1
|
Heider D, Stetefeld H, Meisel A, Bösel J, Artho M, Linker R, Angstwurm K, Neumann B. POLAR: prediction of prolonged mechanical ventilation in patients with myasthenic crisis. J Neurol 2024; 271:2875-2879. [PMID: 38329540 PMCID: PMC11055720 DOI: 10.1007/s00415-024-12208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Dominik Heider
- Department of Machine Learning for Medical Data, Institute for Computer Science, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Henning Stetefeld
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Meisel
- Department of Neurology With Experimental Neurology, Neuroscience Clinical Research Center, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Marie Artho
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Ralf Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany.
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Perlasberger Straße 41, 94469, Deggendorf, Germany.
| |
Collapse
|
2
|
Karnina R, Sugiarto A, Sedono R, Aditianingsih D, Manggala SK, Purwaamidjaja DB. Decision for early tracheostomy in respiratory failure of a paralyzed myasthenia gravis patient with sepsis-induced pneumonia: A case report. Int J Surg Case Rep 2024; 117:109514. [PMID: 38479127 PMCID: PMC10945206 DOI: 10.1016/j.ijscr.2024.109514] [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: 02/03/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION The neuromuscular condition myasthenia gravis (MG) can make treating sepsis-induced pneumonia more challenging. Since these patients risk respiratory failure, decisions about airway treatment, including tracheostomy, can be difficult. We report a case of a patient with sepsis and concurrent MG who underwent an early tracheostomy due to acute respiratory failure. PRESENTATION OF CASE A 44-year-old woman with a history of MG presented to the emergency department with a stiff tongue, hypersalivation, limb paralysis and a phlegmy cough causing severe respiratory distress, aggravated by community-acquired pneumonia. A chest X-ray showed extensive infiltration and consolidation in the lower lobes. The patient was transferred immediately to the intensive care unit on mechanical ventilation. Despite initial treatment with antibiotics and respiratory support, her mental and respiratory status deteriorated rapidly. Given the risk of myasthenic crisis, sepsis and impending respiratory failure, with anticipated lengthy ventilator utilization and hospitalization, a multidisciplinary team decided to perform an early tracheostomy. DISCUSSION The early tracheostomy procedure was carried out securely on the third day of hospitalization. This allowed for better pulmonary hygiene, adequate ventilation, airway clearance and rehabilitation therapy. The family contributed to stoma care and breathing exercises. The patient's respiratory condition steadily improved over the following weeks. The cough reflex remained well, and mechanical ventilation was gradually weaned off. CONCLUSION Early tracheostomy in a paralyzed MG patient with sepsis-induced pneumonia can improve clinical outcomes and optimize airway management.
Collapse
Affiliation(s)
- Resiana Karnina
- Trainee of Intensive Care Fellowship Program, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Ciptomangunkusumo Hospital, Jakarta, Indonesia; Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Muhammadiyah Jakarta, Jakarta, Indonesia.
| | - Adhrie Sugiarto
- Intensive Care Consultant, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Ciptomangunkusumo Hospital, Jakarta, Indonesia
| | - Rudyanto Sedono
- Intensive Care Consultant, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Ciptomangunkusumo Hospital, Jakarta, Indonesia
| | - Dita Aditianingsih
- Intensive Care Consultant, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Ciptomangunkusumo Hospital, Jakarta, Indonesia
| | - Sidharta Kusuma Manggala
- Intensive Care Consultant, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia, Ciptomangunkusumo Hospital, Jakarta, Indonesia
| | - Dis Bima Purwaamidjaja
- Intensive Care Consultant, Department of Anesthesiology and Intensive Care, Gatot Soebroto Army Central Hospital, Jakarta, Indonesia
| |
Collapse
|
3
|
Mehnert A, Bershan S, Kollmus-Heege J, Gerischer L, Herdick ML, Hoffmann S, Lehnerer S, Scheibe F, Stascheit F, Stein M, Buchan AM, Meisel A, Aigner A, Mergenthaler P. Identifying patients at risk for myasthenic crisis with hemogram and inflammation-related laboratory parameters - a pilot study. Front Neurol 2024; 15:1297997. [PMID: 38469587 PMCID: PMC10925644 DOI: 10.3389/fneur.2024.1297997] [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: 09/20/2023] [Accepted: 01/29/2024] [Indexed: 03/13/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease characterized by fatigable weakness of the voluntary muscles and can exacerbate to life-threatening myasthenic crisis (MC), requiring intensive care treatment. Routine laboratory parameters are a cost-effective and widely available method for estimating the clinical outcomes of several diseases, but so far, such parameters have not been established to detect disease progression in MG. Methods We conducted a retrospective analysis of selected laboratory parameters related to inflammation and hemogram for MG patients with MC compared to MG patients without MC. To identify potential risk factors for MC, we applied time-varying Cox regression for time to MC and, as a sensitivity analysis, generalized estimating equations logistic regression for the occurrence of MC at the next patient visit. Results 15 of the 58 examined MG patients suffered at least one MC. There was no notable difference in the occurrence of MC by antibody status or sex. Both regression models showed that higher counts of basophils (per 0.01 unit increase: HR = 1.32, 95% CI = 1.02-1.70), neutrophils (per 1 unit increase: HR = 1.40, 95% CI = 1.14-1.72), potentially leukocytes (per 1 unit increase: HR = 1.15, 95% CI = 0.99-1.34), and platelets (per 100 units increase: HR = 1.54, 95% CI = 0.99-2.38) may indicate increased risk for a myasthenic crisis. Conclusion This pilot study provides proof of the concept that increased counts of basophils, neutrophils, leukocytes, and platelets may be associated with a higher risk of developing MC in patients with MG.
Collapse
Affiliation(s)
- Anne Mehnert
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Sivan Bershan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Jil Kollmus-Heege
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Meret Luise Herdick
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
- Berlin Institute of Health at Charité, Digital Health Center, Berlin, Germany
| | - Franziska Scheibe
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Maike Stein
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Alastair M. Buchan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Annette Aigner
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
4
|
Neumann B, Angstwurm K, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Lee DH, Gerner ST, Huttner HB, Thieme A, Steinbrecher A, Dunkel J, Roth C, Schneider H, Reichmann H, Fuhrer H, Kleiter I, Schneider-Gold C, Alberty A, Zinke J, Schroeter M, Linker R, Meisel A, Bösel J, Stetefeld HR. Weaning and extubation failure in myasthenic crisis: a multicenter analysis. J Neurol 2024; 271:564-574. [PMID: 37923937 DOI: 10.1007/s00415-023-12016-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/06/2023]
Abstract
Myasthenic crisis (MC) requiring mechanical ventilation is a serious complication of myasthenia gravis (MG). Here we analyze the frequency and risk factors of weaning- and extubation failure as well as its impact on the clinical course in a large cohort. We performed a retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015. Weaning failure (WF) was defined as negative spontaneous breathing trial, primary tracheostomy, or extubation failure (EF) (reintubation or death). WF occurred in 138 episodes (64.2%). Older Age (p = 0.039), multiple comorbidities (≥ 3) (p = 0.007, OR = 4.04), late-onset MG (p = 0.004, OR = 2.84), complications like atelectasis (p = 0.008, OR = 3.40), pneumonia (p < 0.0001, OR = 3.45), cardio-pulmonary resuscitation (p = 0.005, OR = 5.00) and sepsis (p = 0.02, OR = 2.57) were associated with WF. WF occurred often in patients treated with intravenous immungloblins (IVIG) (p = 0.002, OR = 2.53), whereas WF was less often under first-line therapy with plasma exchange or immunoadsorption (p = 0.07, OR = 0.57). EF was observed in 58 of 135 episodes (43.0%) after first extubation attempt and was related with prolonged mechanical ventilation, intensive care unit stay and hospital stay (p ≤ 0.0001 for all). Extubation success was most likely in a time window for extubation between day 7 and 12 after intubation (p = 0.06, OR = 2.12). We conclude that WF and EF occur very often in MC and are associated with poor outcome. Older age, multiple comorbidities and development of cardiac and pulmonary complications are associated with a higher risk of WF and EF. Our data suggest that WF occurs less frequently under first-line plasma exchange/immunoadsorption compared with first-line use of IVIG.
Collapse
Affiliation(s)
- Bernhard Neumann
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Department of Neurology, Sana Klinikum Landkreis Biberach, Biberach, Germany
| | | | - De-Hyung Lee
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Andrea Thieme
- Department of Neurology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
- Department of Neurology, HELIOS Klinik Mühlheim, Mühlheim, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Moenchengladbach, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Schroeter
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Ralf Linker
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henning R Stetefeld
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| |
Collapse
|
5
|
Gilhus NE. Myasthenia gravis, respiratory function, and respiratory tract disease. J Neurol 2023:10.1007/s00415-023-11733-y. [PMID: 37101094 PMCID: PMC10132430 DOI: 10.1007/s00415-023-11733-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
Myasthenia gravis (MG) is characterized by muscle weakness caused by autoantibodies that bind to the postsynaptic membrane at the neuromuscular junction and impair acetylcholine receptor function. Weakness of respiratory muscles represents the most severe MG manifestation, and 10-15% of all patients experience an MG crisis with the need of mechanical ventilatory support at least once in their life. MG patients with respiratory muscle weakness need active immunosuppressive drug treatment long term, and they need regular specialist follow-up. Comorbidities affecting respiratory function need attention and optimal treatment. Respiratory tract infections can lead to MG exacerbations and precipitate an MG crisis. Intravenous immunoglobulin and plasma exchange are the core treatments for severe MG exacerbations. High-dose corticosteroids, complement inhibitors, and FcRn blockers represent fast-acting treatments that are effective in most MG patients. Neonatal myasthenia is a transient condition with muscle weakness in the newborn caused by mother's muscle antibodies. In rare cases, treatment of respiratory muscle weakness in the baby is required.
Collapse
Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| |
Collapse
|
6
|
Early prediction of hospital outcomes in patients tracheostomized for complex mechanical ventilation weaning. Ann Intensive Care 2022; 12:73. [PMID: 35934745 PMCID: PMC9357593 DOI: 10.1186/s13613-022-01047-z] [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: 03/24/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Tracheostomy is often performed in the intensive care unit (ICU) when mechanical ventilation (MV) weaning is prolonged to facilitate daily care. Tracheostomized patients require important healthcare resources and have poor long-term prognosis after the ICU. However, data lacks regarding prediction of outcomes at hospital discharge. We looked for patients’ characteristics, ventilation parameters, sedation and analgesia use (pre-tracheostomy) that are associated with favorable and poor outcomes (post-tracheostomy) using univariate and multivariate logistic regressions. Results Eighty tracheostomized patients were included (28.8% women, 60 [52–71] years). Twenty-three (28.8%) patients were intubated for neurological reasons. Time from intubation to tracheostomy was 14.7 [10–20] days. Thirty patients (37.5%) had poor outcome (19 patients deceased and 11 still tracheostomized at hospital discharge). All patients discharged with tracheostomy (n = 11) were initially intubated for a neurological reason. In univariate logistic regressions, older age and higher body-mass index (BMI) were associated with poor outcome (OR 1.18 [1.07–1.32] and 1.04 [1.01–1.08], p < 0.001 and p = 0.025). No MV parameters were associated with poor outcome. In the multiple logistic regression model higher BMI and older age were also associated with poor outcome (OR 1.21 [1.09–1.36] and 1.04 [1.00–1.09], p < 0.001 and p = 0.046). Conclusions Hospital mortality of patients tracheostomized because of complex MV weaning was high. Patients intubated for neurological reasons were frequently discharged from the acute care hospital with tracheostomy in place. Both in univariate and multivariate logistic regressions, only BMI and older age were associated with poor outcome after tracheostomy for patients undergoing prolonged MV weaning. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01047-z.
Collapse
|
7
|
Tonev D, Georgieva R, Vavrek E. Our Clinical Experience in the Treatment of Myasthenia Gravis Acute Exacerbations with a Novel Nanomembrane-Based Therapeutic Plasma Exchange Technology. J Clin Med 2022; 11:jcm11144021. [PMID: 35887784 PMCID: PMC9322121 DOI: 10.3390/jcm11144021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
According to the American Academy of Neurology 2011 guidelines, there is insufficient evidence to support or refute the use of therapeutic plasma exchange (TPE) for myasthenia gravis (MG). The goal of this study was to determine whether a novel nanomembrane-based TPE could be useful in the treatment of MG. Thirty-six adult patients, MGFA 4/4B and 5, with acute MG episodes were enrolled into a single-center retrospective before-and-after study to compare a conventional treatment group (n = 24) with a nanomembrane-based TPE group (n = 12). TPE or intravenous immunoglobulins (IVIG) infusions were used in impending/manifested myasthenic crises, especially in patients at high-risk for prolonged invasive ventilation (IMV) and in those tolerating non-invasive ventilation (NIV). The clinical improvement was assessed using the Myasthenia Muscle Score (0–100), with ≥20 increase for responders. The primary outcome measures included the rates of implemented TPE, IVIG, and corticosteroids immunotherapies, NIV/IMV, early tracheotomy, MMS scores, extubation time, neuro-ICU/hospital LOS, complications, and mortality rates. The univariate analysis found that IMV was lower in the nanomembrane-based group (42%) compared to the conventional treatment group (83%) (p = 0.02). The multivariate analysis using binary logistic regression revealed TPE and NIV as independent predictors for short-term (≤7 days) respiratory support (p = 0.014 for TPE; p = 0.002 for NIV). The novel TPE technology moved our clinical practice towards proactive rather than protective treatment in reducing prolonged IMV during MG acute exacerbations.
Collapse
Affiliation(s)
- Dimitar Tonev
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Department of Anesthesiology and Intensive Care, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
- Correspondence:
| | - Radostina Georgieva
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Neurological Intensive Care Unit, Department of Neurology, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
| | - Evgeniy Vavrek
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Neurological Intensive Care Unit, Department of Neurology, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
| |
Collapse
|
8
|
Erfani Z, Jelodari Mamaghani H, Rawling JA, Eajazi A, Deever D, Mirmoeeni S, Azari Jafari A, Seifi A. Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations. Cureus 2022; 14:e25616. [PMID: 35784955 PMCID: PMC9249029 DOI: 10.7759/cureus.25616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/09/2022] Open
Abstract
Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.
Collapse
|
9
|
Mergenthaler P, Stetefeld HR, Dohmen C, Kohler S, Schönenberger S, Bösel J, Gerner ST, Huttner HB, Schneider H, Reichmann H, Fuhrer H, Berger B, Zinke J, Alberty A, Kleiter I, Schneider-Gold C, Roth C, Dunkel J, Steinbrecher A, Thieme A, Lee DH, Linker RA, Angstwurm K, Meisel A, Neumann B. Seronegative myasthenic crisis: a multicenter analysis. J Neurol 2022; 269:3904-3911. [PMID: 35389099 PMCID: PMC8988104 DOI: 10.1007/s00415-022-11023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022]
Abstract
Myasthenic crisis (MC) is a life-threatening condition for patients with myasthenia gravis (MG). Seronegative patients represent around 10–15% of MG, but data on outcome of seronegative MCs are lacking. We performed a subgroup analysis of patients who presented with MC with either acetylcholine-receptor-antibody-positive MG (AChR-MG) or seronegative MG between 2006 and 2015 in a retrospective German multicenter study. We identified 15 seronegative MG patients with 17 MCs and 142 AChR-MG with 159 MCs. Seronegative MCs were younger (54.3 ± 14.5 vs 66.5 ± 16.3 years; p = 0.0037), had a higher rate of thymus hyperplasia (29.4% vs 3.1%; p = 0.0009), and were more likely to be female (58.8% vs 37.7%; p = 0.12) compared to AChR-MCs. Time between diagnosis of MG and MC was significantly longer in seronegative patients (8.2 ± 7.6 vs 3.1 ± 4.4 years; p < 0.0001). We found no differences in duration of mechanical ventilation (16.2 ± 15.8 vs 16.5 ± 15.9 days; p = 0.94) and length of stay at intensive care unit (17.6 ± 15.2 vs 17.8 ± 15.4 days; p = 0.96), or in-hospital mortality (11.8% vs. 10.1%; p = 0.69). We conclude that MC in seronegative MG affects younger patients after a longer period of disease, but that crisis treatment efficacy and outcome do not differ compared to AChR-MCs.
Collapse
Affiliation(s)
- Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Academy, 10117 Berlin, Germany
| | - Henning R. Stetefeld
- Faculty of Medicine, Department of Neurology, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Christian Dohmen
- Faculty of Medicine, Department of Neurology, University of Cologne, University Hospital Cologne, Cologne, Germany
- Department of Neurology, LVR-Klinik Bonn, Bonn, Germany
| | - Siegfried Kohler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
| | | | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Stefan T. Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Giesen, Germany
| | - Hagen B. Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Giesen, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Mönchengladbach, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen Für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | | | - Andrea Thieme
- Department of Neurology, Helios Klinikum Erfurt, Erfurt, Germany
| | - De-Hyung Lee
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Ralf A. Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charite-Universitatsmedizin Berlin, Berlin, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
- Present Address: Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | | |
Collapse
|
10
|
Hallan DR, Simion C, Rizk E. Early Versus Late Tracheostomy in Spontaneous Intracerebral Hemorrhage. Cureus 2022; 14:e24059. [PMID: 35573583 PMCID: PMC9097938 DOI: 10.7759/cureus.24059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/12/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Recent literature supports early tracheostomy (<=7 days) over delayed tracheostomy (>7 days-3 months) to improve overall clinical outcomes for patients admitted with an acute head injury. There is conflicting evidence for the same in hemorrhagic stroke. Using a multi-institutional database, we explored this question in nontraumatic spontaneous intracerebral hemorrhage (sICH) patients. METHODS We used a de-identified database network (TriNetX's Research Network) to gather information on early tracheostomy (<=7 days) and late tracheostomy (>7d-3 months) in sICH patients. After accounting for the most common comorbidities, we explored the impact of this intervention on multiple patient outcomes including intensive care unit (ICU) length of stay, pneumonia, and mortality at 30, 90, and 365 days. RESULTS After propensity score matching, a total of 1210 patients were identified for both early tracheostomy (cohort 1) and late tracheostomy (cohort 2) cohorts. The 30-day survival rate was 0.9287 in cohort 1 vs 0.9536 in cohort 2, with a risk difference of 2.39% (95% confidence interval (CI) 0.557%-4.23%; relative risk (RR) 1.54, 95% CI (1.10-2.15); OR 1.577, 95% CI (1.11-2.24); p = 0.006). The 90-day and 365-day end-point survival rates were not statistically different between cohorts. ICU level of care codes were billed an average of 9.76 (SD 8.964) times in cohort 1 vs 14.618 (SD 11.851) in cohort 2 (p<0.0001). At 365 days, there were no differences between the two groups for pulmonary embolism, myocardial infarction, deep venous thrombosis, palliative care consultation, and percutaneous endoscopic gastrostomy tube placement. Cohort 1 had decreased incidence of pneumonia with 665 (54.95%) patients compared to cohort 2 with 725 (59.91%) (RR 0.917, 95% CI (0.856-0.983), OR 0.816, 95% CI (0.695-0.95), p = 0.013). CONCLUSION Early tracheostomy in sICH patients was associated with decreased pneumonia risk, decreased length of ICU care, and no difference in mortality at 90 and 365 days.
Collapse
Affiliation(s)
- David R Hallan
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Christopher Simion
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| |
Collapse
|