Relationship between Use of Rehabilitation Resources and ICU Readmission and ER Visits in ICU Survivors: the Korean ICU National Data Study 2008-2015

BACKGROUND

Despite the increasing importance of rehabilitation for critically ill patients, there is little information regarding how rehabilitation therapy is utilized in clinical practice. Our objectives were to evaluate the implementation rate of rehabilitation therapy in the intensive care unit (ICU) survivors and to investigate the effects of rehabilitation therapy on outcomes.

METHODS

A retrospective nationwide cohort study with including > 18 years of ages admitted to ICU between January 2008 and May 2015 (n = 1,465,776). The analyzed outcomes were readmission to ICU readmission and emergency room (ER) visit.

RESULTS

During the study period, 249,918 (17.1%) patients received rehabilitation therapy. The percentage of patients receiving any rehabilitation therapy increased annually from 14% in 2008 to 20% in 2014, and the percentages for each type of therapy also increased over time. The most common type of rehabilitation was physical therapy (91.9%), followed by neuromuscular electrical stimulation (29.6%), occupational (28.6%), respiratory, (11.6%) and swallowing (10.3%) therapies. After adjusting for confounding variables, the risk of 30-day ICU readmission was lower in patients who received rehabilitation therapy than in those who did not (P < 0.001; hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.65-0.75). And, the risk of 30-day ER visit was also lower in patients who received rehabilitation therapy (P < 0.001; HR, 0.83; 95% CI, 0.77-0.88).

CONCLUSION

In this nationwide cohort study in Korea, only 17% of all ICU patients received rehabilitation therapy. However, rehabilitation is associated with a significant reduction in the risk of 30-day ICU readmission and ER visit.

Central Nervous System Complications after Allogeneic Hematopoietic Stem Cell Transplantation in Children

Central nervous system complications (CNSCs) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) are common and may be a significant source of morbidity and mortality. We performed a retrospective study of 153 pediatric patients who underwent allo-HSCT to determine CNSC type, incidence, and impact on survival. A total of 34 patients (22.2%) developed CNSCs. The cumulative incidence of CNSCs at 100 days and 3 years was 18.30 and 22.73%, respectively. The most common CNSC was calcineurin inhibitor (CNI)-associated neurotoxicity (50.0%). Risk factors for CNSCs were the time from diagnosis to HSCT ≥4.8 months (p = 0.032) and the development of acute graft-versus-host disease (aGVHD) grade III-IV (p = 0.002). CNSCs after allo-HSCT negatively impacted overall survival (hazard ratio [HR] 1.97, p = 0.043) and nonrelapse mortality (HR 4.84, p < 0.001). In conclusion, CNSCs after allo-HSCT are associated with poor outcomes; patients with severe aGVHD and/or late transplantation should be given more attention.

Health effects associated with chronic exposure to low-level hydrogen sulfide from geothermoelectric power plants. A residential cohort study in the geothermal area of Mt. Amiata in Tuscany

BACKGROUND

Geothermal power plants for the production of electricity are currently active in Mt. Amiata, Italy. The present study aimed to investigate the association between chronic low-level exposure to H₂S and health outcomes, using a residential cohort study design.

METHODS

Spatial variability of exposure to chronic levels of H₂S was evaluated using dispersion modelling. Cohorts included people residing in six municipalities of the geothermal district from 01/01/1998 to 31/12/2016. Residence addresses were georeferenced and each subject was matched with H₂S exposure metrics and socio-economic status available at census tract level. Mortality and hospital discharge data for neoplasms and diseases of the respiratory, central nervous and cardiovascular systems were taken from administrative health databases. Cox proportional hazard models were used to test the association between H₂S exposure and outcomes, with age as the temporal axis and adjusting for gender, socio-economic status and calendar period.

RESULTS

The residential cohort was composed of 33,804 subjects for a total of 391,002 person-years. Analyses reported risk increases associated with high exposure to H₂S for respiratory diseases (HR = 1.12 95%CI: 1.00-1.25 for mortality data; HR = 1.02 95%CI: 0.98-1.06 for morbidity data), COPD and disorders of the peripheral nervous system. Neoplasms were negatively associated with increased H₂S exposure.

CONCLUSIONS

The most consistent findings were reported for respiratory diseases. Associations with increased H₂S exposure were coherent in both mortality and hospitalization analyses, for both genders, with evidence of exposure-related trends. No positive associations were found for cancer or cardiovascular diseases.

Neurologic Complications of Influenza B Virus Infection in Adults, Romania

Infection with this virus should be considered as an etiologic factor for encephalitis.

We characterized influenza B virus–related neurologic manifestations in an unusually high number of hospitalized adults at a tertiary care facility in Romania during the 2014–15 influenza epidemic season. Of 32 patients with a confirmed laboratory diagnosis of influenza B virus infection, neurologic complications developed in 7 adults (median age 31 years). These complications were clinically diagnosed as confirmed encephalitis (4 patients), possible encephalitis (2 patients), and cerebellar ataxia (1 patient). Two of the patients died. Virus sequencing identified influenza virus B (Yam)-lineage clade 3, which is representative of the B/Phuket/3073/2013 strain, in 4 patients. None of the patients had been vaccinated against influenza. These results suggest that influenza B virus can cause a severe clinical course and should be considered as an etiologic factor for encephalitis.

A comparison between oral chemotherapy combined with radiotherapy and radiotherapy for newly diagnosed glioblastoma: A systematic review and meta-analysis

The prognosis of glioblastoma (GBM), a major subtype of grade IV glioma, is rather poor nowadays. The efficiency of chemotherapy serving as the adjunct to radiotherapy (RT) for treating GBM is still controversial. In this study, we aim to investigate the overall survival (OS) and progression-free survival (PFS) in patients with newly diagnosed GBM received RT plus chemotherapy or with RT alone.Literatures were searched from the PubMed, Embase, and Cochrane Library between January 2001 and June 2015. Study selection was conducted based on the following criteria: randomized clinical trial (RCT) of adjuvant RT plus chemotherapy versus RT alone; studies comparing OS and/or PFS; and studies including cases medically confirmed of newly diagnosed GBM.Five RCTs (1655 patients) were eligible in this study. The meta-analysis showed a significant improvement in OS of patients treated with RT plus oral chemotherapy compared with that of RT alone (hazard ratio 0.70; 95% confidence interval, 0.56-0.88, P = .002).Adjuvant chemotherapy confers a survival benefit in patients newly diagnosed with GBM.

Survival and medical utilization of children and adolescents with prolonged ventilator-dependent and associated factors

Over the course of a year, more than 20,000 patients in Taiwan require prolonged mechanical ventilation (PMV). Data from the National Health Insurance Research Database for patients between 2005 and 2011 were used to conduct a retrospective analysis on ventilator dependence. The study subjects were PMV patients aged <17 years in Taiwan. A multiple regression model employing general estimating equations was applied to investigate the factors affecting the use of medical resources by children and adolescent PMV patients. A Cox proportional hazard model was incorporated to explore the factors affecting the survival of these patients. Data were collected for a total of 1,019 children and adolescent PMV patients in Taiwan. The results revealed that the average number of outpatient visits per subject was 32.1 times per year, whereas emergency treatments averaged 1.56 times per year per subject and hospitalizations averaged 160.8 days per year per subject. Regarding average annual medical costs, hospitalizations accounted for the largest portion at NT$821,703 per year per subject, followed by outpatient care at NT$123,136 per year per subject and emergency care at NT$3,806 per year per subject. The demographic results indicated that the patients were predominately male (61.24%), with those under 1 year of age accounting for the highest percentage (36.38%). According to the Kaplan—Meier curve, the 1-year and 5-year mortality rates of the patients were approximately 32% and 47%, respectively. The following factors affecting the survival rate were considered: age, the Charlson Comorbidity Index (CCI), diagnosis type necessitating ventilator use, and whether an invasive ventilator was used. This study investigated the use of medical resources and the survival rates of children and adolescent PMV patients. The findings of this study can serve as a reference for the National Health Insurance Administration in promoting its future integrated pilot projects on ventilator dependency.

[Statistics of causes of death and analysis of risk factors in a surgical intensive care unit]

OBJECTIVE

To summarize the causes of death and to analyze the risk factors in a surgical intensive care unit (SICU).

METHODS

The relevant information of patients died in the SICU of Xijing Hospital of Fourth Military Medical University in past 15 years (from December 1999 to February 2015) was retrospectively analyzed. The gender, age, reason and date of hospitalization, date of transfer SICU, past medical history, whether or not admitted directly from emergency department or transferred from other department, operated or not, date of death, the main cause of death, acute physiology and chronic health evaluation II (APACHE II) score, the history of undergoing mechanical ventilation, continuous renal replacement therapy (CRRT), or antifungal therapy, as well as the ratio of the patients with body temperature higher than 39 °C, white blood cell (WBC) count higher than 10 x 10⁹/L, platelet (PLT) count below 100 x 10⁹/L, albumin (Alb) below 35 g/L of two periods, namely from December 1999 to July 2007 (the first period), and from August 2007 to February 2015 (the second period) were compared. The above parameters were compared with those of 201 survivors in SICU, and the risk factors leading to death were analyzed by logistic regression.

RESULTS

From December 1999 to February 2015, 4 317 patients were taken care of in the SICU. Among them, the number of death was 186, and the mortality rate was 4.3%. In the first time period (from December 1999 to July 2007), the total number of patients was 1 356, and the number of death were 109 (the mortality rate was 8.0%). In the second period, i.e. from August 2007 to February 2015, the number of SICU patients was 2,961, and 77 died (the mortality rate was 2.6%). The difference of mortality rate between the two periods was statistically significant (χ² = 66.707, P = 0.001 ). The death rate of patients transferred directly from emergency department in the first period was 79.8% (87/109), and it was lower in the second period (51.9%, 40/77, χ² = 16.181, P = 0.001 ). The death rate of the patients with blood A1b below 35 g/L in the second period (59.7%, 46/77) was higher than that of the first period (41.3%, 45/109, χ² = 6.151, P = 0.017). The top three causes of death from December 1999 to February 2015 were sepsis (38.2%), trauma (16.7%), and operation for cancer (14.0%). In the first period, the top three causes of death were sepsis (35.8%), trauma (22.0%), and operation for cancer (13.8%). In the second period, the top three causes of death were sepsis (41.6%), damage of the central nervous system (16.9%), and operation for cancer (14.3%). Top three reasons for SICU admission were trauma (29.03%), abdominal pain (20.97%) and other reasons (18.82%). Top three departments from which the patients were transferred were the emergency department (19.35%), orthopedics department (17.20%), and hepatobiliary department (16.13%). Logistic regression analysis showed that age [odds ratio (OR) = 2.025, 95% confidence interval (95% CI) = 1.500-2.734, P = 0.000], mechanical ventilation (OR = 3.514, 95% CI = 1.701-7.259, P = 0.001), CRR T (OR = 5.604, 95% CI = 3.003-10.459, P = 0.000 ), body temperature higher than 39 °C (OR = 1.992, 95%CI = 1.052-3.771, P = 0.034) were the risk factors of death in SICU patients.

CONCLUSION

Sepsis and severe trauma are the leading causes of death in severe SICU patients, to whom with risk factors of death enough attention should be given.

Competing Risk Analysis of Neurologic versus Nonneurologic Death in Patients Undergoing Radiosurgical Salvage After Whole-Brain Radiation Therapy Failure: Who Actually Dies of Their Brain Metastases?

PURPOSE

To estimate the hazard for neurologic (central nervous system, CNS) and nonneurologic (non-CNS) death associated with patient, treatment, and systemic disease status in patients receiving stereotactic radiosurgery after whole-brain radiation therapy (WBRT) failure, using a competing risk model.

PATIENTS AND METHODS

Of 757 patients, 293 experienced recurrence or new metastasis following WBRT. Univariate Cox proportional hazards regression identified covariates for consideration in the multivariate model. Competing risks multivariable regression was performed to estimate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for both CNS and non-CNS death after adjusting for patient, disease, and treatment factors. The resultant model was converted into an online calculator for ease of clinical use.

RESULTS

The cumulative incidence of CNS and non-CNS death at 6 and 12 months was 20.6% and 21.6%, and 34.4% and 35%, respectively. Patients with melanoma histology (relative to breast) (aHR 2.7, 95% CI 1.5-5.0), brainstem location (aHR 2.1, 95% CI 1.3-3.5), and number of metastases (aHR 1.09, 95% CI 1.04-1.2) had increased aHR for CNS death. Progressive systemic disease (aHR 0.55, 95% CI 0.4-0.8) and increasing lowest margin dose (aHR 0.97, 95% CI 0.9-0.99) were protective against CNS death. Patients with lung histology (aHR 1.3, 95% CI 1.1-1.9) and progressive systemic disease (aHR 2.14, 95% CI 1.5-3.0) had increased aHR for non-CNS death.

CONCLUSION

Our nomogram provides individual estimates of neurologic death after salvage stereotactic radiosurgery for patients who have failed prior WBRT, based on histology, neuroanatomical location, age, lowest margin dose, and number of metastases after adjusting for their competing risk of death from other causes.

Relative survival of patients with non-malignant central nervous system tumours: a descriptive study by the Austrian Brain Tumour Registry

BACKGROUND

Unlike malignant primary central nervous system (CNS) tumours outcome data on non-malignant CNS tumours are scarce. For patients diagnosed from 1996 to 2002 5-year relative survival of only 85.0% has been reported. We investigated this rate in a contemporary patient cohort to update information on survival.

METHODS

We followed a cohort of 3983 cases within the Austrian Brain Tumour Registry. All patients were newly diagnosed from 2005 to 2010 with a histologically confirmed non-malignant CNS tumour. Vital status, cause of death, and population life tables were obtained by 31 December 2011 to calculate relative survival.

RESULTS

Overall 5-year relative survival was 96.1% (95% CI 95.1-97.1%), being significantly lower in tumours of borderline (90.2%, 87.2-92.7%) than benign behaviour (97.4%, 96.3-98.3%). Benign tumour survival ranged from 86.8 for neurofibroma to 99.7% for Schwannoma; for borderline tumours survival rates varied from 83.2 for haemangiopericytoma to 98.4% for myxopapillary ependymoma. Cause of death was directly attributed to the CNS tumour in 39.6%, followed by other cancer (20.4%) and cardiovascular disease (15.8%).

CONCLUSION

The overall excess mortality in patients with non-malignant CNS tumours is 5.5%, indicating a significant improvement in survival over the last decade. Still, the remaining adverse impact on survival underpins the importance of systematic registration of these tumours.

Can we improve the prevention and detection of congenital abnormalities? An audit of early pregnancy care in New Zealand

AIM

To determine whether there were "quality gaps" in the provision of care during pregnancies that resulted in a perinatal death due to congenital abnormality.

METHOD

Perinatal deaths from congenital cardiovascular, central nervous system or chromosomal abnormality in 2010 were identified retrospectively. Data were extracted by retrospective clinical note review and obtained by independent review of ultrasound scans.

RESULTS

There were 137 perinatal deaths due to a congenital cardiovascular (35), central nervous system (29) or chromosomal abnormality (73). First contact with a health professional during pregnancy was predominantly with a general practitioner. First contact occurred within 14 weeks in 85% of pregnancies and there was often a significant delay before booking. Folate supplements were taken by 7% pre-conceptually and 54% of women in the antenatal period. There were 20 perinatal deaths from neural tube defects that could potentially have been prevented through the use of pre-conceptual folate. Antenatal screening was offered to 75% of the women who presented prior to 20 weeks and 84% of these undertook at least one of the available antenatal screening tests. Review of ultrasound images found five abnormalities could have been detected earlier.

CONCLUSION

Delay in booking or failure to offer screening early were the most common reasons for delay in diagnosis of screen detectable abnormalities. The preventative value and timing of (pre-conceptual) folate needs emphasis.

[On the problem of unexpected death resulting from a disease of the central nervous system]

The problem of unexpected death is challenging for many medical disciplines including forensic medicine. In 2011 the ratio of violent to non-violent deaths was 1:1.7. The structure of non-violent mortality changed due to the rise in the number of deaths from cerebrovascular diseases. International epidemiological studies demonstrated that stroke presently holds the second or third place in the structure of overall mortality in the world's population. The lethality rate attributable to hemorrhagic stroke is estimated at 79.5%. Of special interest for both forensic medical experts and general practitioners is the combination of cerebrovascular disease and the preceding craniocerebral injury. The discrepancy between clinical and pathologo-anatomical diagnoses amounts to 46.5%. According to the data collected by the Russian Centre of Forensic Medical Expertise in 2010, cerebrovascular pathology remained unrecognized in 62.4% of the cases and was erroneously diagnosed as a cerebrocranial injury in 52.2% of the patients. It is believed that forensic medical experts can render assistance to health facilities as regards the improvement of the quality of medical aid and preventive measures provided to the population by means of analysis of available information and the development of relevant recommendations.

Efficacy of vinblastine in central nervous system Langerhans cell histiocytosis: a nationwide retrospective study

BACKGROUND

Vinblastine (VBL) is the standard treatment for systemic Langerhans cell histiocytosis (LCH), but little is known about its efficacy in central nervous system (CNS) mass lesions.

METHODS

A retrospective chart review was conducted. Twenty patients from the French LCH Study Group register met the inclusion criteria. In brief, they had CNS mass lesions, had been treated with VBL, and were evaluable for radiologic response.

RESULTS

The median age at diagnosis of LCH was 11.5 years (range: 1-50). Intravenous VBL 6 mg/m2 was given in a 6-week induction treatment, followed by a maintenance treatment. The median total duration was 12 months (range: 3-30). Eleven patients received steroids concomitantly. Fifteen patients achieved an objective response; five had a complete response (CR: 25%), ten had a partial response (PR: 50%), four had stable disease (SD: 20%) and one patient progressed (PD: 5%). Of interest, four out of the six patients who received VBL without concomitant steroids achieved an objective response. With a median follow-up of 6.8 years, the 5-year event-free and overall survival was 61% and 84%, respectively. VBL was well-tolerated and there were no patient withdrawals due to adverse events.

CONCLUSION

VBL, with or without steroids, could potentially be a useful therapeutic option in LCH with CNS mass lesions, especially for those with inoperable lesions or multiple lesions. Prospective clinical trials are warranted for the evaluation of VBL in this indication.

Intensive versus conventional insulin therapy in critically ill neurologic patients

BACKGROUND

Previous studies of glycemic control in non-neurologic ICU patients have shown conflicting results. The purpose was to investigate whether intensive insulin therapy (IIT) to keep blood glucose levels from 80 to 110 mg/dl or conventional treatment to keep levels less than 151 mg/dl was associated with a reduction of mortality and improved functional outcome in critically ill neurologic patients.

METHODS

Within 24 h of ICU admission, mechanically ventilated adult neurologic patients were enrolled after written informed consent and randomized to intensive or conventional control of blood glucose levels with insulin. Primary outcome measure was death within 3 months. Secondary outcome measures included 90-day modified Rankin scale (mRS) score, ICU, and hospital LOS.

RESULTS

81 patients were enrolled. The proportion of deaths was higher among IIT patients but this was not statistically significant (36 vs. 25%, P = 0.34). When good versus poor outcome at 3 months was dichotomized to mRS score 0-2 versus 3-6, respectively, there was no difference in outcome between the two groups (76.2 vs. 75% had a poor 3-month outcome, P = 1.0). There was also no difference in ICU or hospital LOS. Hypoglycemia (<60 mg/dl) and severe hypoglycemia (<40 mg/dl) were more common in the intensive arm (48 vs. 11%, P = 0.0006; and 4 vs. 0%, P = 0.5, respectively).

CONCLUSION

There was no benefit to IIT in this small critically ill neurologic population. This is the first glycemic control study to specifically examine both critically ill stroke and traumatic brain injury (TBI) patients and functional outcome. Given these results, IIT cannot be recommended over conventional control.

Mortality trends of stranded marine mammals on Cape Cod and southeastern Massachusetts, USA, 2000 to 2006

To understand the cause of death of 405 marine mammals stranded on Cape Cod and southeastern Massachusetts between 2000 and 2006, a system for coding final diagnosis was developed and categorized as (1) disease, (2) human interaction, (3) mass-stranded with no significant findings, (4) single-stranded with no significant findings, (5) rock and/or sand ingestion, (6) predatory attack, (7) failure to thrive or dependent calf or pup, or (8) other. The cause of death for 91 animals could not be determined. For the 314 animals that could be assigned a cause of death, gross and histological pathology results and ancillary testing indicated that disease was the leading cause of mortality in the region, affecting 116/314 (37%) of cases. Human interaction, including harassment, entanglement, and vessel collision, fatally affected 31/314 (10%) of all animals. Human interaction accounted for 13/29 (45%) of all determined gray seal Halichoerus grypus mortalities. Mass strandings were most likely to occur in northeastern Cape Cod Bay; 97/106 (92%) of mass stranded animals necropsied presented with no significant pathological findings. Mass strandings were the leading cause of death in 3 of the 4 small cetacean species: 46/67 (69%) of Atlantic white-sided dolphin Lagenorhynchus acutus, 15/21 (71%) of long-finned pilot whale Globicephala melas, and 33/54 (61%) of short-beaked common dolphin Delphinus delphis. These baseline data are critical for understanding marine mammal population health and mortality trends, which in turn have significant conservation and management implications. They not only afford a better retrospective analysis of strandings, but ultimately have application for improving current and future response to live animal stranding.

Analysis of causes of mortality in patients with autosomal dominant polycystic kidney disease: a single center study

This study was aimed at determining the median survival and most frequent causes of death in patients with the autosomal dominant polycystic kidney disease (ADPKD). A retrospective, observational analysis was made on patients registered with a diagnosis of ADPKD, in the computer records of the Sheffield Kidney Institute (SKI), United Kingdom, during the years 1981 to 1999. Data on 363 patients were analyzed from these computer records and further information, if any, was obtained from the patients' clinical notes. During this period, 88 patients died. The median age of the patients who died was 60.5 years, with the youngest being 37 years old and the oldest being 82 years. The major causes of death in this study group were cardiovascular (46.6%), infection (15.9%), central nervous system (CNS) disorders (11.36%), and miscellaneous causes (11.36%). Our study suggests that the major cause of death in patients with ADPKD was cardiovascular followed by infection, of which 42% of the deaths were due to septicemia. CNS causes of death comprised 11.36% of whom 60% had cerebrovascular events including subarachnoid hemorrhage in 20% of the patients. Uremia was the cause of death in only 2.2% of the patients in this series.

Infectious diseases consultation lowers mortality from Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is a lethal and increasingly common infection in hospitalized patients. We assessed the impact of infectious diseases consultation (IDC) on clinical management and hospital mortality of SAB in 240 hospitalized patients in a retrospective cohort study. Patients who received IDC were older than those who did not (57.9 vs. 51.7 yr; p = 0.05), and were more likely to have a health care-associated infection (63% vs. 45%; p < 0.01). In patients who received IDC, there was a higher prevalence of severe complications of SAB such as central nervous system involvement (5% vs. 0%, p = 0.01), endocarditis (20% vs. 2%; p < 0.01), or osteomyelitis (15.6% vs. 3.4%; p < 0.01). Patients who received IDC had closer blood culture follow-up and better antibiotic selection, and were more likely to have pus or prosthetic material removed. Hospital mortality from SAB was lower in patients who received IDC than in those who did not (13.9% vs. 23.7%; p = 0.05). In multivariate survival analysis, IDC was associated with substantially lower hazard of hospital mortality during SAB (hazard 0.46; p = 0.03). This mortality benefit accrued predominantly in patients with methicillin-resistant SAB (hazard 0.3; p < 0.01), and in patients who did not require ICU admission (hazard 0.15; p = 0.01). In conclusion, IDC is associated with reduced mortality in patients with staphylococcal bacteremia.

[Analysis of fatal cases and irreversible CNS injuries as complications of anesthetic maintenance]

The authors made a retrospective analysis of the 1988-2007 forensic medical examinations. They selected 45 fatal cases and 9 cases of severe irreversible CNS injuries occurring within 30 days after surgery as absolute complications due to anesthetic maintenance and postoperative management. Among the victims there were 7 children and 47 adults. In each case concerned, an attempt was made to reveal all critical incidents and factors associated with an evolving fatal outcome and it was suggested that a poor outcome could be prevented. It was noted that the most critical incidents resulting in death or severe irreversible CNS injuries were associated with respiratory disorders. These incidents were most frequently observed in the induction of anesthesia when tracheal intubation was attempted and in the early period (within 2 hours) after surgery. The most common associated factors should include inadequate preparation of a patient for surgery, improper medical care in the early postoperative period, and unavailability of automatic monitoring systems. It was ascertained that there was a potential for the prevention of death in most cases (53/54).

Late onset psychosis in survivors of pediatric central nervous system malignancies

Survivors of pediatric intracranial malignancies are at recognized high risk for neurocognitive and psychosocial dysfunction, endocrinopathies, growth abnormalities, and second neoplasms. The late onset of persistent psychosis may represent an additional serious psychiatric consequence of childhood intracranial malignancies. The authors report eight survivors of pediatric intracranial malignancies whose course was complicated by the delayed onset of hallucinations, delusions, and bizarre behavior 2 to 12 years after diagnosis and treatment of brain tumors. The purpose of this report is to alert others to the generally unrecognized risk of psychosis following the treatment of brain tumors in children and adolescents.

Early treatment of premature infants with steroids: neurological sequelae

(1) For more than 30 years premature infants with respiratory disorders have been routinely prescribed a steroid during the first days of life. (2) A number of immediate adverse effects have been described, and studies in which infants were monitored until they were 3 years old have raised concerns about neurological sequelae. (3) 146 children who participated in a randomised placebo-controlled trial of systemic steroid therapy in the early postnatal period were monitored until they were eight years old. (4) Mean height was lower in the dexamethasone group than among placebo-treated controls (121 cm to 122 cm, depending on gender, versus 124 cm to 126 cm), and mean cranial circumference was also smaller (49.8 cm versus 50.6 cm). (5) Scores for various motor and cognitive tests, as well as some school examinations, were lower in children exposed to dexamethasone. (6) Disabilities were more frequent in the group exposed to dexamethasone (28 of 72 children versus 16 of 74 controls; p <0.05). (7) These data confirm the neurological adverse effects of prolonged treatment of premature infants with systemic steroids in the early postnatal period. Such steroid regimen should no longer be used in this setting.

Infectious embolisation to the central nervous system from endocarditis: analyses of 99 cases

Within a cohort of 606 cases of infective endocarditis, 263 were complicated and 99 embolizing, of them 32 to the central nervous system (CNS). Significant predictors of CNS embolisation were inappropriate therapy (p<0.01) and enterococcal etiology (p<0.01). Mortality in patients with CNS emboli was 65% what was significantly higher than in cases without embolisation - 15% (p<0.01).

Central nervous system-related permanent consequences in patients with Langerhans cell histiocytosis

BACKGROUND

Permanent consequences in Langerhans cell histiocytosis (LCH) are irreversible late sequelae related to the disease that may severely impair the quality of life of survivors. The frequency and pattern of permanent consequences affecting the central nervous system (CNS) remains to be determined.

PROCEDURE

In this single center study, 25 LCH patients observed for a median time of 10 years 3 months underwent a uniform thorough follow-up program including neuropsychological testing and electrophysiological evaluation.

RESULTS

Overall permanent consequences were seen in 9 of 25 patients. Intracranial abnormalities were the most frequent including diabetes insipidus (DI) in seven patients, anterior pituitary deficiencies in five patients, and neurodegenerative CNS disease in five patients. No patient had overt neurological symptoms upon neurological evaluation, but psychological testing revealed subtle deficits in short-term auditory memory (STAM) in 14 patients. Brain stem evoked potentials showed abnormalities in four of nine tested patients, all of these four had neurodegeneration on MRI.

CONCLUSION

Psychoneuroendocrine sequelae were found in an unexpectedly high number of patients in this single center study. Long-term follow-up focusing on such sequelae are important in LCH survivors, in order to detect early deficits, to monitor the evolution of the disease, and to provide specific support.

Ethnic variation in disease patterns and health outcomes in systemic lupus erythematosus

OBJECTIVE

In a single-center multiethnic lupus cohort, to investigate the influence of ethnicity on the prevalence of cumulative renal and central nervous system (CNS) lupus disease and damage, overall end-organ damage, and mortality.

METHODS

Clinical features, end-organ damage, and mortality were compared by ethnic origin among patients at a lupus clinic followed prospectively in a longitudinal design over a 32-year period. Statistical analysis to compare demographic features, cumulative disease manifestations, and damage included chi-square test as well as linear, logistic, and Poisson regressions adjusting for disease duration, age at diagnosis, and presence of dialysis and hypertension. Kaplan-Meier and proportional hazard analyses were performed to compare survival.

RESULTS

There were a total of 1017 patients: 853 Caucasian, 88 African-Canadian, and 76 Chinese-Canadian. Age at diagnosis was younger and disease duration was shorter for Chinese-Canadians compared to Caucasians, but similar between African-Canadians and Caucasians. There was no significant difference in CNS disease, comparing Caucasians to Chinese-Canadians. However, CNS disease was greater in African-Canadians than Chinese-Canadians. There was no significant difference between ethnic groups in CNS damage. Renal disease was more common in African-Canadians than Caucasians, with no significant difference between Caucasian and Chinese-Canadian patients. Renal damage was more common in African-Canadians and Chinese-Canadians than Caucasians. There was no significant difference in mortality among the 3 ethnic groups.

CONCLUSION

In this single referral center cohort study, there was no significant difference in CNS damage or mortality among the 3 ethnic groups. African-Canadians had a higher prevalence of renal disease and damage. Further investigation into other determinants such as genetic predisposition, treatment, and cultural perceptions is needed.

[Health effects of environmental contamination due to volcanic ash of Mount Etna in autumn 2002]

OBJECTIVE

During autumn 2002 a large eruption of Mount Etna (Sicily, Italy) occurred. High levels (over 200 microg/m3) of total suspended particles (PM10) were recorded. The aim of the study was to evaluate the acute health effects on mortality and hospital admissions in the area around the volcano.

DESIGN

Deaths and hospital admissions occurring during the eruption period were compared with the corresponding figures during the same periods of the previous year (same day of the week). Relative risks, RR, and their 95% confidence intervals, CI, were computed. Variations in daily hospital admissions for cardiovascular diseases associated with daily level of PM10 were estimated.

RESULTS

No effects on overall and cause-specific mortality were observed during the eruption period. Increases were observed in hospital admissions for cardiovascular diseases (ischemic diseases: RR 1.31, 95% CI 1.10-1.56; myocardial infarction: RR 1.34, 95% CI 1.02-1.76) and for cerebrovascular diseases (RR 1.24, 95% CI 1.05-1.47). The excesses were stronger among the elderly. Daily admissions for cardiovascular diseases were not associated to PM10 levels.

CONCLUSION

The effects of the eruption of Mount Etna were limited to a temporary increase of cardiovascular morbidity, especially among the elderly, possibly as a consequence of stress.

Mortality updates (1970-1997) of two refinery/petrochemical plant cohorts at Baton Rouge, Louisiana, and Baytown, Texas

OBJECTIVE

The purpose of this retrospective cohort study is to update mortality experience at refinery/petrochemical plant facilities in Baton Rouge, Louisiana, and Baytown, Texas.

METHODS

Standardized mortality ratios (SMRs) were calculated for 1970-1997 based on death rates in the respective states.

RESULTS

SMRs are near or below unity for most causes of death. Among elevations, Baton Rouge has an SMR of 2.42 (95% CI = 1.16-4.45) for chronic lymphocytic leukemia, 1.58 (95% CI = 1.17-2.08) for hypertension with heart disease, and 1.47 (95% CI = 0.98-2.11) for non-Hodgkin's lymphoma. Baytown has an SMR of 2.13 (95% CI = 1.10-3.73) for acute nonlymphocytic leukemia (ANLL) and 3.11 (95% CI = 1.01-7.26) for unspecified brain/spinal cord neoplasms. The above findings pertain to pre-1950 hires and exhibit no apparent job-related patterns. Both cohorts have approximately twofold increases in mesothelioma deaths, similar to the last update, with most decedents having held maintenance jobs.

CONCLUSIONS

Periodic examination of mortality patterns has an important role in assessing overall employee health status and identifying potential areas of increased risk. Mortality surveillance will continue to monitor these outcomes among more recent workers.

Ventilación mecánica en pacientes con patologías agudas del Sistema Nervioso Central: sobrevida y pronóstico funcional

BACKGROUND

The need of mechanical ventilation among patients with acute neurological diseases is considered a poor prognostic sign.

AIM

To determine the mortality and functional recovery of neurological patients requiring mechanical ventilation.

PATIENTS AND METHODS

Prospective study of 77 patients (42 men, age 54+/-19 years, with 11+/-4 points of Glasgow coma scale (GCS), 61% with cerebrovascular disease), that were admitted to the intensive care unit with neurological disease and that required mechanical ventilation. Functional recovery was assessed at 18 months with Glasgow outcome scale (GOS) and Barthel index.

RESULTS

Thirty percent of patients died during follow up. Among surviving patients, 47% had a good recovery or moderate disability, and 74% had a Barthel index equal to or over 70. Arterial hypertension, age over 70 and mechanical ventilation longer than 6 days were associated with bad functional prognosis.

CONCLUSIONS

Neurological patients requiring mechanical ventilation had a lower mortality than previously reported, and half of the survivors have an independent life. This study supports intensive care management in this group of patients.

Coxsackievirus B3 and the neonatal CNS: the roles of stem cells, developing neurons, and apoptosis in infection, viral dissemination, and disease

Neonates are particularly susceptible to coxsackievirus infections of the central nervous system (CNS), which can cause meningitis, encephalitis, and long-term neurological deficits. However, viral tropism and mechanism of spread in the CNS have not been examined. Here we investigate coxsackievirus B3 (CVB3) tropism and pathology in the CNS of neonatal mice, using a recombinant virus expressing the enhanced green fluorescent protein (eGFP). Newborn pups were extremely vulnerable to coxsackievirus CNS infection, and this susceptibility decreased dramatically by 7 days of age. Twenty-four hours after intracranial infection of newborn mice, viral genomic RNA and viral protein expression were detected in the choroid plexus, the olfactory bulb, and in cells bordering the cerebral ventricles. Many of the infected cells bore the anatomical characteristics of type B stem cells, which can give rise to neurons and astrocytes, and expressed the intermediate filament protein nestin, a marker for progenitor cells. As the infection progressed, viral protein was identified in the brain parenchyma, first in cells expressing neuron-specific class III beta-tubulin, an early marker of neuronal differentiation, and subsequently in cells expressing NeuN, a marker of mature neurons. At later time points, viral protein expression was restricted to neurons in specific regions of the brain, including the hippocampus, the entorhinal and temporal cortex, and the olfactory bulb. Extensive neuronal death was visible, and appeared to result from virus-induced apoptosis. We propose that the increased susceptibility of the neonatal CNS to CVB infection may be explained by the virus' targeting neonatal stem cells; and that CVB is carried into the brain parenchyma by developing neurons, which continue to migrate and differentiate despite the infection. On full maturation, some or all of the infected neurons undergo apoptosis, and the resulting neuronal loss can explain the longer-term clinical picture.

CT and MR imaging of central nervous system effects of therapy in patients treated for hematological malignancies

The purpose of this article is to present the imaging appearance of central nervous system effects of therapy that may occur in patients treated for hematological malignancies. Imaging in these patients relates to complications of high-dose therapy, bone marrow transplantation, infections occurring in immunocompromised patients, central nervous system dysfunction due to failure of other organ systems, or cerebral hemorrhages due to platelet refractoriness. Rapid and accurate diagnosis is essential but often difficult, as neurological manifestations are rarely disease specific. Neurological imaging, in combination with electrophysiological studies as well as blood and cerebrospinal fluid investigations, may be helpful for diagnosing most of these complications, as well as in differentiating between the manifestations of the underlying disease and complications of the treatment.

Long-term outcomes of allogeneic stem cell transplant recipients after calcineurin inhibitor-induced neurotoxicity

Calcineurin inhibitor-induced central nervous system toxicities are uncommon and often resolve after discontinuation of the offending drug. The long-term outcome of these patients is, however, unknown. Resolution of symptoms occurred in 70% of 30 allografted recipients who developed calcineurin inhibitor-induced neurotoxicity. When patients were rechallenged with the same or a different calcineurin inhibitor, symptoms recurred in 41%, leading to permanent discontinuation of the drug. De novo or progressive acute graft-versus-host disease (GVHD) was observed in 54% of patients at a median of 7 d (range 1-70 d) after initial onset of neurotoxicity. The prognosis was grim, with 24 (80%) of these patients dying a median 33 d after the onset of neurotoxicity (range 2-594 d). GVHD and/or infection occurred in 54% and were the most common primary causes of death. We conclude that calcineurin inhibitor-induced neurotoxicity is frequently reversible but associated with a poor prognosis.

Unexpected out-of-hospital deaths in persons aged 85 years or older: an autopsy study of 1886 patients

PURPOSE

The aim of this study was to determine the causes of death in the very elderly.

METHODS

We reviewed 24,081 consecutive autopsies performed over 10 years (1989 to 1998) at the Institute of Forensic Medicine, Vienna, Austria. We focused on autopsies of people aged 85 years or older who died unexpectedly out of hospital.

RESULTS

The mean age of the 1886 patients (561 men and 1325 women) at the time of death was 88 +/- 3 years (range, 85 to 108 years). Thirty-one percent (n = 588) of those who died were described as having been previously healthy. Cardiovascular disease was the most common cause of death (n = 1465 [77%]). Thirteen percent (n = 246) died of respiratory illness, 5% (n = 94) of gastrointestinal disorders, and 3% (n = 53) of diseases of the central nervous system. Genitourinary and metabolic diseases were uncommon.

CONCLUSION

Although this out-of-hospital sample is not representative of the entire elderly population, postmortem examinations emphasize the importance of cardiovascular diseases in causing unexpected deaths in older persons.

Multiple organ dysfunction syndrome in hematopoietic stem cell transplantation

OBJECTIVE

To review the data demonstrating that central nervous system, pulmonary, and hepatic dysfunctions during hematopoietic stem cell transplantation have similar laboratory correlates and clinical outcomes, suggesting that they are individual organ manifestations of a systemic disorder at presentation, a disorder similar to the multiple organ dysfunction syndrome seen in other populations of critically ill patients.

DATA SOURCES AND STUDY SELECTION

Reports of clinical research studies on the natural history and laboratory correlates of central nervous system, pulmonary, and hepatic dysfunction (generally manifesting as the syndrome of hepatic veno-occlusive disease) during hematopoietic stem cell transplantation.

DATA EXTRACTION AND SYNTHESIS

During hematopoietic stem cell transplantation, pulmonary dysfunction (manifesting as hypoxia), central nervous system dysfunction (detected by alteration of the Mini-Mental Status Exam), and hepatic dysfunction (presenting as the syndrome of hepatic veno-occlusive disease) are all associated with significant decreases in the levels of antithrombin III and protein C and an increase in the platelet transfusion requirement. Each of these three organ dysfunctions is associated with a high likelihood of being followed by the other two and, eventually, death. Patients with these organ dysfunctions have higher levels of interleukin-6, interleukin-10, and tumor necrosis factor-alpha than patients who never develop these complications. Mortality rates for patients with these organ dysfunctions vary from 15% in patients with only one organ dysfunction to 100% in patients who have progressed to all three. Patients who develop none of these organ dysfunctions have a mortality rate that approaches zero.

CONCLUSIONS

Central nervous system, pulmonary, and hepatic dysfunctions are intimately involved in the mortal complications of hematopoietic stem cell transplantation. Because these organ dysfunctions have similar correlates and similar outcomes, the hypothesis that they are individual parts of a systemic disorder is proposed. The additional observation that these organ dysfunctions are associated with abnormally high levels of inflammation-related cytokines raises the possibility that their pathogenesis is similar to that of multiple organ dysfunction syndrome in other populations of critically ill patients.

Long-term follow-up of neurosarcoidosis

The authors evaluated the long-term clinical outcome of neurosarcoidosis and determined predictive factors of disease course. Twenty-seven patients with neurosarcoidosis were followed for at least 5 years from the onset of neurologic symptoms. Patients with CNS involvement during the course of the disease had a higher Modified Oxford Handicap Scale score than those with peripheral nervous system involvement (p < 0.02). CNS involvement may be a predictive factor for a less favorable disease course. Early and intensive treatment should be considered in such cases.

The effects of restraint stress on the neuropathogenesis of Theiler's virus infection: I. Acute disease

Restraint stress was found to have a profound effect on the acute phase of Theiler's virus infection. Increased mortality rates were observed in restrained CBA mice infected with the BeAn strain of Theiler's virus. In addition, restrained mice developed higher CNS viral titers than infected/nonrestrained mice. Thymic atrophy was observed in both infected and uninfected restrained mice. Decreased microgliosis, perivascular cuffing, and astrocytosis were observed in restrained mice compared to nonrestrained infected mice at 7 days postinfection. Restraint-stressed mice also developed decreased numbers of lymphocytes and increased numbers of neutrophils in the blood. The mechanism proposed for these alterations involves stress-induced corticosterone, which causes immunosuppression, decreased trafficking of inflammatory cells in the CNS, and, consequently, increased viral replication.

Acute neurology and neurophysiology of haemolytic-uraemic syndrome

Involvement of the central nervous system (CNS) is found in around 30% of children with haemolytic-uraemic syndrome (HUS). This complication is the single most common cause of mortality and also a major contributor to the morbidity associated with HUS. We reviewed 22 children with HUS and acute CNS involvement. Both global and focal derangements occurred, and in survivors, early regional EEG abnormalities-especially those in the occipital and temporal areas-were prognostically useful.

Cerebral function monitoring in paediatric intensive care: useful features for predicting outcome

Neurological integrity in sick children is difficult to assess clinically. The aim of this study was to determine the predictive value of EEG activity recorded with a bedside EEG analysing monitor in an intensive care unit. EEG activity was monitored in 108 children (age range 2 weeks to 16 years, median 1.7 years) considered at risk for cerebral abnormalities with a cerebral function analysing monitor (CFAM). Recordings were evaluated for features of background EEG activity including mean amplitude, frequencies, and symmetry. Electrical seizure activity was quantified if present. Predictive value of the EEG features was evaluated relative to the clinical neurological outcome after one year. Asymmetrical recordings were not seen in any child with a normal outcome. Suppression of background activity was seen in 75% of the children who died. Seizures were present in 68% of children with a poor outcome. Seventeen of the 32 children (65%) who died had prolonged seizures. Absence of seizures and the presence of superimposed fast EEG activity in response to benzodiazepine infusions correlated with good outcome. A combination of two or more predictive EEG features demonstrated >90% specificity and positive predictive likelihood of poor outcome. EEG features provide information about the functional cerebral integrity of sick children. Changes in cerebral activity detected by the CFAM aid decision making by providing such information readily at the bedside in intensive care.

Inhalation exposure to white spirit causes region-dependent alterations in the levels of glial fibrillary acidic protein

Enhanced expression of glial fibrillary acidic protein (GFAP) is known to be associated with toxicant-induced gliosis, a homotypic response of the central nervous system to neural injury. A variety of neurochemical and neurophysiological effects have been observed in experimental animals exposed to white spirit, but a linkage of such effects to neural damage has not been established. Here we evaluated the regional levels of GFAP to assess potential sites of CNS damage in the rat, following exposure to dearomatized and aromatic white spirit. Samples from rats exposed to dearomatized white spirit were assayed for GFAP levels in the United States and Denmark. The results were remarkably similar between countries. Small region-dependent increases and decreases in GFAP were observed with the cerebellum showing the most consistent effects (increases). In contrast, samples from rats exposed to aromatic white spirit showed large (as much as 150% of control) increases in regional levels of GFAP; again, the cerebellum showed the most consistent effects. The data are indicative of an aromatic white-spirit-induced astrogliosis in several regions of the rat CNS and suggest that chronic exposure to this solvent may be associated with underlying neural damage.

Frequency of central nervous system involvement in primary cutaneous B-cell lymphoma

BACKGROUND

Primary cutaneous B-cell lymphoma (CBCL) constitutes approximately 20% of all primary cutaneous lymphomas. Apart from primary cutaneous large B-cell lymphoma presenting on the legs (PCLBCL-leg), primary CBCLs run an indolent clinical course, rarely disseminate to extracutaneous sites, and have an excellent prognosis. Because of recent observations in two patients who developed central nervous system (CNS) involvement, follow-up data of all primary CBCL patients registered at the Dutch Cutaneous Lymphoma Group between 1985 and 1998 were investigated for evidence of CNS involvement.

METHODS

Follow-up data from 160 primary CBCLs were evaluated. This group included 122 primary cutaneous follicle center cell lymphomas (PCFCCLs), 16 primary cutaneous immunocytomas or marginal zone B-cell lymphomas, and 22 PCLBCL-leg.

RESULTS

Of all 160 patients with primary CBCLs, 11 died of lymphoma, including 4 of 122 patients (3%) with PCFCCL and 7 of 22 patients (32%) with PCLBCL-leg. Four of these 11 patients, including 3 with PCFCCL and 1 with PCLBCL-leg, had developed CNS involvement 3-93 months (median, 30 months) after diagnosis. All patients died 1-9 months (median, 7 months) after the development of CNS involvement. In the group of 122 patients with PCFCCL, CNS involvement occurred in 3 of 7 patients (43%) who developed extracutaneous disease and accounted for 3 of 4 lymphoma-related deaths (75%).

CONCLUSIONS

The results of this study indicate that approximately 2% of all primary CBCLs may develop CNS involvement. Whereas, in rare PCFCCL patients, developing extracutaneous disease CNS involvement was an important cause of death, patients with PCLBCL-leg and secondary CBCL died more frequently due to involvement of non-CNS organ systems.

Evidence that CNS hypomyelination does not cause death of jimpy-msd mutant mice

Mice expressing three of the proteolipid protein (Plp) mutations in the mouse (jimpy, jimpy-msd, and jimpy-4J) all have a severe deficiency of CNS myelin and oligodendrocytes (OLs), and die sometime in their 4th postnatal week. The prevailing view has been that the animals' shortened life span and lack of myelin are causally related. Here we describe the survival of jimpy-msd males for as long as postnatal day (P) 210. Although these spontaneously occurring longer-lived jimpy-msd males show a 2- to 8-fold increase in numbers of myelinated axons in many CNS regions, this does not protect them from a later but still premature death. Investigating the cause of premature death may reveal previously undiscovered properties of the myelin genes or the cells that express them, or perhaps additional unsuspected cellular responses that contribute to the disease. This study identifies small accumulations of inflammatory cells in the brain parenchyma of jimpy-msd mice as young as P14 and as old as P60, suggesting that the pathology of the disease produced by at least this Plp mutation may be far more complex than has been previously recognized.

Quaking*shiverer double-mutant mice survive for at least 100 days with no CNS myelin

Mice expressing mutations that produce CNS hypomyelination often die prematurely: the more severe the hypomyelination, the shorter the life span. However, we have previously described jimpy-msd mice that survive twice as long as usual; although they acquire significantly increased amounts of myelin, they still succumb long before their unaffected littermates. This result contradicts any postulated causal relationship between extent of CNS hypomyelination and premature death of the animal. Here we have addressed this question in another way, by using an animal model that does not involve a proteolipid protein (Plp) gene mutation. We demonstrate that quaking*shiverer double-mutant mice can survive for at least 100 days without any CNS myelin whatsoever. Therefore, at least for a mouse, absence of CNS myelin is not lethal per se.

Central nervous system dysfunction as the first manifestation of multiple organ dysfunction syndrome in stem cell transplant patients

Development of CNS dysfunction in the setting of hematopoietic stem cell transplant (HSCT) has been previously shown to predict for subsequent second organ dysfunction and death. In this paper, we describe the characteristics of this isolated CNS dysfunction, and its relationship to multiple organ dysfunction syndrome (MODS) after HSCT. Twenty-one of 186 patients undergoing HSCT developed CNS dysfunction as their first organ dysfunction a mean of 22.8 +/- 0.9 days after the start of the preparative regimen. Compared with 137 patients who developed no organ dysfunction, patients presenting with CNS dysfunction were more likely to have undergone allogeneic HSCT (P = 0.001) and to have received a total body irradiation-based regimen (P = 0.001), and were less likely to have been transplanted for lymphoma (P = 0.008). Patients who developed CNS dysfunction were more likely to die than those with no organ dysfunction (P < 0. 001). Of the 21 patients who developed CNS dysfunction, 48% resolved their dysfunction by a mean of 4.6 days later without progression to second organ dysfunction, and 90% of these patients survived to day 100. Fifty-two percent of patients with CNS dysfunction progressed to second organ dysfunction (pulmonary or hepatic) a mean of 5.5 days later, and only 36% survived to day 100 (P = 0.02). The patients who progressed to second organ dysfunction and those who did not were not different in terms of type of HSCT (allogeneic vs autologous), stem cell source (blood vs bone marrow), age, diagnosis or preparative regimen. Development of CNS dysfunction in the setting of HSCT, as with other organ dysfunctions (such as hepatic veno-occlusive disease), probably represents an early manifestation of a systemic disorder predisposing for MODS, increasing the risk of transplant-related mortality. Early systemic therapies directed at modulating this systemic disorder are probably indicated. Bone Marrow Transplantation (2000) 25, 79-83.

Short-term mortality after a first epileptic seizure: a population-based study

PURPOSE

To determine the short-term mortality in a prospective incidence cohort of patients included after any kind of first afebrile epileptic seizure (i.e., provoked and unprovoked).

METHODS

Information on death occurring within the first year of follow-up was collected in a cohort of 804 patients with a first seizure between March 1, 1984, and February 28, 1985, in southwest France. The variables analyzed were the etiology of seizure, cause of death, interval between seizure and death, and age of patients.

RESULTS

By the end of the 1-year follow-up, there were 149 deaths among these patients as compared with 16 expected deaths [standardized mortality ratio (SMR), 9.3; 95% confidence interval (CI), 7.9-10.9]. There were no deaths in patients with idiopathic seizures. Patients with cryptogenic seizures had slightly increased mortality (SMR, 1.6; 95% CI, 0.4-4.1). Mortality was increased for patients with remote symptomatic seizures (SMR, 6.5; 95% CI, 3.8-10.5), provoked seizures (SMR, 10.1; 95% CI, 8.1-12.4), and seizures due to a progressive neurologic condition (SMR, 19.8; 95% CI, 14.0-27.3). Causes of death were underlying pathology (64%), unrelated condition (20%), unknown cause (9%), seizure-related death (6%), and one suicide.

CONCLUSIONS

Early mortality clearly differed according to the etiology of the first seizure. The highest mortality was associated with provoked seizures and with seizures caused by progressive central nervous system disorders. Patients died far more often from underlying or unrelated conditions than from seizures.

Influence of maternal magnesium sulphate and ritodrine treatment on the neonate: a study with six-month follow-up

Magnesium sulphate and ritodrine are commonly used drugs in the prevention of preterm delivery. However, the effects of these treatments on the newborn are controversial. It has previously been suggested that antenatal tocolytic magnesium sulphate decreases the incidence of cerebral palsy, but increases paediatric mortality. On the other hand, antenatal ritodrine treatment has been reported to increase the incidence of neonatal peri-intra-ventricular haemorrhage (PIVH). We investigated the cerebral ultrasonographic findings, neurological outcome and apparent life-threatening events (ALTE) among 63 infants, born before 33 wk of gestation, whose mothers were antenatally treated for premature birth with ritodrine or magnesium sulphate, and for pre-eclampsia with magnesium sulphate. Cerebral ultrasonography was performed during the first week of life and repeated before hospital discharge. The pathological findings were confirmed by a paediatric radiologist. A paediatrician and a physiotherapist performed the neurological follow-up examination of the survivors at 6 mo of age. We found Grade 3-4 PIVH in 15% of the infants exposed to maternal ritodrine treatment, in 9% of the infants whose mothers received tocolytic magnesium treatment, and in none of those exposed to maternal magnesium treatment for pre-eclampsia (p = 0.19). However, no differences were observed in 6-mo development or in the rate of paediatric mortality and ALTE among these three study groups. Because of the retrospective design and the limited number of subjects, the results of this study must be interpreted with caution.

Does a focal neurologic deficit contraindicate operation in a patient with endocarditis?

BACKGROUND

As many as 40% of patients with left-sided bacterial endocarditis will sustain a neurologic insult. The importance of a neurologic change as an indication or a contraindication for valve replacement remains controversial.

METHODS

We performed a retrospective analysis of the records of 33 patients admitted to the University of Virginia Health Sciences Center between January 1, 1978, and June 30, 1996, with a diagnosis of endocarditis and a neurologic change.

RESULTS

All 33 patients had echocardiographic or pathologic evidence of left-sided endocarditis; 23 were seen with focal neurologic findings and had a mortality rate of 22% (5 of 23), and 10 patients were seen with nonfocal, diffuse encephalopathy and had a mortality rate of 60% (6 of 10) (p<0.05). Of the 33 patients, 14 underwent operation and 19 were treated medically. The mortality rate was 21.4% (3 of 14) in the surgical group and 42.1% (8 of 19) in the medical group (p = not significant). In 71% (10 of 14) of the surgical patients, the operation was done within 1 week of the neurologic event. Additional neurologic deterioration occurred in 18.2% (2 of 11) of survivors in the surgical group and 9.1% (1 of 11) in the medical group (p = not significant).

CONCLUSIONS

Choosing therapy for a patient with endocarditis and a neurologic change remains a difficult challenge. Initial findings of nonfocal, global dysfunction on examination are a predictor of a poor outcome. By comparing surgical and medical groups derived from the same series of patients, it is clear that patients with bacterial endocarditis and central nervous system changes face substantial mortality regardless of intervention. However, these data demonstrate that when compared with a similar group of medical patients, surgical patients who require and receive operation early in the course of their illness do comparatively well. Improving outcomes by delaying surgical intervention may serve to "select out" hardier patients but will lead to the death of patients who might benefit from such intervention.