment restrictions (including DNR orders) and death and the long median time between a DNR order and death suggest that this relation may, in part, be causal, possibly due to an overall lack of aggressive care.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - Burak Konya
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - Marjolein Geurts
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.).,Department of Neurology, Erasmus Medical Center, University Medical Center Rotterdam, the Netherlands (M.G.)
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
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Sutter R, Meyer-Zehnder B, Baumann SM, Marsch S, Pargger H. Advance Directives in the Neurocritically Ill: A Systematic Review. Crit Care Med 2020; 48:1188-1195. [PMID: 32697490 DOI: 10.1097/ccm.0000000000004388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the frequency of advance directives or directives disclosed by healthcare agents and their influence on decisions to withdraw/withhold life-sustaining care in neurocritically ill adults. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY SELECTION Screening was performed using predefined search terms to identify studies describing directives of neurocritically ill patients from 2000 to 2019. The review was registered prior to the screening process (International Prospective Register of Systematic Reviews identification number 149185). DATA EXTRACTION Data were collected using standardized forms. Primary outcomes were the frequency of directives and associated withholding/withdrawal of life-sustaining care. DATA SYNTHESIS Out of 721 articles, 25 studies were included representing 35,717 patients. The number of studies and cohort sizes increased over time. A median of 39% (interquartile range, 14-72%) of patients had directives and/or healthcare agents. The presence of directives was described in patients with stroke, status epilepticus, neurodegenerative disorders, neurotrauma, and neoplasms, with stroke patients representing the largest subgroup. Directives were more frequent among patients with neurodegenerative disorders compared with patients with other illnesses (p = 0.043). In reference to directives, care was adapted in 71% of European, 50% of Asian, and 42% of American studies, and was withheld or withdrawn more frequently over time with a median of 58% (interquartile range, 39-89%). Physicians withheld resuscitation in reference to directives in a median of 24% (interquartile range, 22-70%). CONCLUSIONS Studies regarding the use and translation of directives in neurocritically ill patients are increasing. In reference to directives, care was adapted in up to 71%, withheld or withdrawn in 58%, and resuscitation was withheld in every fourth patient, but the quality of evidence regarding their effects on critical care remains weak and the risk of bias high. The limited number of patients having directives is worrisome and studies aiming to increase the use and translation of directives are scarce. Efforts need to be made to increase the perception, use, and translation of directives of the neurocritically ill.
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Affiliation(s)
- Raoul Sutter
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | | | | | - Stephan Marsch
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Hans Pargger
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Madhok DY, Vitt JR, MacIsaac D, Hsia RY, Kim AS, Hemphill JC. Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage. Neurocrit Care 2020; 34:492-499. [PMID: 32661793 DOI: 10.1007/s12028-020-01014-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists. METHODS We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24 h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model. RESULTS A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant. CONCLUSIONS The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.
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Affiliation(s)
- Debbie Y Madhok
- Department of Emergency Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | - Jeffrey R Vitt
- Department of Neurology, University of California, San Francisco, USA
| | | | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, USA
| | - Anthony S Kim
- Department of Neurology, University of California, San Francisco, USA
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, USA
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Lillemoe K, Lord A, Torres J, Ishida K, Czeisler B, Lewis A. Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage. Neurohospitalist 2020; 10:168-175. [PMID: 32549939 DOI: 10.1177/1941874419873812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. Methods We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Results Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Conclusions Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.
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Affiliation(s)
- Kaitlyn Lillemoe
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Aaron Lord
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Jose Torres
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Koto Ishida
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Barry Czeisler
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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Hammond G, Luke AA, Elson L, Towfighi A, Joynt Maddox KE. Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality. Stroke 2020; 51:2131-2138. [PMID: 32833593 DOI: 10.1161/strokeaha.120.029318] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata. METHODS Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme. RESULTS There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51-0.59], P<0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57-0.73], P<0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%, P<0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94-1.0], P=0.086; large towns, 1.05 [1.01-1.09], P=0.009; small towns, 1.10 [1.06-1.15], P<0.001; micropolitan rural, 1.16 [1.11-1.21], P<0.001; and remote rural 1.21 [1.15-1.27], P<0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00-1.26], P<0.001) to 2017 (adjusted odds ratio, 1.27 [1.13-1.42], P<0.001). CONCLUSIONS Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.
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Affiliation(s)
| | - Alina A Luke
- Washington University School of Medicine, St Louis, MO (A.A.L., L.E.)
| | - Lauren Elson
- Washington University School of Medicine, St Louis, MO (A.A.L., L.E.)
| | - Amytis Towfighi
- Department of Neurology, University of Southern California Keck School of Medicine (A.T.)
| | - Karen E Joynt Maddox
- Division of Cardiology (G.H., K.E.J.M.).,Institute for Public Health at Washington University, St Louis, MO (K.E.J.M.)
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Sahgal S, Yande A, Thompson BB, Chen EP, Fagerlin A, Morgenstern LB, Zahuranec DB. Surrogate Satisfaction with Decision Making After Intracerebral Hemorrhage. Neurocrit Care 2020; 34:193-200. [PMID: 32556855 DOI: 10.1007/s12028-020-01018-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND/OBJECTIVE Surrogate decision makers for patients with intracerebral hemorrhage (ICH) are frequently asked to make difficult decisions on use of life-sustaining treatments. We explored ICH surrogate satisfaction with decision making and experience of decision regret using validated measures in a prospective multicenter study. METHODS Cases of non-traumatic ICH were enrolled from three hospitals (September 2015-December 2016), and surrogate decision makers were invited to complete a self-administered survey. The primary outcome was the 10-item decision-making subscale of the Family Satisfaction in the Intensive Care Unit scale (FSICU-DM, range 0-100, higher is greater satisfaction), and the secondary outcome was the decision regret scale (range 0-100, higher is greater regret). Linear regression models were used to assess the association between satisfaction with decision making and pre-specified covariates using manual backward selection. RESULTS A total of 73 surrogates were approached for participation (in person or mail), with 48 surrogates returning a completed survey (median surrogate age 60.5 years, 63% female, 77% white). Patients had a median age of 72.5, 54% were female, with a median admission Glasgow coma scale of 10, in-hospital mortality of 31%, and 56% with an in-hospital DNR order. Physicians commonly made treatment recommendation (> 50%) regarding brain surgery or transitions to comfort measures, but rarely made recommendations (< 20%) regarding DNR orders. Surrogate satisfaction with decision making was generally high (median FSICU-DM 85, IQR 57.5-95). Factors associated with higher satisfaction on multivariable analysis included greater use of shared decision making (P < 0.0001), younger patient age (p = 0.02), ICH score of 3 or higher (p = 0.03), and surrogate relationship (spouse vs. other, p = 0.02). Timing of DNR orders was not associated with satisfaction (P > 0.25). Decision regret scores were generally low (median 12.5, IQR 0-31.3). CONCLUSIONS Considering the severity and abruptness of ICH, it is reassuring that surrogate satisfaction with decision making was generally high and regret was generally low. However, more work is needed to define the appropriate outcome measures and optimal methods of recruitment for studies of surrogate decision makers of ICH patients.
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Affiliation(s)
- Savina Sahgal
- College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, USA
| | - Aneesha Yande
- College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, USA
| | - Bradford B Thompson
- Departments of Neurology and Neurosurgery, Alpert Medical School at Brown University, Providence, USA
| | - Emily P Chen
- Stroke Program, Department of Neurology, University of Michigan Medical Center, 1500 E Medical Center Dr. CVC 3392, SPC 5855, Ann Arbor, MI, 48109-5855, USA.,Center for Bioethics and Social Sciences in Medicine, Michigan Medicine, Ann Arbor, USA
| | - Angela Fagerlin
- Center for Bioethics and Social Sciences in Medicine, Michigan Medicine, Ann Arbor, USA.,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, USA.,Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, USA
| | - Lewis B Morgenstern
- Stroke Program, Department of Neurology, University of Michigan Medical Center, 1500 E Medical Center Dr. CVC 3392, SPC 5855, Ann Arbor, MI, 48109-5855, USA.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA.,Department of Emergency Medicine, Michigan Medicine, Ann Arbor, USA
| | - Darin B Zahuranec
- Stroke Program, Department of Neurology, University of Michigan Medical Center, 1500 E Medical Center Dr. CVC 3392, SPC 5855, Ann Arbor, MI, 48109-5855, USA. .,Center for Bioethics and Social Sciences in Medicine, Michigan Medicine, Ann Arbor, USA.
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Godoy DA, Núñez-Patiño RA, Zorrilla-Vaca A, Ziai WC, Hemphill JC. Intracranial Hypertension After Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Prevalence and Mortality Rate. Neurocrit Care 2020; 31:176-187. [PMID: 30565090 DOI: 10.1007/s12028-018-0658-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The objective of this study was to determine the prevalence of intracranial hypertension (IHT) and the associated mortality rate in patients who suffered from primary intracerebral hemorrhage (ICH). A secondary objective was to assess predisposing factors to IHT development. We conducted a systematic literature search of major electronic databases (MEDLINE, EMBASE, and Cochrane Library), for studies that assessed intracranial pressure (ICP) monitoring in patients with acute ICH. Study level and outcome measures were extracted. The meta-analysis was performed using a random-effects model. A total of six studies comprising 381 patients were pooled to estimate the overall prevalence of any episode of IHT (ICP > 20 mmHg) after ICH. The pooled prevalence rate for any episode of IHT after ICH was 67% (95% CI 51-84%). Four studies comprising 239 patients were pooled in order to estimate the overall mortality rate associated with IHT. Pooled mortality rate was 50% (95% CI 24-76%). For both outcomes, heterogeneity was statistically significant, and risk of bias was nonsignificant. Reported variables correlated significantly with increased ICP were lower Glasgow Coma Scale score at admission, midline shift, hemorrhage volume, and hydrocephalus. The prevalence and mortality rates associated with IHT after ICH are high and may be underestimated. Predicting factors for the development of IHT reflect the magnitude of the primary injury. However, the results of present meta-analysis should be interpreted with caution due to methodological limitations such as selection bias of patients who had ICP monitoring, and lack of standardized IHT definition.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Intensive Care Unit, Hospital San Juan Bautista, Chacabuco 675, 4700, Catamarca, Argentina.
| | - Rafael A Núñez-Patiño
- Faculty of Health Sciences, School of Medicine, Pontificia Universidad Javeriana, Cali, Colombia
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA.,Faculty of Health, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Wendy C Ziai
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA.,Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Claude Hemphill
- Kenneth Rainin Endowed Chair in Neurocritical Care, Professor of Neurology and Neurological Surgery, University of California, San Francisco, USA
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Hypertension is a Leading Cause of Nontraumatic Intracerebral Hemorrhage in Young Adults. J Stroke Cerebrovasc Dis 2020; 29:104719. [PMID: 32122779 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104719] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the etiology and discharge outcome of nontraumatic intracerebral hemorrhage (ICH) in young adults admitted to a comprehensive stroke center. METHODS A retrospective chart review was performed on patients with a discharge diagnosis of nontraumatic ICH admitted from 7/1/2011 to 6/30/2016. Data was collected on demographics, clinical history, ICH score, hemorrhage location, do-not-resuscitate (DNR) orders, likely etiology, and discharge disposition. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH, and ICH score with the discharge outcome. RESULTS Sixty-three patients met the study criteria, with mean age 35.4 ± 6.4 years including 26 (41%) women and 40 (64%) whites. Headache (65%) and change in mental status (48%) were the most common presenting symptoms. Hemorrhage was most commonly seen in the deep structures in 29 (46%) patients followed by lobar ICH in 14 (22%) patients. The most common etiology of ICH was hypertension in 23 (37%) patients, followed by vascular abnormalities in 18 (29%) patients. Forty-two (67%) had good outcome defined as discharge to home (n = 25) or acute inpatient rehabilitation (n = 17). Twenty-one (33%) patients had bad outcome with discharge to skilled nursing facility (n = 6), hospice (n = 1) or died in the hospital (n = 14). Hospital DNR orders were noted in 11 (18%) patients. Higher ICH score (P < .0001) and use of DNR orders (P < .0001) were associated with bad outcome. All 11 patients with DNR orders died in the hospital. Location or etiology of hemorrhage were not associated with discharge outcome. CONCLUSIONS Hypertension, a modifiable risk factor, is a major cause of nontraumatic ICH in young adults. Aggressive management of hypertension is essential to halt the recent increased trends of ICH due to hypertension. Early DNR orders may need to be cautiously used in the hospital.
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Intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2020; 44:203-211. [PMID: 32008128 DOI: 10.1007/s10143-020-01248-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 11/06/2019] [Accepted: 01/20/2020] [Indexed: 12/29/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating and life-threatening condition with high mortality and morbidity. Even though there is an association with intracranial pressure (ICP) raise and aSAH, there is a lack of recommendations regarding the indications for ICP monitoring in patients with aSAH. Defining what patients are at a higher risk to develop intracranial hypertension and its role in the functional outcome and mortality in patients with aSAH will be the purpose of the following systematic review and meta-analysis. The primary endpoint is to determine the prevalence and impact on mortality of ICP in patients with aSAH. Secondary endpoints aim to describe the variables related to the development of ICP and the relationship between traumatic and aneurysmal etiology of intracranial hypertension. PubMed, Embase, Central Cochrane Registry of Controlled Trials, and research meeting abstracts were searched up to August 2019 for studies that performed ICP monitoring, assessed the prevalence of intracranial hypertension and the mortality, in adults. Newcastle Ottawa scale (NOS) was used to assess study quality. The statistical analysis was performed using the Mantel-Haenszel methodology for the prevalence and mortality of intracranial hypertension for reasons with a randomized effect analysis model. Heterogeneity was assessed by I2. A total of 110 bibliographic citations were identified, 20 were considered potentially eligible, and after a review of the full text, 12 studies were considered eligible and 5 met the inclusion criteria for this review. One study obtained 7 points in the NOS, another obtained 6 points, and the rest obtained 5 points. Five studies were chosen for the final analysis, involving 793 patients. The rate of intracranial hypertension secondary to aSAH was 70.69% (95% CI 56.79-82.84%) showing high heterogeneity (I2 = 92.48%, p = < 0.0001). The results of the meta-analysis of mortality rate associated with intracranial hypertension after aSAH found a total of four studies, which involved 385 patients. The mortality rate was 30.3% (95% CI: 14.79-48.57%). Heterogeneity was statistically significant (I2 = 90.36%; p value for heterogeneity < 0.001). We found that in several studies, they reported that a high degree of clinical severity scale (Hunt and Hess or WNFS) and tomographic (Fisher) were significantly correlated with the increase in ICP above 20 mmHg (P < 0.05). The interpretation of the results could be underestimated for the design heterogeneity of the included studies. New protocols establishing the indications for ICP monitoring in aSAH are needed. Given the high heterogeneity of the studies included, we cannot provide clinical recommendations regarding this issue.
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Martinez J, Mouzinho M, Teles J, Guilherme P, Nogueira J, Félix C, Ferreira F, Marreiros A, Nzwalo H. Poor intensive stroke care is associated with short-term death after spontaneous intracerebral hemorrhage. Clin Neurol Neurosurg 2020; 191:105696. [PMID: 32014803 DOI: 10.1016/j.clineuro.2020.105696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The case fatality from spontaneous ICH (SICH) remains high. The quality and intensity of early treatment is one of the determinants of the outcome. We aimed to study the association of early intensive care, using the Intracerebral Hemorrhage-Specific Intensity of Care Quality Metrics (IHSICQM) with the 30-day in-hospital mortality in Algarve, Portugal. PATIENTS AND METHODS analysis of prospective collected data of 157 consecutive SICH patients (2014-2016). Logistic regression was performed to assess the role of IHSICQM on the 30-day in-hospital mortality controlling for the most common clinical and radiological predictors of death. Receiver operating characteristic (ROC) curve was developed to evaluate the prediction accuracy of the IHSICQM score (C-statistics). RESULTS forty-five (29 %) patients died. The group of deceased patients had lower intensity of care (lower IHSICQM score) and higher proportion of poor prognosis associated factors (pre-ICH functional dependency, intraventricular dissection/glycaemia). On the multivariate analysis, higher IHSICQM was associated with reduction of the odds of death, 0.27 (0.14-0.50) per each increasing point. The ROC curve showed a high discriminating ability of isolated IHSICQM in predicting the 30-day mortality (AUC = 0,95; 95 % CI = [0,86; 0,95]). CONCLUSION the early intensity of quality of care independently predicts the 30-day in-hospital mortality. Quantification of the intensity of SICH is a valid tool to persuade improvement of SICH care, as well to help comparison of performances within and between hospitals.
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Affiliation(s)
- Joana Martinez
- Faculty of Medicine and Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Maria Mouzinho
- Faculty of Medicine and Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Joana Teles
- Faculty of Medicine and Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Patrícia Guilherme
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Jerina Nogueira
- Faculty of Medicine and Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Catarina Félix
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Fátima Ferreira
- Neurology Department, Centro Hospitalar Universitário do Algarve, Algarve, Portugal
| | - Ana Marreiros
- Faculty of Medicine and Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal; Algarve Biomedical Center, Portugal
| | - Hipólito Nzwalo
- Faculty of Medicine and Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal; Algarve Biomedical Center, Portugal.
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