1
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Jimenez AD, Gopaul M, Asbell H, Aydemir S, Basha MM, Batra A, Damien C, Day GS, Eka O, Eschbach K, Fatima S, Fields MC, Foreman B, Gerard EE, Gofton TE, Haider HA, Hantus ST, Hocker S, Jongeling A, Kalkach Aparicio M, Kandula P, Kang P, Kazazian K, Kellogg MA, Kim M, Lee JW, Marcuse LV, McGraw CM, Mohamed W, Orozco J, Pimentel C, Punia V, Ramirez AM, Steriade C, Struck AF, Taraschenko O, Treister AK, Yoo JY, Zafar S, Zhou DJ, Zutshi D, Gaspard N, Hirsch LJ, Hanin A. Comparative analysis of patients with new onset refractory status epilepticus preceded by fever (febrile infection-related epilepsy syndrome) versus without prior fever: An interim analysis. Epilepsia 2024. [PMID: 38625055 DOI: 10.1111/epi.17988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a subset of new onset refractory status epilepticus (NORSE) that involves a febrile infection prior to the onset of the refractory status epilepticus. It is unclear whether FIRES and non-FIRES NORSE are distinct conditions. Here, we compare 34 patients with FIRES to 30 patients with non-FIRES NORSE for demographics, clinical features, neuroimaging, and outcomes. Because patients with FIRES were younger than patients with non-FIRES NORSE (median = 28 vs. 48 years old, p = .048) and more likely cryptogenic (odds ratio = 6.89), we next ran a regression analysis using age or etiology as a covariate. Respiratory and gastrointestinal prodromes occurred more frequently in FIRES patients, but no difference was found for non-infection-related prodromes. Status epilepticus subtype, cerebrospinal fluid (CSF) and magnetic resonance imaging findings, and outcomes were similar. However, FIRES cases were more frequently cryptogenic; had higher CSF interleukin 6, CSF macrophage inflammatory protein-1 alpha (MIP-1a), and serum chemokine ligand 2 (CCL2) levels; and received more antiseizure medications and immunotherapy. After controlling for age or etiology, no differences were observed in presenting symptoms and signs or inflammatory biomarkers, suggesting that FIRES and non-FIRES NORSE are very similar conditions.
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Affiliation(s)
- Anthony D Jimenez
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margaret Gopaul
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hannah Asbell
- Section of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Seyhmus Aydemir
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Maysaa M Basha
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ayush Batra
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Charlotte Damien
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Gregory S Day
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Onome Eka
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Krista Eschbach
- Section of Neurology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Safoora Fatima
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elizabeth E Gerard
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Teneille E Gofton
- University Hospital London Health Sciences Center, London, Ontario, Canada
| | - Hiba A Haider
- Epilepsy Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Stephen T Hantus
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sara Hocker
- Mayo Clinic, Minnesota, Rochester, Minnesota, USA
| | - Amy Jongeling
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, New York, New York, USA
| | | | - Padmaja Kandula
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Peter Kang
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Karnig Kazazian
- University Hospital London Health Sciences Center, London, Ontario, Canada
| | | | - Minjee Kim
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lara V Marcuse
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher M McGraw
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wazim Mohamed
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Janet Orozco
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Cederic Pimentel
- Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vineet Punia
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alexandra M Ramirez
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Claude Steriade
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, New York, New York, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, Wisconsin, USA
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Ji Yeoun Yoo
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel J Zhou
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Deepti Zutshi
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Nicolas Gaspard
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Hôpital Universitaire de Bruxelles-Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aurelie Hanin
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, Assistance Publique- Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences, Epilepsy Unit and Department of Clinical Neurophysiology, Paris, France
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2
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Hanin A, Eschbach K, Gofton TE, Gopaul M, Howe CL, Lai YC, Koh S, Shen H, Hirsch LJ. New onset refractory status epilepticus: Summary of the NORSE Institute roundtable during the 2023 American Epilepsy Society meeting, Orlando, Florida. Epilepsia 2024; 65:1145-1146. [PMID: 38421053 DOI: 10.1111/epi.17934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Aurélie Hanin
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences, Epilepsy Unit and Department of Clinical Neurophysiology, Paris, France
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Teneille E Gofton
- University Hospital, London Health Sciences Center, London, Ontario, Canada
| | - Margaret Gopaul
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles L Howe
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi-Chen Lai
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sookyong Koh
- Children's Hospital and Medical Center, Department of Pediatrics, University of Nebraska, Omaha, Nebraska, USA
| | - Haying Shen
- Children's Hospital and Medical Center, Department of Pediatrics, University of Nebraska, Omaha, Nebraska, USA
| | - Lawrence J Hirsch
- Department of Neurology, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, Connecticut, USA
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3
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Kolisnyk M, Kazazian K, Rego K, Novi SL, Wild CJ, Gofton TE, Debicki DB, Owen AM, Norton L. Correction to: Predicting neurologic recovery after severe acute brain injury using resting-state networks. J Neurol 2024; 271:624-625. [PMID: 37831129 DOI: 10.1007/s00415-023-12018-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Affiliation(s)
- Matthew Kolisnyk
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Karnig Kazazian
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
| | - Karina Rego
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sergio L Novi
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Conor J Wild
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Derek B Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Adrian M Owen
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Psychology, Western University, London, Canada
| | - Loretta Norton
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Psychology, King's University College at Western University, London, Canada
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4
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Kolisnyk M, Kazazian K, Rego K, Novi SL, Wild CJ, Gofton TE, Debicki DB, Owen AM, Norton L. Predicting neurologic recovery after severe acute brain injury using resting-state networks. J Neurol 2023; 270:6071-6080. [PMID: 37665382 DOI: 10.1007/s00415-023-11941-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE There is a lack of reliable tools used to predict functional recovery in unresponsive patients following a severe brain injury. The objective of the study is to evaluate the prognostic utility of resting-state functional magnetic resonance imaging for predicting good neurologic recovery in unresponsive patients with severe brain injury in the intensive-care unit. METHODS Each patient underwent a 5.5-min resting-state scan and ten resting-state networks were extracted via independent component analysis. The Glasgow Outcome Scale was used to classify patients into good and poor outcome groups. The Nearest Centroid classifier used each patient's ten resting-state network values to predict best neurologic outcome within 6 months post-injury. RESULTS Of the 25 patients enrolled (mean age = 43.68, range = [19-69]; GCS ≤ 9; 6 females), 10 had good and 15 had poor outcome. The classifier correctly and confidently predicted 8/10 patients with good and 12/15 patients with poor outcome (mean = 0.793, CI = [0.700, 0.886], Z = 2.843, p = 0.002). The prediction performance was largely determined by three visual (medial: Z = 3.11, p = 0.002; occipital pole: Z = 2.44, p = 0.015; lateral: Z = 2.85, p = 0.004) and the left frontoparietal network (Z = 2.179, p = 0.029). DISCUSSION Our approach correctly identified good functional outcome with higher sensitivity (80%) than traditional prognostic measures. By revealing preserved networks in the absence of discernible behavioral signs, functional connectivity may aid in the prognostic process and affect the outcome of discussions surrounding withdrawal of life-sustaining measures.
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Affiliation(s)
- Matthew Kolisnyk
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Karnig Kazazian
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.
| | - Karina Rego
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sergio L Novi
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Conor J Wild
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Derek B Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Adrian M Owen
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Department of Psychology, Western University, London, Canada
| | - Loretta Norton
- Western Institute of Neuroscience, Western Interdisciplinary Research Building, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
- Department of Psychology, King's University College at Western University, London, Canada
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5
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Bessemer R, Iansavichene A, Jenkins ME, Finger E, Gofton TE. Clinical milestones as triggers for palliative care intervention in progressive Supranuclear palsy and multiple system atrophy. J Neurol Sci 2023; 448:120614. [PMID: 37001415 DOI: 10.1016/j.jns.2023.120614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/31/2023]
Abstract
not required for reviews.
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Affiliation(s)
- Robin Bessemer
- Department of Clinical Neurologic Sciences, Schulich School of Medicine and Dentistry, Western University; 339 Windermere Road London, Ontario N6A 5A5, Canada
| | - Alla Iansavichene
- Library Services, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada
| | - Mary E Jenkins
- Department of Clinical Neurologic Sciences, Schulich School of Medicine and Dentistry, Western University; 339 Windermere Road London, Ontario N6A 5A5, Canada
| | - Elizabeth Finger
- Department of Clinical Neurologic Sciences, Schulich School of Medicine and Dentistry, Western University; 339 Windermere Road London, Ontario N6A 5A5, Canada
| | - Teneille E Gofton
- Department of Clinical Neurologic Sciences, Schulich School of Medicine and Dentistry, Western University; 339 Windermere Road London, Ontario N6A 5A5, Canada.
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6
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Gopaul MT, Hanin A, Cespedes J, Pulluru Y, Kazazian K, van Baalen A, Gofton TE, Gaspard N, Hirsch LJ. The Seasonality of New-Onset Refractory Status Epilepticus (NORSE). Epilepsia 2023. [PMID: 37013696 DOI: 10.1111/epi.17606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023]
Abstract
The etiology of New-Onset Refractory Status Epilepticus (NORSE), including its subtype with prior fever known as FIRES (Febrile Infection-Related Epilepsy Syndrome), remains uncertain. Several arguments suggest NORSE is a disorder of immunity, likely post-infectious. Consequently, seasonal occurrence might be anticipated. Here, we investigated if seasonality is a notable factor regarding NORSE presentation. We combined four different datasets with a total of 342 cases, all from the northern hemisphere, and 62% adults. The incidence of NORSE cases differed between seasons (p=0.0068) and was highest in summer (32.2%) (p=0.0022) and lowest in spring (19.0%, p=0.010). While both FIRES and non-FIRES cases occurred most commonly during the summer, there was a trend towards FIRES cases being more likely to occur in winter than non-FIRES cases (OR 1.62, p=0.071). The seasonality of NORSE cases differed according to the etiology (p=0.024). NORSE cases eventually associated with autoimmune/paraneoplastic encephalitis occurred most frequently in summer (p=0.032) and least frequently in winter (p=0.047), while there was no seasonality for cryptogenic cases. This study suggests that NORSE overall and NORSE related to autoimmune/paraneoplastic encephalitis are more common in summer, but that there is no definite seasonality in cryptogenic cases.
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Affiliation(s)
- Margaret T Gopaul
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
| | - Aurélie Hanin
- Dept. of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
- Sorbonne Université, Institut du Cerveau, Paris Brain Institute, ICM, Inserm, CNRS, AP-HP, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Paris, France
- AP-HP, Hôpital de la Pitié-Salpêtrière, DMU Neurosciences 6, Epilepsy Unit and Dept. of Clinical Neurophysiology, Paris, France
| | - Jorge Cespedes
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Universidad Autonoma de Centro America, School of Medicine. San Jose, Costa Rica
| | - Yashwanth Pulluru
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Nebraska Medical Center, Omaha, NE, USA
| | - Karnig Kazazian
- University Hospital London Health Sciences Centers, London, ON, Canada
- Schulich School of Medicine and Dentistry Western University, Department of Clinical Neurological Sciences, London, ON, Canada
| | - Andreas van Baalen
- Department of Neuropediatrics, University Medical Center Schleswig-Holstein, Kiel University (CAU), Kiel, Germany
| | - Teneille E Gofton
- University Hospital London Health Sciences Centers, London, ON, Canada
- Schulich School of Medicine and Dentistry Western University, Department of Clinical Neurological Sciences, London, ON, Canada
| | - Nicolas Gaspard
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
- Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University School of Medicine New Haven, CT, USA
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7
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Shemie SD, Wilson LC, Hornby L, Basmaji J, Baker AJ, Bensimon CM, Chandler JA, Chassé M, Dawson R, Dhanani S, Mooney OT, Sarti AJ, Simpson C, Teitelbaum J, Torrance S, Boyd JG, Brennan J, Brewster H, Carignan R, Dawe KJ, Doig CJ, Elliott-Pohl K, Gofton TE, Hartwick M, Healey A, Honarmand K, Hornby K, Isac G, Kanji A, Kawchuk J, Klowak JA, Kramer AH, Kromm J, LeBlanc AE, Lee-Ameduri K, Lee LA, Leeies M, Lewis A, Manara A, Matheson S, McKinnon NKA, Murphy N, Briard JN, Pope TM, Sekhon MS, Shanker JJS, Singh G, Singh J, Slessarev M, Soliman K, Sutherland S, Weiss MJ, Shaul RZ, Zuckier LS, Zorko DJ, Rochwerg B. A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline. Can J Anaesth 2023; 70:483-557. [PMID: 37131020 PMCID: PMC10203028 DOI: 10.1007/s12630-023-02431-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 05/04/2023] Open
Abstract
This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists' Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.
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Affiliation(s)
- Sam D Shemie
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
- McGill University, Montreal, QC, Canada.
- MUHC Research Institute, Montreal, QC, Canada.
- Canadian Blood Services, Ottawa, ON, Canada.
| | | | | | | | - Andrew J Baker
- Unity Health Toronto, Toronto, ON, Canada
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Sonny Dhanani
- University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Owen T Mooney
- University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Gift of Life Program, Winnipeg, MB, Canada
- St. Boniface Hospital, Winnipeg, MB, Canada
| | - Aimee J Sarti
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christy Simpson
- Canadian Blood Services, Ottawa, ON, Canada
- Dalhousie University, Halifax, NS, Canada
| | - Jeanne Teitelbaum
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
- McGill University, Montreal, QC, Canada
| | | | - J Gordon Boyd
- Kingston General Hospital, Kingston, ON, Canada
- Queen's University, Kingston, ON, Canada
| | | | | | | | - Kirk J Dawe
- Eastern Health, St. John's, NL, Canada
- Memorial University of Newfoundland, St. John's, NL, Canada
| | - Christopher J Doig
- University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | | | | | - Michael Hartwick
- University of Ottawa, Ottawa, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- McMaster University, Hamilton, ON, Canada
- William Osler Health System, Brampton, ON, Canada
| | - Kimia Honarmand
- Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
| | | | - George Isac
- University of British Columbia, Vancouver, BC, Canada
| | - Aly Kanji
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
- McGill University, Montreal, QC, Canada
| | - Joann Kawchuk
- Saskatchewan Health Authority, Saskatoon, SK, Canada
| | | | - Andreas H Kramer
- University of Calgary, Calgary, AB, Canada
- Southern Alberta Organ & Tissue Donation Program, Calgary, AB, Canada
| | - Julie Kromm
- University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | - Allana E LeBlanc
- University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health, Vancouver, BC, Canada
- Canadian Association of Critical Care Nurses, London, ON, Canada
| | - Katarina Lee-Ameduri
- University of Manitoba, Winnipeg, MB, Canada
- St. Boniface Hospital, Winnipeg, MB, Canada
| | - Laurie A Lee
- University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital, Calgary, AB, Canada
| | - Murdoch Leeies
- University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Gift of Life Program, Winnipeg, MB, Canada
- Canadian Critical Care Society, Markham, ON, Canada
| | - Ariane Lewis
- NYU Langone Medical Center, New York City, NY, USA
| | | | | | - Nicole K A McKinnon
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
- Peter Gilgan Center for Research and Learning, Toronto, ON, Canada
| | | | | | - Thaddeus M Pope
- University of Ottawa, Ottawa, ON, Canada
- Mitchell Hamline School of Law, Saint Paul, MN, USA
- Queensland University of Technology, Brisbane, Qld, Australia
- Albany Medical College, Albany, NY, USA
- University of Minnesota Center for Bioethics, Minneapolis, MN, USA
| | - Mypinder S Sekhon
- University of British Columbia, Vancouver, BC, Canada
- Vancouver General Hospital, Vancouver, BC, Canada
| | | | - Gurmeet Singh
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Singh
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Marat Slessarev
- Western University, London, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
| | - Karim Soliman
- Queen's University, Kingston, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Lakeridge Health, Oshawa, ON, Canada
| | | | - Matthew J Weiss
- Transplant Québec, Montreal, QC, Canada
- CHU de Québec - Université Laval, Quebec City, QC, Canada
- Université Laval, Quebec City, QC, Canada
| | - Randi Zlotnik Shaul
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
| | - Lionel S Zuckier
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - David J Zorko
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
| | - Bram Rochwerg
- McMaster University, Hamilton, ON, Canada
- Canadian Critical Care Society, Markham, ON, Canada
- Canadian Critical Care Trials Group, Markham, ON, Canada
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8
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Gofton TE, Norton L, Laforge G, Gibson R, Debicki D, Althenayan E, Scales N, Beinum AV, Hornby L, Shemie S, Dhanani S, Slessarev M. Cerebral cortical activity after withdrawal of life-sustaining measures in critically ill patients. Am J Transplant 2022; 22:3120-3129. [PMID: 35822321 DOI: 10.1111/ajt.17146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/09/2022] [Accepted: 07/04/2022] [Indexed: 01/25/2023]
Abstract
Establishing when cerebral cortical activity stops relative to circulatory arrest during the dying process will enhance trust in donation after circulatory determination of death. We used continuous electroencephalography and arterial blood pressure monitoring prior to withdrawal of life sustaining measures and for 30 min following circulatory arrest to explore the temporal relationship between cessation of cerebral cortical activity and circulatory arrest. Qualitative and quantitative EEG analyses were completed. Among 140 screened patients, 52 were eligible, 15 were enrolled, 11 completed the full study, and 8 (3 female, median age 68 years) were included in the analysis. Across participants, EEG activity stopped at a median of 78 (Q1 = -387, Q3 = 111) seconds before circulatory arrest. Following withdrawal of life sustaining measures there was a progressive reduction in electroencephalographic amplitude (p = .002), spectral power (p = .008), and coherence (p = .003). Prospective recording of cerebral cortical activity in imminently dying patients is feasible. Our results from this small cohort suggest that cerebral cortical activity does not persist after circulatory arrest. Confirmation of these findings in a larger multicenter study are needed to help promote stakeholder trust in donation after circulatory determination of death.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Loretta Norton
- Department of Psychology, King's University College at Western University, London, Ontario, Canada
| | - Geoffrey Laforge
- Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Raechelle Gibson
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Derek Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Eyad Althenayan
- Department of Medicine/Critical Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nathan Scales
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Laura Hornby
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Canadian Blood Services, Ottawa, Ontario, Canada
| | - Sam Shemie
- Canadian Blood Services, Ottawa, Ontario, Canada.,Pediatric Intensive Care, McGill University Health Centre & Research Institute, Montreal, Quebec, Canada
| | - Sonny Dhanani
- Pediatric Critical Care, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Marat Slessarev
- Department of Psychology, King's University College at Western University, London, Ontario, Canada.,Department of Medicine/Critical Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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9
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Abstract
Life-limiting and life-threatening neurologic conditions often progress slowly. Patients live with a substantial symptom burden over a long period of time, and there is often a high degree of functional and cognitive impairment. Because of this, the most appropriate time to initiate neuropalliative care is often difficult to identify. Further challenges to the incorporation of neuropalliative care include communication barriers, such as profound dysarthria or language impairments, and loss of cognitive function and decision-making capacity that prevent shared decision making and threaten patient autonomy. As a result, earlier initiation of at least some components of palliative care is paramount to ensuring patient-centered care while the patient is still able to communicate effectively and participate as fully as possible in their medical care. For these reasons, neuropalliative care is also distinct from palliative care in oncology, and there is a growing evidence base to guide timely initiation and integration of neuropalliative care. In this chapter, we will focus on when to initiate palliative care in patients with life-limiting, life-threatening, and advanced neurologic conditions. We will address three main questions, which patients with neurologic conditions will benefit from initiation of palliative care, what aspects of neurologic illness are most amenable to neuropalliative care, and when to initiate neuropalliative care?
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Affiliation(s)
- Benjamin Dawson
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Kayla McConvey
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Teneille E Gofton
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada.
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10
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Kazazian K, Norton L, Laforge G, Abdalmalak A, Gofton TE, Debicki D, Slessarev M, Hollywood S, Lawrence KS, Owen AM. Improving Diagnosis and Prognosis in Acute Severe Brain Injury: A Multimodal Imaging Protocol. Front Neurol 2021; 12:757219. [PMID: 34938260 PMCID: PMC8685572 DOI: 10.3389/fneur.2021.757219] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/10/2021] [Indexed: 12/12/2022] Open
Abstract
Multi-modal neuroimaging techniques have the potential to dramatically improve the diagnosis of the level consciousness and prognostication of neurological outcome for patients with severe brain injury in the intensive care unit (ICU). This protocol describes a study that will utilize functional Magnetic Resonance Imaging (fMRI), electroencephalography (EEG), and functional Near Infrared Spectroscopy (fNIRS) to measure and map the brain activity of acute critically ill patients. Our goal is to investigate whether these modalities can provide objective and quantifiable indicators of good neurological outcome and reliably detect conscious awareness. To this end, we will conduct a prospective longitudinal cohort study to validate the prognostic and diagnostic utility of neuroimaging techniques in the ICU. We will recruit 350 individuals from two ICUs over the course of 7 years. Participants will undergo fMRI, EEG, and fNIRS testing several times over the first 10 days of care to assess for residual cognitive function and evidence of covert awareness. Patients who regain behavioral awareness will be asked to complete web-based neurocognitive tests for 1 year, as well as return for follow up neuroimaging to determine which acute imaging features are most predictive of cognitive and functional recovery. Ultimately, multi-modal neuroimaging techniques may improve the clinical assessments of patients' level of consciousness, aid in the prediction of outcome, and facilitate efforts to find interventional methods that improve recovery and quality of life.
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Affiliation(s)
- Karnig Kazazian
- Graduate Program in Neuroscience, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,Brain and Mind Institute, Western University, London, ON, Canada
| | - Loretta Norton
- Department of Psychology, King's University College at Western University, London, ON, Canada
| | - Geoffrey Laforge
- Brain and Mind Institute, Western University, London, ON, Canada.,Department of Psychology, Western University, London, ON, Canada
| | - Androu Abdalmalak
- Brain and Mind Institute, Western University, London, ON, Canada.,Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Derek Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marat Slessarev
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Sarah Hollywood
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Keith St Lawrence
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Adrian M Owen
- Brain and Mind Institute, Western University, London, ON, Canada.,Department of Psychology, Western University, London, ON, Canada.,Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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11
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Fridman S, Bres Bullrich M, Jimenez-Ruiz A, Costantini P, Shah P, Just C, Vela-Duarte D, Linfante I, Sharifi-Razavi A, Karimi N, Bagur R, Debicki DB, Gofton TE, Steven DA, Sposato LA. Stroke risk, phenotypes, and death in COVID-19: Systematic review and newly reported cases. Neurology 2020; 95:e3373-e3385. [PMID: 32934172 DOI: 10.1212/wnl.0000000000010851] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To investigate the hypothesis that strokes occurring in patients with coronavirus disease 2019 (COVID-19) have distinctive features, we investigated stroke risk, clinical phenotypes, and outcomes in this population. METHODS We performed a systematic search resulting in 10 studies reporting stroke frequency among patients with COVID-19, which were pooled with 1 unpublished series from Canada. We applied random-effects meta-analyses to estimate the proportion of stroke among COVID-19. We performed an additional systematic search for cases series of stroke in patients with COVID-19 (n = 125), and we pooled these data with 35 unpublished cases from Canada, the United States, and Iran. We analyzed clinical characteristics and in-hospital mortality stratified into age groups (<50, 50-70, >70 years). We applied cluster analyses to identify specific clinical phenotypes and their relationship with death. RESULTS The proportions of patients with COVID-19 with stroke (1.8%, 95% confidence interval [CI] 0.9%-3.7%) and in-hospital mortality (34.4%, 95% CI 27.2%-42.4%) were exceedingly high. Mortality was 67% lower in patients <50 years of age relative to those >70 years of age (odds ratio [OR] 0.33, 95% CI 0.12-0.94, p = 0.039). Large vessel occlusion was twice as frequent (46.9%) as previously reported and was high across all age groups, even in the absence of risk factors or comorbid conditions. A clinical phenotype characterized by older age, a higher burden of comorbid conditions, and severe COVID-19 respiratory symptoms was associated with the highest in-hospital mortality (58.6%) and a 3 times higher risk of death than the rest of the cohort (OR 3.52, 95% CI 1.53-8.09, p = 0.003). CONCLUSIONS Stroke is relatively frequent among patients with COVID-19 and has devastating consequences across all ages. The interplay of older age, comorbid conditions, and severity of COVID-19 respiratory symptoms is associated with an extremely elevated mortality.
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Affiliation(s)
- Sebastian Fridman
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Maria Bres Bullrich
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Amado Jimenez-Ruiz
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Pablo Costantini
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Palak Shah
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Caroline Just
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Daniel Vela-Duarte
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Italo Linfante
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Athena Sharifi-Razavi
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Narges Karimi
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Rodrigo Bagur
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Derek B Debicki
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Teneille E Gofton
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - David A Steven
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada
| | - Luciano A Sposato
- From the Department of Clinical Neurological Sciences (S.F., M.B.B., P.S., C.J., D.B.D., T.E.G., D.A.S., L.A.S.), Department of Medicine (R.B.), Division of Cardiology, Department of Anatomy and Cell Biology (L.A.S.), and Department of Epidemiology and Biostatistics (R.B., D.A.S., L.A.S.), Schulich School of Medicine and Dentistry, Heart & Brain Laboratory (A.J.-R., L.A.S.), and Robarts Research Institute (L.A.S.), Western University, London, Ontario, Canada; Instituto de Neurología y Neurocirugía de Neuquén (P.C.), Argentina; Miami Cardiac & Vascular Institute (D.V.-D., I.L.), Baptist Hospital Neuroscience Center, FL; Clinical Research Development Unit of Bou Ali Sina Hospital (A.S.-R.) and Immunogenetics Research Center (N.K.), Toxoplasmosis Research Center, Mazandaran University of Medical Sciences, Sari, Iran; and Lawson Health Research Institute (L.A.S.), London, Ontario, Canada.
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12
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Sarpal A, Schulz VN, Gofton TE. A Pilot Cross-Discipline Evidence-Based Palliative Care Curriculum for Postgraduate Medical Trainees. J Pain Symptom Manage 2020; 60:678-687.e3. [PMID: 32422183 DOI: 10.1016/j.jpainsymman.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION It is widely recognized that physicians of all backgrounds benefit from having a general palliative care skill set to optimally manage their patients at the end of life. However, strategies to teach palliative care skills to trainees outside palliative medicine vary widely. In this report, we provide an evidence-based and cross-disciplinary palliative care framework applicable to a spectrum of specialty training environments and intended for nonpalliative care trainees. INNOVATION We developed and implemented a concise, multimodal, and evidence-based pilot palliative care curriculum focused on essential general palliative care skills required by physicians providing patient care along the continuum of life across specializations. A needs assessment (local research, literature review, and consensus expert opinion) in combination with learner characteristics (Kolb Learning Style Inventory, Palliative Medicine Comfort and Confidence Survey, and knowledge pretest) informed the development of a curricular outline. The first iteration of the curriculum was formulated and delivered. Extensive evaluation, reassessment, and feedback led to a second iteration, which is presented here. OUTCOMES Although the context will differ according to specialization, there are essential palliative care skills required of most specialist physicians. General palliative themes identified for focus include symptom management, communication, psychosocial aspects of care, care coordination and access, and myths and pitfalls in palliative care. COMMENT Specialty trainees' value embedded training in essential themes in palliative care within the context of their training program. The process and results of this project, including the provision of a framework, may be applied to postgraduate training programs in various specialties.
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Affiliation(s)
- Amrita Sarpal
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Valerie N Schulz
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Continuing Professional Development, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
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13
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Gofton TE, Hirsch LJ. Author response: New onset refractory status epilepticus research: What is on the horizon? Neurology 2020; 94:596. [PMID: 32229639 DOI: 10.1212/wnl.0000000000009187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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14
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Sarpal A, Gofton TE. Addressing the competency of breaking bad news: What are Canadian general paediatric residency programs currently doing. Paediatr Child Health 2019; 24:173-178. [PMID: 31110458 PMCID: PMC6519638 DOI: 10.1093/pch/pxy124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 09/07/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To describe how breaking bad news (BBN) is currently taught in Canadian general paediatric residency programs and the confidence level of fourth year paediatric residents (Ped-PGY4) in BBN and managing end-of-life-care (EOLC). METHODS A prospective, cross-sectional survey of General Paediatric Residency Program Directors (PDs) and Ped-PGY4s was conducted. RESULTS When learning to BBN, residents state faculty observation (22/23) and interactive workshops (14/23) are the most helpful, while PDs state interactive workshops (9/16) and deliberate practice (5/16) are ideal. Residents identified a knowledge gap and discomfort with providing anticipatory guidance, and symptom management, including prescribing opioids. CONCLUSIONS In the era of competency-based medical education, there is an opportunity to create a standardized national curriculum addressing universal competencies related to BBN and EOLC.
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Affiliation(s)
- Amrita Sarpal
- Department of Pediatrics, Western University Schulich School of Medicine and Dentistry, London, Ontario
| | - Teneille E Gofton
- Department of Clinical Neurological Sciences, Western University Schulich School of Medicine and Dentistry, London, Ontario
- Department of Critical Care, Western University Schulich School of Medicine and Dentistry, London, Ontario
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Gofton TE, Wong N, Hirsch LJ, Hocker SE. Communication Challenges: A Spotlight on New-Onset Refractory Status Epilepticus. Mayo Clin Proc 2019; 94:857-863. [PMID: 30935709 DOI: 10.1016/j.mayocp.2018.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 11/04/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Abstract
New-onset refractory status epilepticus (NORSE) is a rare, potentially devastating condition that occurs abruptly in previously healthy patients of any age but most commonly in children and young adults. It has an unpredictable clinical course requiring immediate, often prolonged, critical care support with multiple specialists involved and frequently results in severe life-altering sequelae or death. Communication in NORSE is challenging because its etiology in a given patient is initially unknown (and often remains so), the clinical course and outcome are unpredictable, and many health care team members are involved in the care of a patient. We address the communication challenges seen in NORSE through proactive communication on 3 levels: (1) in the shared decision-making process with the family, (2) within an individual hospital, and (3) across institutions. Intentional organizational change and enhanced information dissemination may help break down barriers to effective communication. Key initiatives for enhancing information dissemination in NORSE are (1) the identification of a most responsible physician to integrate information from subspecialties, to communicate frequently and candidly with the family, and to provide continuity of care over a prolonged period of time and (2) the early involvement of palliative care services alongside ongoing therapies with curative intent to support families and the medical team in decision making and communication.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | | | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT
| | - Sara E Hocker
- Division of Critical Care Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
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Gofton TE, Gaspard N, Hocker SE, Loddenkemper T, Hirsch LJ. New onset refractory status epilepticus research: What is on the horizon? Neurology 2019; 92:802-810. [PMID: 30894443 DOI: 10.1212/wnl.0000000000007322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus (RSE) that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Febrile infection-related epilepsy syndrome is a subset of NORSE in which fever began at least 24 hours prior to the RSE. Both terms apply to all age groups. Until recently, NORSE was a poorly recognized entity without a consistent definition or approach to care. We review the current state of knowledge in NORSE and propose a roadmap for future collaborative research. Research investigating NORSE should prioritize the following 4 domains: (1) clinical features, etiology, and pathophysiology; (2) treatment; (3) adult and pediatric evaluation and management approaches; and (4) public advocacy, professional education, and family support. We consider international collaboration and multicenter research crucial in achieving these goals.
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Affiliation(s)
- Teneille E Gofton
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT.
| | - Nicolas Gaspard
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Sara E Hocker
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Tobias Loddenkemper
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Lawrence J Hirsch
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
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Hirsch LJ, Gaspard N, van Baalen A, Nabbout R, Demeret S, Loddenkemper T, Navarro V, Specchio N, Lagae L, Rossetti AO, Hocker S, Gofton TE, Abend NS, Gilmore EJ, Hahn C, Khosravani H, Rosenow F, Trinka E. Proposed consensus definitions for new-onset refractory status epilepticus (NORSE), febrile infection-related epilepsy syndrome (FIRES), and related conditions. Epilepsia 2018; 59:739-744. [DOI: 10.1111/epi.14016] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Lawrence J. Hirsch
- Comprehensive Epilepsy Center; Department of Neurology; Yale University; New Haven CT USA
| | - Nicolas Gaspard
- Department of Neurology; Université Libre de Bruxelles - Hôpital Erasme; Bruxelles Belgium
| | - Andreas van Baalen
- Department of Neuropediatrics; Christian-Albrechts University; University Medical Center Schleswig-Holstein; Kiel Germany
| | - Rima Nabbout
- Reference Center for Rare Epilepsies; Department of Child Neurology; Necker Enfants Malades Hospital; AP-HP, Paris Descartes University; Paris France
| | - Sophie Demeret
- AP-HP, Neurological Intensive Care Unit; Pitié-Salpêtrière Hospital; Paris France
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital & Harvard Medical School; Boston MA USA
| | - Vincent Navarro
- AP-HP, GH Pitie-Salpêtrière-Charles Foix; Epilepsy Unit, Brain and Spine Institute; Sorbonne University; UPMC University; Paris France
| | - Nicola Specchio
- Department of Neuroscience; Bambino Gesù Children's Hospital, IRCCS; Rome Italy
| | - Lieven Lagae
- Department of Development and Regeneration; Section of Pediatric Neurology; University Hospitals Leuven; Leuven Belgium
| | - Andrea O. Rossetti
- Department of Neurology; CHUV and University of Lausanne; Lausanne Switzerland
| | - Sara Hocker
- Division of Critical Care Neurology; Department of Neurology; Mayo Clinic; Rochester MN USA
| | - Teneille E. Gofton
- Department of Clinical Neurological Sciences; Western University; Schulich School of Medicine and Dentistry; London ON Canada
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics; Children's Hospital of Philadelphia and University of Pennsylvania; Philadelphia PA USA
| | - Emily J. Gilmore
- Comprehensive Epilepsy Center; Department of Neurology; Yale University; New Haven CT USA
| | - Cecil Hahn
- Division of Neurology; The Hospital for Sick Children and Department of Paediatrics; University of Toronto; Toronto ON Canada
| | - Houman Khosravani
- Division of Neurology and Interdepartmental Division of Critical Care; Department of Medicine; Sunnybrook Health Sciences Centre; University of Toronto; Toronto ON Canada
- Interdepartmental Division of Critical Care; Department of Medicine; University of Toronto; Toronto ON Canada
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main; Center of Neurology and Neurosurgery; Goethe-University Frankfurt; Frankfurt/Main Germany
| | - Eugen Trinka
- Department of Neurology; Christian Doppler Medical Center; Paracelsus Medical University; Center for Cognitive Neuroscience; Salzburg Austria
- Institute of Public Health; Department of Public Health; Health Services and HTA; UMIT; Hall in Tirol Austria
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Gofton TE, Chum M, Schulz V, Gofton BT, Sarpal A, Watling C. Challenges facing palliative neurology practice: A qualitative analysis. J Neurol Sci 2017; 385:225-231. [PMID: 29277430 DOI: 10.1016/j.jns.2017.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 11/14/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE This study aimed to develop a conceptual understanding of the specific characteristics of palliative care in neurology and the challenges of providing palliative care in the setting of neurological illness. METHOD The study was conducted at London Health Sciences Centre in Canada using grounded theory methodology. Qualitative thematic analysis was applied to focus group (health care providers physicians, nursing, allied health, trainees) and semi-structured interview (patient-caregiver dyads) data to explore challenges facing the delivery of palliative care in neurology. RESULTS Specific characteristics of neurological disease that affect palliative care in neurology were identified: 1) timelines of disease progression, 2) barriers to communication arising from neurologic disease, 3) variability across disease progression, and 4) threat to personhood arising from functional and cognitive impairments related to neurologic disease. Moreover, three key challenges that shaped and complicated palliative care in neurology were identified: 1) uncertainty with respect to prognosis, support availability and disease trajectory, 2) inconsistency in information, attitudes and skills among care providers, care teams, caregivers and families, and 3) existential distress specific to neurological disease, including emotional, psychological and spiritual distress resulting from loss of function, autonomy and death. These challenges were experienced across groups, but manifested themselves in different ways for each group. CONCLUSIONS Further research regarding prognosis, improved identification of patients with palliative care needs, developing an approach to palliative care delivery within neurology and the creation of more robust educational resources for teaching palliative neurology are expected to improve neurologists' comfort with palliative care, thereby enhancing care delivery in neurology.
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Affiliation(s)
- T E Gofton
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Department of Critical Care, Western University, London, Ontario, Canada.
| | - M Chum
- Division of Neurology, Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, Canada
| | - V Schulz
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
| | | | - A Sarpal
- Department of Pediatrics, Western University, London, Ontario, Canada
| | - C Watling
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
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Abstract
BACKGROUND Bowel ischemia is a rare life threatening complication seen in patients with refractory status epilepticus (RSE). The few reported cases of bowel ischemia in this setting have been associated with the use continuous barbiturate infusions. We report two patients with RSE in the absence of barbiturate infusion and without clear structural, infectious, anatomic, vascular, or autoimmune etiology. We review the clinical details of the cases and potential factors involved in the development of non-occlusive bowel ischemia in patients with RSE. METHODS The following is a retrospective review of two cases of non-occlusive mesenteric ischemia that occurred during the management of RSE. The clinical data and the details of pathological examination of the infarcted segments of bowel are presented in both cases. RESULTS In both cases, the bowel ischemia occurred in the absence of barbiturate infusion or evidence of clear thrombosis, infection, or autoimmune etiology. Case 1 had extensive ischemic necrosis of the small bowel with secondary pseudomembrane formation, and case 2 had full thickness infarction of both the large and small bowel. CONCLUSIONS The mechanism of bowel infarction in these cases is likely multifactorial and was not associated with barbiturate use. Likely contributors to ischemia include RSE itself, systemic hypotension, vasopressor use, general anesthesia, and abnormal cardiac function. During the management of RSE, every effort must be made to avoid the secondary complications such as bowel ischemia.
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Affiliation(s)
- P Rizek
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada.
| | - K M Ikeda
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada.
| | - T Mele
- Department of Surgery, Western University, London, ON, Canada. .,Department of Critical Care Medicine, Western University, London, ON, Canada.
| | - B Garcia
- Department of Pathology, Western University, London, ON, Canada.
| | - T E Gofton
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada. .,Department of Critical Care Medicine, Western University, London, ON, Canada. .,London Health Sciences Centre, University Hospital, Room B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada.
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Melinyshyn AN, Gofton TE, Schulz V. Supernumerary phantom limbs in ICU patients with acute inflammatory demyelinating polyneuropathy. Neurology 2016; 86:1726-8. [PMID: 26968516 DOI: 10.1212/wnl.0000000000002541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/20/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore the previously undescribed phenomenon of phantom limb generation in patients with severe acute inflammatory demyelinating polyradiculoneuropathy (AIDP). METHODS Between April 2011 and January 2014, we encountered 3 patients with AIDP in our intensive care unit who experienced features of self-limited supernumerary phantom limbs (SPLs) during their course. RESULTS The following case series describes the phenomenon of SPLs in AIDP. CONCLUSIONS This report aims to raise awareness of the possibility of SPLs in the course of AIDP. The pathophysiology and management strategies for this clinical phenomenon are unknown.
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Affiliation(s)
- Alexander N Melinyshyn
- From the Departments of Clinical Neurological Sciences (A.N.M., T.E.G.) and Anesthesia and Perioperative Medicine (V.S.), Western University, London, Canada
| | - Teneille E Gofton
- From the Departments of Clinical Neurological Sciences (A.N.M., T.E.G.) and Anesthesia and Perioperative Medicine (V.S.), Western University, London, Canada.
| | - Valerie Schulz
- From the Departments of Clinical Neurological Sciences (A.N.M., T.E.G.) and Anesthesia and Perioperative Medicine (V.S.), Western University, London, Canada
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Gofton TE, Kumar H, Roberts-South A, Speechley M, Jog MS. Validity, Reliability, and Insights from Applying the McGill Quality of Life Questionnaire to People Living with Parkinson's Disease (MQoL-PD). J Palliat Care 2016; 31:213-20. [PMID: 26856121 DOI: 10.1177/082585971503100402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Existing quality-of-life instruments for Parkinson's disease (PD) may not fully assess quality of life (QoL) for people with PD in a holistic and multidimensional manner. This study examines the subscale structure, validity, and internal-consistency reliability of the McGill Quality of Life (MQoL) Questionnaire in a sample of people with PD. This cross-sectional study evaluates the MQoL-PD by using Cronbach's alpha and principal components analysis. A total of 81 consenting people with PD from a tertiary care outpatient clinic were studied. Scores were tabulated for the motor Unified Parkinson's Disease Rating Scale (mUPDRS), the Short Form Health Survey (SF-36), the Parkinson's Disease Questionnaire (PDQ-39), the MQoL Single-Item Scale (MQoL-SIS), and the MQoL Questionnaire (MQoL). Cronbach's alpha for the MQoL-PD was: physical symptoms, 0.83; psychological symptoms, 0.59; and existential/support symptoms, 0.76. Important contributors to QoL in PD include mobility, bowel and bladder function, fatigue, and pain. The MQoL Questionnaire is a valid and reliable measure of physical, psychological, and existential/support symptoms for people with PD.
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Abstract
Sepsis-associated encephalopathy (SAE) is a diffuse brain dysfunction that occurs secondary to infection in the body without overt CNS infection. SAE is frequently encountered in critically ill patients in intensive care units, and in up to 70% of patients with severe systemic infection. The severity of SAE can range from mild delirium to deep coma. Seizures and myoclonus are infrequent and cranial nerves are almost always spared, but most severe cases have an associated critical illness neuromyopathy. Development of SAE probably involves a number of mechanisms that are not mutually exclusive and vary from patient to patient. Substantial neurological and psychological morbidities often occur in survivors. Mortality is almost always due to multiorgan failure rather than neurological complications, and is almost 70% in patients with severe SAE. Further research into the pathophysiology, management and prevention of SAE is needed. This Review discusses the epidemiology and clinical presentation of SAE. Recent evidence for SAE pathophysiology is outlined and a diagnostic approach to patients with this syndrome is presented. Lastly, prognosis and management of SAE is discussed.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University Hospital, University of Western Ontario, 339 Windermere Road, London, ON N6A 5A5, Canada
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Gofton TE, Graber J, Carver A. Identifying the palliative care needs of patients living with cerebral tumors and metastases: a retrospective analysis. J Neurooncol 2012; 108:527-34. [DOI: 10.1007/s11060-012-0855-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
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Abstract
Mefloquine, an antimalarial medication with efficacy against JC virus, was used to treat progressive multifocal leukoencephalopathy. A 54-year-old woman with sarcoidosis presented with a progressive cerebellar syndrome. MRI showed lesions affecting the right cerebellum that progressed over time to the brainstem. JC virus was found in the cerebrospinal fluid (CSF), and brain biopsy confirmed the diagnosis of progressive multifocal leukoencephalopathy. Mefloquine 1000 mg/week was initiated 6 months after symptom onset. Clinical progression stopped immediately, and JC virus became undetectable in the CSF. No clinical or imaging evidence of disease progression has occurred over 20 months of follow-up. This is the first report of successful treatment of progressive multifocal leukoencephalopathy with mefloquine.
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Affiliation(s)
- T E Gofton
- Department of Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada
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Gofton TE, Chouinard PA, Young GB, Bihari F, Nicolle MW, Lee DH, Sharpe MD, Yen YF, Takahashi AM, Mirsattari SM. Functional MRI study of the primary somatosensory cortex in comatose survivors of cardiac arrest. Exp Neurol 2009; 217:320-7. [DOI: 10.1016/j.expneurol.2009.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 03/09/2009] [Accepted: 03/10/2009] [Indexed: 12/23/2022]
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Abstract
An 81-year-old right handed man presented with bilateral leg weakness. The patient had been previously independent and was medicated with warfarin for atrial flutter. He had longstanding type 2 diabetes, controlled by oral hypoglycemic medication. At presentation, he reported sudden onset left sided weakness with accompanying neck pain at 22h00 the previous evening. Pertinent findings on neurological examination included a left pronator drift and profound left leg weakness with unsustained antigravity strength. Deep tendon reflexes were brisk throughout but absent at the ankles and there was a left extensor plantar response. Cranial nerve and sensory examinations were normal.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurosciences, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
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Abstract
BACKGROUND Hypoxia in tumors is associated with malignant progression, metastatic spread, and increased resistance to radiotherapy and chemotherapy. Molecular O(2) is required for the cellular production of nitric oxide (NO) by the enzyme NO synthase (NOS), and NO may block components of the adaptive response to hypoxia. Hence, we hypothesized that hypoxia increases drug resistance in tumor cells by inhibiting endogenous NO production. METHODS Human breast carcinoma (MDA-MB-231) and mouse melanoma (B16F10) cells were pre-exposed to 20% O(2), 5% O(2), or 1% O(2), incubated with a pharmacologic inhibitor of endogenous NO production, and then treated with chemotherapeutic agents. Resistance was assessed by colony-formation assays, and western blot analysis was used to measure NOS protein levels. All P values were two-sided. RESULTS Incubation of MDA-MB-231 tumor cells in 1% O(2) maximally increased their resistance to doxorubicin and 5-fluorouracil by 8.5-fold (P =.002) and 2.3-fold (P =.002), respectively, compared with incubation in 20% O(2). B16F10 mouse melanoma cells preincubated in 1% O(2) (versus 20% O(2)) for 12 hours exhibited a twofold increase in resistance to doxorubicin (P<.001). The rapid acquisition of drug resistance after exposure to 1% O(2) could be mimicked by incubating the MDA-MB-231 cells for 12 hours with the NOS inhibitor N(G)-monomethyl-Larginine (fivefold increase; P<.001). Conversely, replacement of NO activity by use of the NO-mimetic glyceryl trinitrate (GTN) and diethylenetriamine NO adduct produced statistically significant attenuations in the development of resistance of 59% (P<.001) and 40% (P<.001), respectively, in MDA-MB-231 cells. Treatment of B16F10 cells with GTN produced a 58% reduction in resistance (P<.001). MDA-MB-231 cells expressed all three isoforms of the NOS enzyme at levels that were not altered by exposure to hypoxia. CONCLUSIONS NO mediates chemosensitivity in tumor cells, and hypoxia-induced drug resistance appears to result, in part, from downstream suppression of endogenous NO production. These results raise the possibility that administration of small doses of NO mimetics could be used as an adjuvant in chemotherapy.
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Affiliation(s)
- N E Matthews
- Department of Anatomy and Cell Biology, Queen's University, Kingston, ON, Canada
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