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Satyanarayan S, Spiegel J, Hovsepian D, Markert M, Thomas R, Muffly L, Miklos D, Graber K, Scott BJ. Continuous EEG monitoring detects nonconvulsive seizure and Ictal-Interictal Continuum abnormalities in moderate to severe ICANS following systemic CAR-T therapy. Neurohospitalist 2023; 13:53-60. [PMID: 36531846 PMCID: PMC9755619 DOI: 10.1177/19418744221128852] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background and Purpose Immune Cell Effector Associated Neurotoxicity Syndrome (ICANS) is common amongst patients receiving CD19 targeted Chimeric Antigen Receptor T-cell (CAR-T) therapy. The purpose of this study is to characterize the incidence of seizures and ictal-interictal continuum (IIC) abnormalities in patients with ICANS. Methods Retrospective review of consecutive patients treated with axicabtagene ciloleucel (axi-cel) for recurrent high-grade systemic lymphoma at Stanford Medical Center between 2/2016-6/2019. Electronic medical records (EMR) were reviewed for clinical features, treatment information, EEG data, CRS (cytokine release syndrome)/ICANS severity, and clinical outcomes. Results Fifty-six patients met inclusion criteria. 85.7% of patients developed CRS, and 58.9% developed ICANS. Twenty-eight patients had EEG monitoring, of whom 26 had ICANS. Median duration of EEG monitoring was 30 hours (range .5-126 hours). Four patients (7.1%) had seizures (1 patient had a clinical generalized seizure, 2 patients had clinical and nonconvulsive seizures, and 1 patient had an isolated non-convulsive seizure). Ictal-interictal continuum abnormalities were common, of which generalized periodic discharges (GPDs) with triphasic morphology and GPDs with epileptiform morphology were most frequently seen. Generalized periodic discharges with triphasic wave morphology were found across Grade 2-3 peak ICANS severity, however the majority (86%) of patients with epileptiform GPDs had Grade 3 peak ICANS severity. Conclusions Among patients receiving axi-cel, seizure occurred in 7.1% of the total cohort, representing 12% of patients with ICANS. Ictal-interictal continuum abnormalities are also seen in patients with ICANS, most commonly GPDs. 75% of patients with seizures had nonconvulsive seizures supporting the use of continuous video EEG monitoring in this population.
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Affiliation(s)
- Sammita Satyanarayan
- Department of Neurology, Mount Sinai Icahn School of Medicine, New York, NY, USA
| | - Jay Spiegel
- Department of Medicine, University of Miami Health System, Miami, FL, USA
| | - Dominic Hovsepian
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Matthew Markert
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Reena Thomas
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Lori Muffly
- Department of Medicine- Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA, USA
| | - David Miklos
- Department of Medicine- Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA, USA
| | - Kevin Graber
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Brian J. Scott
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
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Kvam KA, Bernier E, Gold CA. Quality Improvement Metrics and Methods for Neurohospitalists. Neurol Clin 2021; 40:211-230. [PMID: 34798971 DOI: 10.1016/j.ncl.2021.08.011] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Measurement of clinical performance is largely driven by the requirements of the Centers for Medicare and Medicaid Services and accrediting bodies like The Joint Commission. Performance measures include length of stay, readmission rate, mortality rate, hospital-acquired complications, and stroke core measures. Hospital rankings also depend heavily on quality and patient safety indicators. Becoming facile with these measures can aid neurohospitalists in understanding their value and garnering resources to support improvement projects. Neurohospitalists can apply a structured A3-based method to define a clinical problem, perform systematic analysis, then design and test solutions to drive improved outcomes for patients with neurologic disease.
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Affiliation(s)
- Kathryn A Kvam
- Neurohospitalist Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 453 Quarry Road, Stanford, CA 94305-5235, USA.
| | - Eric Bernier
- Stanford Health Care, 300 Pasteur Drive, MC 5255, Stanford, CA 94305, USA
| | - Carl A Gold
- Neurohospitalist Program, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, 453 Quarry Road, Stanford, CA 94305-5235, USA
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Lord AS, Lombardi N, Evans K, Deveaux D, Douglas E, Mansfield L, Zakin E, Jakubowska-Sadowska K, Grayson K, Omari M, Yaghi S, Humbert K, Sanger M, Kim S, Boffa M, Szuchumacher M, Jongeling A, Vazquez B, Berberi N, Kwon P, Locascio G, Chervinsky A, Frontera J, Zhou T, Kahn DE, Abou-Fayssal N. Keeping the team together: Transformation of an inpatient neurology service at an urban, multi-ethnic, safety net hospital in New York City during COVID-19. Clin Neurol Neurosurg 2020; 197:106156. [PMID: 32877768 PMCID: PMC7430288 DOI: 10.1016/j.clineuro.2020.106156] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/05/2022]
Abstract
Neurology teams can care for patients with COVID-19 in lieu of being redeployed. Maintaining team structures has advantages to redeployment during pandemic surges. Streamlining neurological services increases capacity to care for COVID-19 patients.
The COVID-19 pandemic dramatically affected the operations of New York City hospitals during March and April of 2020. This article describes the transformation of a neurology division at a 450-bed tertiary care hospital in a multi-ethnic community in Brooklyn during this initial wave of COVID-19. In lieu of a mass redeployment of staff to internal medicine teams, we report a novel method for a neurology division to participate in a hospital’s expansion of care for patients with COVID-19 while maintaining existing team structures and their inherent supervisory and interpersonal support mechanisms.
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Affiliation(s)
- Aaron S Lord
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States.
| | - Nicole Lombardi
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States
| | - Katherine Evans
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States
| | - Dewi Deveaux
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States
| | - Elizabeth Douglas
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States
| | - Laura Mansfield
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States
| | - Elina Zakin
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Katarzyna Jakubowska-Sadowska
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Kammi Grayson
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Mirza Omari
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Shadi Yaghi
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Kelley Humbert
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Matt Sanger
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Sun Kim
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Michael Boffa
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Mariana Szuchumacher
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Amy Jongeling
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Blanca Vazquez
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Nisida Berberi
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Patrick Kwon
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Gianna Locascio
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Alexander Chervinsky
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Jennifer Frontera
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Ting Zhou
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - D Ethan Kahn
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
| | - Nada Abou-Fayssal
- Division of Neurology, NYU Langone Hospital-Brooklyn, Brooklyn, NY, United States; NYU Grossman School of Medicine, NY, NY United States
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