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Oud L, Garza J. The burden of sepsis in critically ill patients with multiple sclerosis: A population-based cohort study. J Crit Care 2022; 69:153985. [PMID: 35026610 DOI: 10.1016/j.jcrc.2022.153985] [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: 10/29/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Multiple sclerosis (MS) is associated with increased risk of critical illness, sepsis, and sepsis-related death, compared to the general population. The epidemiology of sepsis and its impact on the outcomes of critically ill patients with MS are unknown. METHODS A statewide dataset was used to identify retrospectively ICU admissions in Texas aged ≥18 years with a diagnosis of MS during 2010-2017. The prevalence of sepsis and its impact on inpatient resource utilization and short-term mortality (a combination of in-hospital death or discharge to hospice) were examined. RESULTS Among 19,837 ICU admissions with MS, 6244 (31.5%) had sepsis. Compared to ICU admissions without sepsis, those with sepsis were older (aged ≥65 years 34.1% vs 24.1%), less commonly racial/ethnic minority (32.6% vs 35.2%), and had higher mean [SD] Deyo comorbidity index (1.7 [1.8] vs 1.2 [1.7]). On adjusted analyses, sepsis was associated with 42.7% longer hospital length of stay and 26.2% higher total hospital charges. Risk-adjusted short-term mortality among ICU admissions with and without sepsis was 13.4% vs 3.3%, respectively. CONCLUSIONS Sepsis was present in nearly 1 in 3 ICU admissions with MS, had substantial adverse impact on hospital resource utilization, and was associated with over 4-times higher short-term mortality.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th Street, Odessa, TX 79763, United States.
| | - John Garza
- Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th Street, Odessa, TX 79763, United States; Department of Mathematics, The University of Texas of the Permian Basin, 4901 E. University Blvd, Odessa, TX 79762, United States
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Sellner J. Einblicke in die Behandlung der Multiplen Sklerose mit Cladribin-Tabletten seit Beginn der COVID-19-Pandemie. PSYCHOPRAXIS. NEUROPRAXIS 2021. [PMCID: PMC8558779 DOI: 10.1007/s00739-021-00761-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Der Prävention von Infektionskrankheiten kommt bei der Multiplen Sklerose (MS) eine besondere Bedeutung zu, da diese den Krankheitsverlauf ungünstig beeinflussen können. Dies wird uns im Rahmen der COVID-19-Pandemie verdeutlicht, wo die SARS-CoV-2-Infektion als Auslöser von besonders schweren und prolongierten Schüben und klinischer Verschlechterung identifiziert werden konnte. Umso wichtiger ist es daher, den Einfluss der für die MS zugelassenen Immuntherapien auf eine etwaige Suszeptibilität für eine SARS-CoV-2-Infektion, den COVID-19-Krankheitsverlauf und das Impfansprechen zu verstehen. In dieser Übersichtsarbeit werden diese Punkte unter besonderer Berücksichtigung von Cladribin-Tabletten, einer für den hochaktiven MS-Verlauf zugelassenen Immunrekonstitutionstherapie, beleuchtet.
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Affiliation(s)
- Johann Sellner
- Abteilung für Neurologie, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstr. 67, 2130 Mistelbach, Österreich
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Schulte EC, Sellner J. SARS-CoV-2 vaccination in multiple sclerosis: A clearer picture for the time point during CD20 depleting therapy. EBioMedicine 2021; 73:103635. [PMID: 34656879 PMCID: PMC8515038 DOI: 10.1016/j.ebiom.2021.103635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 10/05/2021] [Indexed: 12/21/2022] Open
Affiliation(s)
- Eva C Schulte
- Institute of Virology, Technische Universität München/Helmholtz Zentrum München, Munich, Germany; Institute of Psychiatric Phenomics and Genomics (IPPG), University Hospital, Ludwig-Maximilians-University, Munich, Germany; Department of Psychiatry and Psychotherapy, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria; Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
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Sellner J, Rommer PS. Multiple Sclerosis and SARS-CoV-2 Vaccination: Considerations for Immune-Depleting Therapies. Vaccines (Basel) 2021; 9:vaccines9020099. [PMID: 33525459 PMCID: PMC7911298 DOI: 10.3390/vaccines9020099] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 12/19/2022] Open
Abstract
Several concerns have been raised about the use of immunodepleting agents including alemtuzumab, cladribine and CD20-depleting antibodies in people with multiple sclerosis (pwMS) during the coronavirus disease (COVID) 2019 pandemic. As the end of the pandemic is not yet in sight, vaccination against severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) may be an elegant strategy to overcome the potential hazards associated with initiating and continuing treatment with immune-depleting agents. In this review, we summarize the immunological effects of immune-depleting therapy and underlying considerations for the hitherto existing recommendations that suggest a restricted use of immune-deleting therapies during the pandemic. Moreover, we critically discuss open questions regarding vaccination in general and against SARS-CoV-2 in pwMS.
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Affiliation(s)
- Johann Sellner
- Department of Neurology, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, 81675 München, Germany
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria
- Correspondence: ; Tel.: +43-2572-9004-12850; Fax: +43-2572-9004-49281
| | - Paulus S. Rommer
- Department of Neurology, Medical University of Vienna, 1090 Vienna, Austria;
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5
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Hepgul N, Wilson R, Yi D, Evans C, Bajwah S, Crosby V, Wilcock A, Lindsay F, Byrne A, Young C, Groves K, Smith C, Burman R, Chaudhuri KR, Silber E, Higginson IJ, Gao W. Immediate versus delayed short-term integrated palliative care for advanced long-term neurological conditions: the OPTCARE Neuro RCT. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background
Palliative care is recommended to help meet the needs of patients with progressive non-cancer conditions, such as long-term neurological conditions. However, few trials have tested palliative care in this population.
Objectives
To determine the effectiveness and cost-effectiveness of short-term integrated palliative care in improving symptoms, improving patient- and caregiver-reported outcomes and reducing hospital use for people severely affected by long-term neurological conditions.
Design
Pragmatic, randomised controlled, multicentre, fast-track trial, with an embedded qualitative component and surveys.
Setting
Seven UK centres (South London, Nottingham, Liverpool, Cardiff, Brighton, Ashford and Sheffield) with multiprofessional palliative care teams and neurology services.
Participants
People living with multiple sclerosis, idiopathic Parkinson’s disease, motor neurone disease, multiple system atrophy or progressive supranuclear palsy, with unresolved symptoms and/or complex psychosocial needs. The qualitative study involved patients, caregivers and health-care staff.
Interventions
Participants were randomised to receive short-term integrated palliative care, delivered by multiprofessional teams, immediately or after a 12-week wait (standard care group).
Main outcome measures
The primary outcome was a combined score of eight symptoms measured by the Integrated Palliative care Outcome Scale for Neurological conditions 8 symptom subscale (IPOS Neuro-S8) at 12 weeks. Secondary outcomes included patients’ other physical and psychological symptoms, quality of life (EuroQol-5 Dimensions, five-level version), care satisfaction, caregiver burden, service use and cost, and harms. Data were analysed using multiple imputation, generalised linear mixed models, incremental cost-effectiveness ratios (threshold was the National Institute for Health and Care Excellence £20,000 per quality-adjusted life-year) and cost-effectiveness planes. Qualitative data were analysed thematically.
Results
We recruited 350 patients and 229 caregivers. There were no significant between-group differences for primary or secondary outcomes. Patients receiving short-term integrated palliative care had a significant improvement, from baseline to 12 weeks, on the primary outcome IPOS Neuro-S8 (–0.78, 95% confidence interval –1.29 to –0.26) and the secondary outcome of 24 physical symptoms (–1.95, 99.55% confidence interval –3.60 to –0.30). This was not seen in the control group, in which conversely, care satisfaction significantly reduced from baseline to 12 weeks (–2.89, 99.55% confidence interval –5.19 to –0.59). Incremental cost-effectiveness ratios were smaller than the set threshold (EuroQol-5 Dimensions index score –£23,545; IPOS Neuro-S8 –£1519), indicating that the intervention provided cost savings plus better outcomes. Deaths, survival and hospitalisations were similar between the two groups. Qualitative data suggested that the impact of the intervention encompassed three themes: (1) adapting to losses and building resilience, (2) attending to function, deficits and maintaining stability, and (3) enabling caregivers to care.
Conclusions
Our results indicate that short-term integrated palliative care provides improvements in patient-reported physical symptoms at a lower cost and without harmful effects when compared with standard care.
Limitations
Outcome measures may not have been sensitive enough to capture the multidimensional changes from the intervention. Our surveys found that the control/standard and intervention services were heterogeneous.
Future work
Refining short-term integrated palliative care and similar approaches for long-term neurological conditions, focusing on better integration of existing services, criteria for referral and research to improve symptom management.
Trial registration
Current Controlled Trials ISRCTN18337380.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nilay Hepgul
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Rebecca Wilson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Catherine Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
- Sussex Community NHS Foundation Trust, Brighton, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Vincent Crosby
- Department of Palliative Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Wilcock
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Anthony Byrne
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Carolyn Young
- Department of Neurology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Clare Smith
- Department of Palliative Care, Ashford and St. Peter’s Hospitals NHS Foundation Trust, Surrey, UK
| | - Rachel Burman
- Department of Palliative Care, King’s College Hospital, London, UK
| | - K Ray Chaudhuri
- National Parkinson Foundation Centre of Excellence, King’s College Hospital and King’s College London, London, UK
| | - Eli Silber
- Department of Neurology, King’s College Hospital, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
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Maghzi AH, Houtchens MK, Preziosa P, Ionete C, Beretich BD, Stankiewicz JM, Tauhid S, Cabot A, Berriosmorales I, Schwartz THW, Sloane JA, Freedman MS, Filippi M, Weiner HL, Bakshi R. COVID-19 in teriflunomide-treated patients with multiple sclerosis. J Neurol 2020; 267:2790-2796. [PMID: 32494856 PMCID: PMC7268971 DOI: 10.1007/s00415-020-09944-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 01/08/2023]
Abstract
The outbreak of a severe acute respiratory syndrome caused by a novel coronavirus (COVID-19), has raised health concerns for patients with multiple sclerosis (MS) who are commonly on long-term immunotherapies. Managing MS during the pandemic remains challenging with little published experience and no evidence-based guidelines. We present five teriflunomide-treated patients with MS who subsequently developed active COVID-19 infection. The patients continued teriflunomide therapy and had self-limiting infection, without relapse of their MS. These observations have implications for the management of MS in the setting of the COVID-19 pandemic.
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Affiliation(s)
- Amir Hadi Maghzi
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Mailbox 9002L, Boston, MA, 02115, USA
| | - Maria K Houtchens
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Mailbox 9002L, Boston, MA, 02115, USA
| | - Paolo Preziosa
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carolina Ionete
- Department of Neurology, University of Massachusetts, Worcester, MA, USA
| | | | - James M Stankiewicz
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Mailbox 9002L, Boston, MA, 02115, USA
| | - Shahamat Tauhid
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Mailbox 9002L, Boston, MA, 02115, USA
| | - Ann Cabot
- Department of Neurology, Concord Hospital, Concord, NH, USA
| | | | | | - Jacob A Sloane
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark S Freedman
- University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Massimo Filippi
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Howard L Weiner
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Mailbox 9002L, Boston, MA, 02115, USA
| | - Rohit Bakshi
- Department of Neurology, Ann Romney Center for Neurologic Diseases, Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Mailbox 9002L, Boston, MA, 02115, USA.
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7
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Huang MH, Fry D, Doyle L, Burnham A, Houston N, Shea K, Smith H, Wiske L, Goode J, Khitrik E, Kolanda M. Effects of inspiratory muscle training in advanced multiple sclerosis. Mult Scler Relat Disord 2020; 37:101492. [DOI: 10.1016/j.msard.2019.101492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/22/2019] [Accepted: 10/31/2019] [Indexed: 11/29/2022]
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Toward a Shared-Care Model of Relapsing-Remitting Multiple Sclerosis: Role of the Primary Care Practitioner. Can J Neurol Sci 2019; 45:304-312. [PMID: 29756588 DOI: 10.1017/cjn.2018.7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The objective of this study was to develop a shared-care model to enable primary-care physicians to participate more fully in meeting the complex, multidisciplinary healthcare needs of patients with multiple sclerosis (MS). DESIGN The design consisted of development of consensus recommendations and a shared-care algorithm. PARTICIPANTS A working group of 11 Canadian neurologists involved in the management of patients with MS were included in this study. MAIN MESSAGE The clinical management of patients with multiple sclerosis is increasing in complexity as new disease-modifying therapies (DMTs) become available, and ongoing safety monitoring is required. A shared-care model that includes primary care physicians is needed. Primary care physicians can assist in the early detection of MS of individuals presenting with neurological symptoms. Additional key roles for family physicians are health promotion, symptom management, and safety and relapse monitoring of DMT-treated patients. General principles of health promotion include counseling MS patients on maintaining a healthy lifestyle; performing standard screening measures; and identifying and treating comorbidities. Of particular importance are depression and anxiety, which occur in >20% of MS patients. Standard work-ups and treatments are needed for common MS-related symptoms, such as fatigue, pain, bladder dysfunction, sexual dysfunction, spasticity, and sleep disorders. Ongoing safety monitoring is required for patients receiving specific DMTs. Multiple sclerosis medications are generally contraindicated during pregnancy, and patients should be counseled to practice effective contraception. CONCLUSIONS Multiple sclerosis is a complex, disabling illness, which, similar to other chronic diseases, requires ongoing multidisciplinary care to meet the evolving needs of patients throughout the clinical course. Family physicians can play an invaluable role in maintaining general health, managing MS-related symptoms and comorbidities, monitoring for treatment-related adverse effects and MS relapses, and coordinating allied health services to ensure continuity of care to meet the complex and evolving needs of MS patients through the disease course. RÉSUMÉ: Élaborer un modèle de soins partagés dans les cas de sclérose en plaques récurrente-rémittente. Objectif: Élaborer un modèle de soins partagés afin de permettre aux médecins de première ligne de mieux répondre aux besoins complexes et multidisciplinaires de patients atteints de la sclérose en plaques (SP). Conception : Recommandations résultant d'un consensus et élaboration d'un algorithme en matière de soins partagés. PARTICIPANTS Un groupe de travail formé de onze neurologues canadiens impliqués dans la prise en charge de patients atteints de la SP. Message-clé : La prise en charge clinique de patients atteints de la SP est de plus en plus complexe dans la mesure où des médicaments modificateurs de l'évolution de la maladie (MMSP) deviennent accessibles et où un suivi permanent en matière de sécurité est nécessaire. Soulignons aussi qu'un modèle de soins partagés incluant les médecins de première ligne est nécessaire. Ces professionnels peuvent permettre un dépistage plus rapide de la SP chez des individus présentant des symptômes neurologiques. Ils peuvent aussi jouer un rôle de premier plan en matière de promotion de la santé, de soulagement des symptômes et de suivi de patients traités avec des MMSP en ce qui a trait à leur sécurité et à de possibles rechutes. Parmi les principes généraux de promotion de la santé, on peut inclure les suivants : offrir aux patients atteints de la SP des conseils leur permettant de maintenir de saines habitudes de vie ; adopter des mesures de dépistage standards ; identifier et traiter les comorbidités. À cet égard, l'anxiété et la dépression sont d'une importance particulière et sont fréquemment signalées (> 20 %) chez les patients atteints de SP. Des démarches d'investigation et des traitements standards sont nécessaires dans le cas des symptômes courants reliés à la SP, par exemple de la fatigue, des douleurs, une dysfonction vésicale, des dysfonctions sexuelles, de la spasticité et des troubles du sommeil. On l'a dit, un suivi permanent s'impose dans le cas de patients bénéficiant d'un traitement spécifique avec des MMSP. Les médicaments associés à la SP sont généralement contre-indiqués durant la grossesse de sorte qu'on devrait conseiller aux patients d'adopter des méthodes de contraception efficaces. CONCLUSIONS La SP est une maladie complexe et invalidante qui, à l'instar d'autres maladies chroniques, exige des soins multidisciplinaires continus afin de répondre, en lien avec un tableau clinique précis, aux besoins en constante évolution des patients. Les médecins de première ligne peuvent jouer un rôle irremplaçable à plusieurs égards : dans le maintien d'une bonne santé ; le suivi et le soulagement des symptômes et des comorbidités reliés à la SP ; le suivi des rechutes et des effets indésirables associés aux traitements. N'oublions pas non plus la coordination des services paramédicaux afin d'assurer, durant l'évolution de la SP, une continuité des soins répondant aux besoins complexes et en constante évolution des patients atteints de cette maladie.
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McCann MR, Hill WF, Yan J, Rehou S, Jeschke MG. Burn injury and multiple sclerosis: A retrospective case-control study. Burns 2018; 45:247-252. [PMID: 30477818 DOI: 10.1016/j.burns.2018.08.023] [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: 06/15/2018] [Revised: 08/02/2018] [Accepted: 08/15/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The purpose of this study was to determine whether having a previous diagnosis of multiple sclerosis (MS) changed acute care needs in burn-injured patients. METHODS This was a retrospective case-control study that included adult (aged ≥18years) patients with an acute burn injury. Control patients were matched with eleven patients with a history of MS at a 4:1 ratio. Outcomes included fluid resuscitation volumes, temperature, heart rate, mean arterial pressure, in-hospital complications, and hospital length of stay (LOS). RESULTS There were fifty-five patients included and of those, eleven had a documented history of MS. Fluid resuscitation volumes, temperature, heart rate, and mean arterial pressure were similar between groups during the resuscitation period (p>0.05). LOS was similar between both groups (12, IQR: 2-17 vs. median 16, IQR: 12-21; p=0.090). However, when normalized to % TBSA burn, patients with MS had a significantly higher median LOS/% TBSA burned (1.2, IQR: 0.7-2.0 vs. 2.1, IQR: 1.1-7.1; p=0.031). CONCLUSIONS Patients with concurrent burn injuries and MS have a significantly longer LOS/% TBSA burn suggesting that more time is required to heal their wounds. Surprisingly, there were no other significant differences in the after the burn acute phase between these two cohorts.
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Affiliation(s)
| | | | - Jinhui Yan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Rehou
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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10
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Autoimmune Encephalitis at the Neurological Intensive Care Unit: Etiologies, Reasons for Admission and Survival. Neurocrit Care 2018; 27:82-89. [PMID: 28028790 PMCID: PMC5524849 DOI: 10.1007/s12028-016-0370-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Early recognition and treatment of autoimmune encephalitis (AE) has become an essential issue in clinical practice. However, little is known about patients with deteriorating conditions and the need for intensive care treatment. Here, we aimed to characterize underlying aetiologies, clinical symptoms, reasons for intensive care admission, and mortality of critically ill patients with AE. Methods We conducted a retrospective chart review of all patients with “definite” or “probable” diagnoses of AE treated at our neurological intensive care unit between 2002 and 2015. We collected and analyzed clinical, paraclinical, laboratory findings and assessed the mortality at last follow-up based on patient records. Results Twenty-seven patients [median age 55 years (range 25–87), male = 16] were included. Thirteen (48%) had “definite” AE. The most common reasons for admission were status epilepticus (7/27, 26%) and delirium (4/27, 15%). One-year survival was 82%, all five deceased were male, and 3 (60%) of them had “probable” disease. The non-survivors (median follow-up 1 year) were more likely to have underlying cancer and higher need for respiratory support compared to the survivors (p < 0.041, and p = 0.004, respectively). Conclusions Clinical presentations and outcomes in critically ill patients with AE are diverse, and the most common leading cause for intensive care unit admission was status epilepticus. The association of comorbid malignancy and the need for mechanical ventilation with mortality deserves further attention. Electronic supplementary material The online version of this article (doi:10.1007/s12028-016-0370-7) contains supplementary material, which is available to authorized users.
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11
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Karamyan A, Brandtner H, Grinzinger S, Chroust V, Bacher C, Otto F, Reisp M, Hauer L, Sellner J. Causes of death in critically ill multiple sclerosis patients. Acta Neurol Scand 2017; 136:305-309. [PMID: 28008594 DOI: 10.1111/ane.12724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with multiple sclerosis (MS) experience higher mortality rates as compared to the general population. While the risk of intensive care unit (ICU) admission is also reported to be higher, little is known about causes of death CoD in critically ill MS patients. AIM To study the causes of death (CoD) in the series of critically ill patients with MS verified by autopsy. METHODS We reviewed hospital electronic charts of MS patients treated at the neurological ICU of a tertiary care hospital between 2000 and 2015. We compared clinical and pathological CoD for those who were autopsied. RESULTS Overall, 10 patients were identified (seven female; median age at death 65 years, range 27-80), and six of them were autopsied. The median MS duration prior to ICU admission was 27.5 years (range 1-50), and the median EDSS score at the time of ICU admission was 9 (range 5-9.5). The median length of ICU stay was 3 days (range 2-213). All the individuals in our series had experienced respiratory insufficiency during their ICU stay. The autopsy examination of brain tissue did not reveal evidences of MS lesions in one patient. In another patient, Lewy bodies were found on brain immunohistochemistry. CONCLUSION Mortality in critically ill MS patients is largely driven by respiratory complications. Sporadic disparities between clinical and pathological findings can be expected.
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Affiliation(s)
- A. Karamyan
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
| | - H. Brandtner
- Department of Forensic Medicine; Paris London University; Salzburg Austria
| | - S. Grinzinger
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
| | - V. Chroust
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
| | - C. Bacher
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
| | - F. Otto
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
| | - M. Reisp
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
| | - L. Hauer
- Department of Psychiatry; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
| | - J. Sellner
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Salzburg Austria
- Department of Neurology; Klinikum rechts der Isar; Technische Universität München; München Germany
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Garland A, Metz LM, Bernstein CN, Peschken CA, Hitchon CA, Marrie RA. Hospitalization is associated with subsequent disability in multiple sclerosis. Mult Scler Relat Disord 2017; 14:23-28. [PMID: 28619426 DOI: 10.1016/j.msard.2017.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/13/2017] [Accepted: 03/23/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although an increasing amount of research has evaluated interactions between MS and comorbid chronic disease, few data exist regarding the interactions between MS and acute illness. As compared to age and sex-matched persons without MS, persons with MS experience higher rates of hospitalization and critical illness, and higher mortality rates and health care utilization following critical illness. We aimed to determine whether acute illness requiring hospitalization is associated with progression of multiple sclerosis (MS). METHODS We conducted this population-based, retrospective cohort study by linking data from the regional MS Clinic in Calgary, Canada with the Canadian Discharge Abstract Database to identify non-obstetric hospitalizations. We included individuals with a confirmed diagnosis of MS, at least one recorded Expanded Disability Status Scale (EDSS) measurement, and known age of symptom onset of age 10 years or older. Using data from 2009 to 2014, we used generalized linear models with generalized estimating equations to establish the association within individuals between hospitalization and the time course of MS-related disability (as measured by the EDSS), adjusting for sex, age, disease course at onset, and use of disease-modifying therapies. RESULTS We included 2104 individuals with MS in the analysis, who had a median of 4 EDSS measurements each. Of these 491 (23.3%) had at least one hospitalization. Most subjects were female, with a relapsing disease course at onset, and a mean (SD) age at symptom onset of 33.0 (10.0) years. The underlying rate of disability progression averaged 0.9 EDSS points per decade. Following hospitalization, there was a step increase in EDSS, averaging 0.23 points, equivalent to 2.5 years of time-related disease progression. Hospitalization did not alter the subsequent temporal rate of disability progression. The findings did not differ in those hospitalized for MS versus other reasons. CONCLUSIONS Acute illness requiring hospitalization is associated with a worsening of MS-related disability.
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Affiliation(s)
- Allan Garland
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada; Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada; Manitoba Centre for Health Policy, Winnipeg, Canada
| | - Luanne M Metz
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada; IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
| | - Christine A Peschken
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada; Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada
| | - Carol A Hitchon
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada
| | - Ruth Ann Marrie
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada; Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada.
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