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Du Q, Yu J, Chen Q, Chen X, Jiang Q, Deng L, Li A, Xiong Y. Clinical characteristics and influencing factors of severe fever with thrombocytopenia syndrome complicated by viral myocarditis: a retrospective study. BMC Infect Dis 2024; 24:240. [PMID: 38389047 PMCID: PMC10885462 DOI: 10.1186/s12879-024-09096-4] [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: 09/08/2023] [Accepted: 02/04/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVE This study aimed to investigate the clinical characteristics of severe fever with thrombocytopenia syndrome complicated by viral myocarditis (SFTS-VM) and analyze relevant influencing factors. METHODS Retrospective analysis was conducted on clinical data from 79 SFTS-VM patients, categorized into common (SFTS-CVM, n = 40) and severe groups (SFTS-SVM, n = 39). Clinical manifestations, laboratory results, cardiac ultrasonography, and electrocardiogram features were analyzed. Univariate and multivariate analyses identified significant indicators, which were further assessed using ROC curves to predict SFTS-SVM. RESULTS SFTS-SVM group exhibited higher rates of hypotension, shock, abdominal pain, cough with sputum, and consciousness disorders compared to SFTS-CVM group. Laboratory findings showed elevated platelet count, ALT, AST, amylase, lipase, LDH, D-dimer, procalcitonin, TNI, and NT-proBNP in SFTS-SVM. Abnormal electrocardiograms, especially atrial fibrillation, were more prevalent in SFTS-SVM (P < 0.05). Multivariate analysis identified elevated LDH upon admission (OR = 1.004, 95% CI: 1-1.008, P = 0.050), elevated NT-proBNP (OR = 1.005, 95% CI: 1.001-1.008, P = 0.007), and consciousness disorders (OR = 112.852, 95% CI: 3.676 ~ 3464.292, P = 0.007) as independent risk factors for SFTS-SVM. LDH and NT-proBNP had AUCs of 0.728 and 0.744, respectively, in predicting SFTS-SVM. Critical values of LDH (> 978.5U/L) and NT-proBNP (> 857.5pg/ml)) indicated increased likelihood of SFTS progression into SVM. CONCLUSION Elevated LDH, NT-proBNP, and consciousness disorders independently correlate with SFTS-SVM. LDH and NT-proBNP can aid in early identification of SFTS-SVM development when above specified thresholds.
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Affiliation(s)
- Qian Du
- Department of Infectious Disease, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China
| | - Jin Yu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China
| | - Qianhui Chen
- Department of Infectious Disease, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China
| | - Xiaoping Chen
- Department of Infectious Disease, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China
| | - Qunqun Jiang
- Department of Infectious Disease, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China
| | - Liping Deng
- Department of Infectious Disease, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.
| | - Anling Li
- Department of Laboratory Medicine, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.
| | - Yong Xiong
- Department of Infectious Disease, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.
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Tsuchida Y, Tsubata Y, Nozawa R, Maruyama S, Ikarashi K, Saito N, Morioka T, Kamura T, Shimada H, Narita I. Fatal acute portal vein thrombosis associated with hepatic cysts in a patient with autosomal dominant polycystic kidney disease. CEN Case Rep 2024; 13:32-36. [PMID: 37162720 PMCID: PMC10834907 DOI: 10.1007/s13730-023-00795-6] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) often involves polycystic liver disease (PLD). In severe cases, PLD can develop various complications. However, fatal acute portal vein thrombosis (APVT) associated with PLD has not been reported. A 64-year-old male reported mild consciousness disorder. He had been under maintenance hemodialysis for end-stage renal disease due to ADPKD with PLD. Because of recurring hepatic cyst infections, he had sustained high levels of C-reactive protein. Regarding the mild consciousness disorder, a diagnosis of hepatic encephalopathy was made based on an elevation of serum ammonia without any other abnormal liver function tests. Several days after his admission, hepatobiliary enzymes elevated, and acute liver failure progressed. Enhanced abdominal computed tomography suggested the possibility of complete occlusion of the portal vein by a thrombus. Based on an absence of obvious portosystemic collaterals, a diagnosis of APVT was made. The patient died 19 days after admission. Patients with PLD with repeated cystic infections have been seen to develop liver failure, and APVT formation may be one cause of the rapid progression of fatal liver failure. In conclusion, this is the first paper to report on the involvement of APVT in patients with PLD.
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Affiliation(s)
- Yohei Tsuchida
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan.
| | - Yutaka Tsubata
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Ryosuke Nozawa
- Department of Gastroenterology, Shinrakuen Hospital, Niigata, Japan
| | - Shuntaro Maruyama
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Kouzo Ikarashi
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Noriko Saito
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Tetsuo Morioka
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Takeshi Kamura
- Department of Diagnostic Radiology, Shinrakuen Hospital, Niigata, Japan
| | - Hisaki Shimada
- Department of Nephrology, Shinrakuen Hospital, 3-3-11 Shindori-Minami, Nishi-Ku, Niigata, 950-2087, Japan
| | - Ichiei Narita
- Divisions of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Cheung C, Kernan KF, Berg RA, Zuppa AF, Notterman DA, Pollack MM, Wessel D, Meert KL, Hall MW, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Banks RK, Reeder RW, Holubkov R, Carcillo JA, Fink EL. Acute Disorders of Consciousness in Pediatric Severe Sepsis and Organ Failure: Secondary Analysis of the Multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study. Pediatr Crit Care Med 2023; 24:840-848. [PMID: 37314247 PMCID: PMC10719421 DOI: 10.1097/pcc.0000000000003300] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Acute disorders of consciousness (DoC) in pediatric severe sepsis are associated with increased risk of morbidity and mortality. We sought to examine the frequency of and factors associated with DoC in children with sepsis-induced organ failure. DESIGN Secondary analysis of the multicenter Phenotyping Sepsis-Induced Multiple Organ Failure Study (PHENOMS). SETTING Nine tertiary care PICUs in the United States. PATIENTS Children less than 18 years old admitted to a PICU with severe sepsis and at least one organ failure during a PICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was frequency of DoC, defined as Glasgow Coma Scale (GCS) less than 12 in the absence of sedatives during an ICU stay, among children with severe sepsis and the following: single organ failure, nonphenotypeable multiple organ failure (MOF), MOF with one of the PHENOMS phenotypes (immunoparalysis-associated MOF [IPMOF], sequential liver failure-associated MOF, thrombocytopenia-associated MOF), or MOF with multiple phenotypes. A multivariable logistic regression analysis was performed to evaluate the association between clinical variables and organ failure groups with DoC. Of 401 children studied, 71 (18%) presented with DoC. Children presenting with DoC were older (median 8 vs 5 yr; p = 0.023), had increased hospital mortality (21% vs 10%; p = 0.011), and more frequently presented with both any MOF (93% vs 71%; p < 0.001) and macrophage activation syndrome (14% vs 4%; p = 0.004). Among children with any MOF, those presenting with DoC most frequently had nonphenotypeable MOF and IPMOF (52% and 34%, respectively). In the multivariable analysis, older age (odds ratio, 1.07; 95% CI, 1.01-1.12) and any MOF (3.22 [1.19-8.70]) were associated with DoC. CONCLUSIONS One of every five children with severe sepsis and organ failure experienced acute DoC during their PICU stay. Preliminary findings suggest the need for prospective evaluation of DoC in children with sepsis and MOF.
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Affiliation(s)
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Athena F. Zuppa
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington, DC, USA
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI, USA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI, USA
| | - Rick E. Harrison
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Ericka L. Fink
- Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
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Zilliox MJ, Foecking EM, Kuffel GR, Conneely M, Saban KL, Herrold AA, Kletzel SL, Radke JR, Walsh E, Guernon A, Pape A, Ripley DL, Patil V, Pacheco MS, Rosenow JM, Bhaumik R, Bhaumik D, Pape TLB. An Initial miRNA Profile of Persons With Persisting Neurobehavioral Impairments and States of Disordered Consciousness After Severe Traumatic Brain Injury. J Head Trauma Rehabil 2023; 38:E267-E277. [PMID: 36350037 DOI: 10.1097/htr.0000000000000821] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the merits of using microRNAs (miRNAs) as biomarkers of disorders of consciousness (DoC) due to traumatic brain injury (TBI). SETTINGS Acute and subacute beds. PARTICIPANTS Patients remaining in vegetative and minimally conscious states (VS, MCS), an average of 1.5 years after TBI, and enrolled in a randomized clinical trial ( n = 6). Persons without a diagnosed central nervous system disorder, neurotypical controls ( n = 5). DESIGN Comparison of whole blood miRNA profiles between patients and age/gender-matched controls. For patients, correlational analyses between miRNA profiles and measures of neurobehavioral function. MAIN MEASURES Baseline measures of whole blood miRNAs isolated from the cellular and fluid components of blood and measured using miRNA-seq and real-time polymerase chain reaction (RT-PCR). Baseline neurobehavioral measures derived from 7 tests. RESULTS For patients, relative to controls, 48 miRNA were significantly ( P < .05)/differentially expressed. Cluster analysis showed that neurotypical controls were most similar to each other and with 2 patients (VS: n = 1; and MCS: n = 1). Three patients, all in MCS, clustered separately. The only female in the sample, also in MCS, formed an independent group. For the 48 miRNAs, the enriched pathways identified are implicated in secondary brain damage and 26 miRNAs were significantly ( P < .05) correlated with measures of neurobehavioral function. CONCLUSIONS Patients remaining in states of DoC an average of 1.5 years after TBI showed a different and reproducible pattern of miRNA expression relative to age/gender-matched neurotypical controls. The phenotypes, defined by miRNA profiles relative to persisting neurobehavioral impairments, provide the basis for future research to determine the miRNA profiles differentiating states of DoC and the basis for future research using miRNA to detect treatment effects, predict treatment responsiveness, and developing targeted interventions. If future research confirms and advances reported findings, then miRNA profiles will provide the foundation for patient-centric DoC neurorehabilitation.
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Affiliation(s)
- Michael J Zilliox
- Department of Ophthalmology, Loyola University Medical Center, Maywood, Illinois (Dr Zilliox); Research and Development Service (Drs Foecking, Walsh, Guernon, and Bender Pape), Center for Innovation in Complex Chronic Healthcare & Research Service (Drs Saban, Herrold, Kletzel, and Bender Pape), Rehabilitation Service (Dr Pacheco), and Department of Neurology (Dr Patil), Edward Hines Jr VA Hospital, Hines, Illinois; Department of Otolaryngology-Head and Neck Surgery (Dr Foecking), Marcella Niehoff School of Nursing (Dr Saban), Infectious Diseases and Immunology Research Institute (Dr Radke), and Division of Infectious Diseases (Dr Radke), Loyola University Chicago, Maywood, Illinois; Loyola Genomics Facility, Loyola University, Maywood, Illinois (Ms Kuffel); Chicago Medical School, Rosalind Franklin University of Science and Medicine, North Chicago, Illinois (Dr Conneely); Departments of Psychiatry & Behavioral Sciences (Dr Herrold), Physical Medicine and Rehabilitation (Drs Ripley and Bender Pape), and Neurosurgery (Dr Rosenow), Northwestern University, Feinberg School of Medicine, Chicago, Illinois; Department of Laboratory Medicine and Pathology, University of Washington Medicine, Seattle (Dr Pape); Lewis University, College of Nursing and Health Sciences, Romeoville, Illinois (Dr Guernon); Department of Psychiatry, Biostatistical Research Center, Division of Epidemiology and Biostatistics (Drs R. Bhaumik and D. Bhaumik), University of Illinois at Chicago; HealthBridge, Arlington Heights, Illinois (Dr Ripley); Dr Radke is now at Research Section, Boise VA Hospital, Boise, Idaho; Ms Kuffel is now at National Institutes of Health, Bethesda, Maryland
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Tutal Gursoy G, Yuksel H, Mulkem Simsek I, Oral S, Erdogan Kucukdagli F, Karaman A, Akinci E, Bastug A, Guner HR, Bektas H. Neurological Presentations in Patients with COVID-19 in Cytokine Storm. Can J Neurol Sci 2023; 50:89-95. [PMID: 34866562 PMCID: PMC8649405 DOI: 10.1017/cjn.2021.247] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) infection causes a wide variety of neurological disorders by affecting both central and peripheral nervous systems. The cytokine storm (CS) has been blamed for the development of severe neurological disorders in COVID-19. However, the relationship between COVID-19 CS and neurological manifestations has not been adequately studied. Thus, we aimed to investigate the neurological presentations in patients with COVID-19 CS. METHODS The study population consisted of hospitalized moderate-to-severe COVID-19 patients. It was divided into two groups CS (36 patients, 29.3%) and non-CS (87 patients, 70.7%) based on significant clinical symptoms, elevated inflammatory marker levels, radiological findings, and interleukin-6 levels (IL-6). RESULTS The three most common neurological symptoms in the CS group were altered level of consciousness, headache, and unsteadiness. Altered level of consciousness was higher in the CS group (69.4%) than the non-CS group (25.3%) (p:0.001). The frequency of headache was comparable in both groups (p:0.186). The number of patients requiring intensive care unit and intubation was higher in the CS group (p:0.005 and p:0.001). The mortality rate in the CS group (38.9%) was higher than the non-CS group (8.0%) (p:0.001). IL-6, CRP, ferritin, neutrophil-lymphocyte ratio, procalcitonin, and D-dimer levels were higher in the CS group (for all p:0.001) while lymphocyte count was lower (p:0.003). CONCLUSION The most common neurological presentation in patients with CS was altered level of consciousness. The presence of CS was an independent risk factor for high mortality.
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Affiliation(s)
| | - Hatice Yuksel
- Department of Neurology, Ankara City Hospital, Cankaya, Turkey
| | | | - Saniye Oral
- Department of Neurology, Ankara City Hospital, Cankaya, Turkey
| | | | - Ayberk Karaman
- Department of Neurosurgery, Ankara City Hospital, Cankaya, Turkey
| | - Esragul Akinci
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Hospital, Cankaya, Turkey
| | - Aliye Bastug
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Hospital, Cankaya, Turkey
| | - Hatice Rahmet Guner
- Department of Infectious Diseases and Clinical Microbiology, Ankara City Hospital, Cankaya, Turkey
| | - Hesna Bektas
- Department of Neurology, Ankara City Hospital, Cankaya, Turkey
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Ortiz D, Lindroth HL, Braly T, Perkins AJ, Mohanty S, Meagher AD, Khan SH, Boustani MA, Khan BA. Delirium severity does not differ between medical and surgical intensive care units after adjusting for medication use. Sci Rep 2022; 12:14447. [PMID: 36002562 PMCID: PMC9402532 DOI: 10.1038/s41598-022-18429-9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
Severe delirium is associated with an increased risk of mortality, institutionalization, and length of stay. Few studies have examined differences in delirium severity between different populations of critically ill patients. The objective of the study was to compare delirium severity and the presence of the four core features between adults in the surgical intensive care unit (SICU) and medical intensive care unit (MICU) while controlling for variables known to be associated with delirium. This is a secondary analysis of two parallel randomized multi-center trials conducted from March 2009 to January 2015 at 3 Indianapolis hospitals. A total of 474 adults with delirium were included in the analysis. Subjects were randomized in a 1:1 ratio in random blocks of 4 by a computer program. Patients were randomized to either haloperidol prescribing or de-prescribing regimen vs usual care. Delirium severity was assessed daily or twice-daily using the CAM-ICU-7 beginning after 24 h of ICU admission and until discharge from the hospital, death, or 30 days after enrollment. Secondary outcomes included hospital length of stay, hospital and 30-day mortality, and delirium-related adverse events. These outcomes were compared between SICU and MICU settings for this secondary analysis. Out of 474 patients, 237 were randomized to intervention. At study enrollment, the overall cohort had a mean age of 59 (SD 16) years old, was 54% female, 44% African-American, and 81% were mechanically ventilated upon enrollment. MICU participants were significantly older and severely ill with a higher premorbid cognitive and physical dysfunction burden. In univariate analysis, SICU participants had significantly higher mean total CAM-ICU-7 scores, corresponding to delirium severity, (4.15 (2.20) vs 3.60 (2.32), p = 0.02), and a lower mean RASS score (- 1.79 (1.28) vs - 1.53 (1.27), p < 0.001) compared to MICU participants. Following adjustment for benzodiazepines and opioids, delirium severity did not significantly differ between groups. The presence of Feature 3, altered level of consciousness, was significantly associated with the SICU participants, identifying as Black, premorbid functional impairment, benzodiazepines, opioids, and dexmedetomidine. In this secondary analysis examining differences in delirium severity between MICU and SICU participants, we did not identify a difference between participant populations following adjustment for administered benzodiazepines and opioids. We did identify that an altered level of consciousness, core feature 3 of delirium, was associated with SICU setting, identifying as Black, activities of daily living, benzodiazepines and opioid medications. These results suggest that sedation practice patterns play a bigger role in delirium severity than the underlying physiologic insult, and expression of core features of delirium may vary based on individual factors.Trial registration CT#: NCT00842608.
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Affiliation(s)
- Damaris Ortiz
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN, 46202, USA.
- Sidney & Lois Eskenazi Hospital Smith Level 1 Trauma Center, 720 Eskenazi Ave, Indianapolis, IN, 46202, USA.
- Center of Health Innovation and Implementation Science, Center for Translational Science and Innovation, Indiana University, 410 W. 10th St, Indianapolis, IN, 46202, USA.
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA.
- Sidney & Lois Eskenazi Hospital Smith Level 1 Trauma Center, 720 Eskenazi Avenue, 2nd floor Room 431, Indianapolis, IN, 46202, USA.
| | - Heidi L Lindroth
- Department of Nursing, Mayo Clinic Nursing Research Division, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tyler Braly
- Indiana University School of Medicine, Fort Wayne Campus, 2101 East Coliseum Blvd, Fort Wayne, IN, 46805, USA
| | - Anthony J Perkins
- Indiana University Center of Aging Research, Regenstrief Institute, 1101 W. 10th Street, Indianapolis, IN, 46202, USA
| | - Sanjay Mohanty
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN, 46202, USA
- Center of Health Innovation and Implementation Science, Center for Translational Science and Innovation, Indiana University, 410 W. 10th St, Indianapolis, IN, 46202, USA
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA
| | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN, 46202, USA
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA
| | - Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, 1120 W. Michigan St., CL 260, Indianapolis, IN, 46202, USA
| | - Malaz A Boustani
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA
- Indiana University Center of Aging Research, Regenstrief Institute, 1101 W. 10th Street, Indianapolis, IN, 46202, USA
| | - Babar A Khan
- Sidney & Lois Eskenazi Hospital Smith Level 1 Trauma Center, 720 Eskenazi Ave, Indianapolis, IN, 46202, USA
- Indiana University Center of Aging Research, Regenstrief Institute, 1101 W. 10th Street, Indianapolis, IN, 46202, USA
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, 1120 W. Michigan St., CL 260, Indianapolis, IN, 46202, USA
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Mele C, De Tanti A, Bagnato S, Lucca LF, Saviola D, Estraneo A, Moretta P, Marcuccio L, Lanzillo B, Aimaretti G, Nardone A, Marzullo P, Pingue V. Thyrotropic Axis and Disorders of Consciousness in Acquired Brain Injury: A Potential Intriguing Association? Front Endocrinol (Lausanne) 2022; 13:887701. [PMID: 35872992 PMCID: PMC9302487 DOI: 10.3389/fendo.2022.887701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE A potential involvement of thyrotropic axis in influencing the state of consciousness could be hypothesized. We aimed at investigating thyroid function tests as predictors of disorders of consciousness (DoC) and relating recovery in a large cohort of patients with DoC secondary to acquired brain injury (ABI). METHODS This retrospective, multicenter, cohort study included 151 patients with DoC following ABI, consecutively admitted for a 6-month neurorehabilitation program. Data on etiology of brain injury, evolution of DoC, disability and rehabilitation assessments, and death during rehabilitation were collected at baseline and on discharge. Thyroid function tests (serum TSH, fT4 and fT3 levels) were assessed on admission in all patients and at final discharge in 50 patients. RESULTS Lower baseline TSH levels and greater TSH increments (ΔTSH) after neurorehabilitation predicted a favorable change in DoC independent of age, sex, BMI, etiology of brain injury and initial DoC subtype (TSH: OR=0.712, CI 95% 0.533-0.951, p=0.01; ΔTSH: OR=2.878, CI 95% 1.147-7.223, p=0.02). On the other hand, neither fT4 nor fT3 or their variations appeared to play any role on DoC changes after 6-months inpatient neurorehabilitation. A lower magnitude of ΔfT4 acted as a strong predictor of improved functional disability level (β=0.655, p=0.002) and cognitive functions (β=-0.671, p=0.003), implying that smaller changes in fT4 were associated with higher outcomes. CONCLUSIONS Serum TSH levels assessed in the subacute post-ABI phase and its variation during neurorehabilitation could represent a potential biomarker of DoC evolution, while variations in fT4 levels seem to be associated with rehabilitation and cognitive functions. Further studies are needed to investigate the mechanisms underlying these associations.
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Affiliation(s)
- Chiara Mele
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- *Correspondence: Chiara Mele,
| | - Antonio De Tanti
- Cardinal Ferrari Centre, Santo Stefano Riabilitazione KOS-CARE, Fontanellato, Parma, Italy
| | - Sergio Bagnato
- Unit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy
| | | | - Donatella Saviola
- Cardinal Ferrari Centre, Santo Stefano Riabilitazione KOS-CARE, Fontanellato, Parma, Italy
| | - Anna Estraneo
- Department of Neurorehabilitation for Severe Acquired Brain Injury, Don Carlo Gnocchi Foundation, Scientific Institute for Research and Health Care, Florence, Italy
- Neurology Unit, Santa Maria della Pietà General Hospital, Nola, Italy
| | - Pasquale Moretta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Telese Terme Institute, Telese Terme, Italy
| | - Laura Marcuccio
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Telese Terme Institute, Telese Terme, Italy
| | - Bernardo Lanzillo
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Telese Terme Institute, Telese Terme, Italy
| | - Gianluca Aimaretti
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Antonio Nardone
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation and Spinal Unit of Pavia Institute and Neurorehabilitation Unit of Montescano Institute, Pavia, Italy
| | - Paolo Marzullo
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
- Istituto Auxologico Italiano, IRCCS, Laboratory of Metabolic Research, S. Giuseppe Hospital, Piancavallo, Italy
| | - Valeria Pingue
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation and Spinal Unit of Pavia Institute and Neurorehabilitation Unit of Montescano Institute, Pavia, Italy
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8
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Yamane M, Asayama N, Saino M, Masuda S, Nomura R, Shigita K, Aoyama T, Fukumoto A, Mukai S, Nagata S. [Two rare cases of severe hyponatremia with consciousness disorder following bowel preparation and high fluid intake]. Nihon Shokakibyo Gakkai Zasshi 2022; 119:846-852. [PMID: 36089360 DOI: 10.11405/nisshoshi.119.846] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Symptomatic hyponatremia due to bowel preparation is extremely rare, but it can cause severe neurological symptoms and require hospitalization. We report our experience with two cases of symptomatic hyponatremia after bowel preparation. Our findings suggest that the cause of hyponatremia may be not only oral bowel cleansing agents but also high fluid intake. Adjusting the dose and pace of oral bowel cleansing agents and fluid intake;rehydration should be considered to prevent any recurrences.
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Affiliation(s)
- Masahiro Yamane
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Naoki Asayama
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Masachika Saino
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Satoshi Masuda
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Risa Nomura
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Kenjiro Shigita
- Department of Endoscopy, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Akira Fukumoto
- Department of Endoscopy, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Shinichi Mukai
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
| | - Shinji Nagata
- Department of Gastroenterology, Hiroshima City North Medical Center Asa Citizens Hospital
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9
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Herr K, Coyne PJ, Ely E, Gélinas C, Manworren RCB. Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement. Pain Manag Nurs 2019; 20:404-417. [PMID: 31610992 DOI: 10.1016/j.pmn.2019.07.005] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [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: 05/03/2019] [Revised: 06/25/2019] [Accepted: 07/21/2019] [Indexed: 11/18/2022]
Abstract
Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.
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Affiliation(s)
- Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa.
| | - Patrick J Coyne
- Palliative Care Department, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Ely
- Department of Nursing Research, University of Chicago Hospitals, Chicago, Illinois
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital - CIUSSS, Centre-West-Montréal, Montréal, Québec, Canada
| | - Renee C B Manworren
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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10
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Muller E, Shock JP, Bender A, Kleeberger J, Högen T, Rosenfelder M, Bah B, Lopez-Rolon A. Outcome prediction with serial neuron-specific enolase and machine learning in anoxic-ischaemic disorders of consciousness. Comput Biol Med 2019; 107:145-152. [PMID: 30807909 DOI: 10.1016/j.compbiomed.2019.02.006] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The continuation of life-sustaining therapy in critical care patients with anoxic-ischemic disorders of consciousness (AI-DOC) depends on prognostic tests such as serum neuron-specific enolase (NSE) concentration levels. OBJECTIVES To apply predictive models using machine learning methods to examine, one year after onset, the prognostic power of serial measurements of NSE in patients with AI-DOC. To compare the discriminative accuracy of this method to both standard single-day, absolute, and difference-between-days, relative NSE levels. METHODS Classification algorithms were implemented and K-nearest neighbours (KNN) imputation was used to avoid complete case elimination of patients with missing NSE values. Non-imputed measurements from Day 0 to Day 6 were used for single day and difference-between-days. RESULTS The naive Bayes classifier on imputed serial NSE measurements returned an AUC of (0.81±0.07) for n=126 patients (100 poor outcome). This was greater than logistic regression (0.73±0.08) and all other classifiers. Naive Bayes gave a specificity and sensitivity of 96% and 49%, respectively, for an (uncalibrated) probability decision threshold of 90%. The maximum AUC for a single day was Day 3 (0.75) for a subset of n=79 (61 poor outcome) patients, and for differences between Day 1 and Day 4 (0.81) for a subset of n=46 (39 poor outcome) patients. CONCLUSION Imputation avoided the elimination of patients with missing data and naive Bayes outperformed all other classifiers. Machine learning algorithms could detect automatically discriminatory features and the overall predictive power increased from standard methods due to the larger data set. CODE AVAILABILITY Data analysis code is available under GNU at: https://github.com/emilymuller1991/outcome_prediction_nse.
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Affiliation(s)
- Emily Muller
- Department of Mathematical Sciences, Stellenbosch University, Stellenbosch, South Africa; African Institute Or Mathematical Sciences, Cape Town, South Africa.
| | - Jonathan P Shock
- Department of Mathematics and Applied Mathematics, University of Cape Town, Cape Town, South Africa
| | - Andreas Bender
- Department of Neurology, University of Munich, Munich, Germany; Department of Neurology, Therapiezentrum Burgau, Burgau, Germany
| | | | - Tobias Högen
- Department of Neurology, University of Munich, Munich, Germany
| | - Martin Rosenfelder
- Department of Neurology, Therapiezentrum Burgau, Burgau, Germany; Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Bubacarr Bah
- Department of Mathematical Sciences, Stellenbosch University, Stellenbosch, South Africa; African Institute Or Mathematical Sciences, Cape Town, South Africa
| | - Alex Lopez-Rolon
- Department of Neurology, Therapiezentrum Burgau, Burgau, Germany
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11
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Riganello F, Chatelle C, Schnakers C, Laureys S. Heart Rate Variability as an Indicator of Nociceptive Pain in Disorders of Consciousness? J Pain Symptom Manage 2019; 57:47-56. [PMID: 30267843 DOI: 10.1016/j.jpainsymman.2018.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 06/25/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 01/18/2023]
Abstract
CONTEXT Heart rate variability is thought to reflect the affective and physiological aspects of pain and is emerging as a possible descriptor of the functional brain organization contributing to homeostasis. OBJECTIVES To investigate whether the short-term Complexity Index (CIs), a measure of heart rate variability complexity is useful to discriminate responses to potentially noxious and nonnoxious stimulation in patients with different levels of consciousness. METHODS Twenty-two patients (11 minimally conscious state [MCS], 11 vegetative state/unresponsive wakefulness syndrome [VS/UWS]) and 14 healthy controls (HC) were enrolled. We recorded the electrocardiographic response and calculated the CIs before (baseline), during, and after nonnoxious and noxious stimulation. Mann-Whitney and Wilcoxon's tests were used to investigate differences in CIs according to the level of consciousness (i.e., HC vs. patients and VS/UWS vs. MCS) and the three conditions (i.e., baseline, nonnoxious, noxious). The correlation between the three conditions and the Coma Recovery Scale-Revised was investigated by Spearman's correlations. RESULTS We observed higher CIs values in HC as compared with patients during the baseline (P < 0.034) and after the noxious stimulation (P < 0.0001). We also found higher values in MCS versus VS/UWS patients after the noxious condition (P < 0.001) and lower values in the noxious versus nonnoxious condition solely for the VS/UWS group (P < 0.007). A correlation was found between CIs in noxious condition and Coma Recovery Scale-Revised scores. CONCLUSION Our results suggest a less complex autonomic response to noxious stimuli in VS/UWS patients. Such method may help to better understand sympathovagal response to potentially painful stimulation in brain-injured patients.
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Affiliation(s)
- Francesco Riganello
- GIGA Consciousness, Coma Science Group, Liège, Belgium; Research in Advanced Neurorehabilitation (RAN), S.Anna Institute, Crotone, Italy.
| | - Camille Chatelle
- GIGA Consciousness, Coma Science Group, Liège, Belgium; Laboratory for NeuroImaging of Coma and Consciousness, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caroline Schnakers
- Neurosurgery Department, University of California, Los Angeles, California, USA; Research Institute, Casa Colina Hospital and Centers of Healthcare, Pomona, California, USA
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12
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Jansson PS, Kabrhel C, Miller ES. Altered Mental Status in an Elderly Male. J Emerg Med 2018; 54:232-237. [PMID: 29242011 DOI: 10.1016/j.jemermed.2017.11.025] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/18/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Paul S Jansson
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily S Miller
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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13
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Wislowska M, Del Giudice R, Lechinger J, Wielek T, Heib DPJ, Pitiot A, Pichler G, Michitsch G, Donis J, Schabus M. Night and day variations of sleep in patients with disorders of consciousness. Sci Rep 2017; 7:266. [PMID: 28325926 PMCID: PMC5428269 DOI: 10.1038/s41598-017-00323-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 02/21/2017] [Indexed: 02/01/2023] Open
Abstract
Brain injuries substantially change the entire landscape of oscillatory dynamics and render detection of typical sleep patterns difficult. Yet, sleep is characterized not only by specific EEG waveforms, but also by its circadian organization. In the present study we investigated whether brain dynamics of patients with disorders of consciousness systematically change between day and night. We recorded ~24 h EEG at the bedside of 18 patients diagnosed to be vigilant but unaware (Unresponsive Wakefulness Syndrome) and 17 patients revealing signs of fluctuating consciousness (Minimally Conscious State). The day-to-night changes in (i) spectral power, (ii) sleep-specific oscillatory patterns and (iii) signal complexity were analyzed and compared to 26 healthy control subjects. Surprisingly, the prevalence of sleep spindles and slow waves did not systematically vary between day and night in patients, whereas day-night changes in EEG power spectra and signal complexity were revealed in minimally conscious but not unaware patients.
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Affiliation(s)
- Malgorzata Wislowska
- Laboratory for Sleep, Cognition and Consciousness, & Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Renata Del Giudice
- Laboratory for Sleep, Cognition and Consciousness, & Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Julia Lechinger
- Laboratory for Sleep, Cognition and Consciousness, & Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Tomasz Wielek
- Laboratory for Sleep, Cognition and Consciousness, & Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Dominik P J Heib
- Laboratory for Sleep, Cognition and Consciousness, & Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Alain Pitiot
- Laboratory of Image & Data Analysis, Ilixa Ltd., Nottingham, United Kingdom
| | - Gerald Pichler
- Apallic Care Unit, Neurological Division, Albert-Schweitzer-Klinik, Graz, Austria
| | - Gabriele Michitsch
- Apallic Care Unit, Neurological Division, Pflegewohnhaus Donaustadt, Vienna, Austria
| | - Johann Donis
- Apallic Care Unit, Neurological Division, Pflegewohnhaus Donaustadt, Vienna, Austria
| | - Manuel Schabus
- Laboratory for Sleep, Cognition and Consciousness, & Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria.
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14
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Bartolo M, Chiò A, Ferrari S, Tassorelli C, Tamburin S, Avenali M, Azicnuda E, Calvo A, Caraceni AT, Defazio G, DE Icco R, Formisano R, Franzoni S, Greco E, Jedrychowska I, Magrinelli F, Manera U, Marchioni E, Mariotto S, Monaco S, Pace A, Saviola D, Springhetti I, Tinazzi M, DE Tanti A. Assessing and treating pain in movement disorders, amyotrophic lateral sclerosis, severe acquired brain injury, disorders of consciousness, dementia, oncology and neuroinfectivology. Evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation. Eur J Phys Rehabil Med 2016; 52:841-854. [PMID: 27579582] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Pain is an important non-motor symptom in several neurological diseases, such as Parkinson's disease, cervical dystonia, amyotrophic lateral sclerosis, severe acquired brain injury, disorders of consciousness and dementia, as well as in oncology and neuroinfectivology. To overcome the lack of evidence-based data on pain management in these diseases, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) has defined criteria for good clinical practice among Italian neurorehabilitation professionals. Here a review of the literature (PubMed, EMBASE and gray literature) on pain characteristics, treatment and impact of pain in a neurorehabilitation setting is provided. Despite the heterogeneity of data, a consensus was reached on pain management for patients with these diseases: it is an approach originating from an analysis of the available data on pain characteristics in each disease, the evolution of pain in relation to the natural course of the disease and the impact of pain on the overall process of rehabilitation. There was unanimous consensus regarding the utility of a multidisciplinary approach to pain therapy, combining the benefits of pharmacological therapy with the techniques of physiotherapy and neurorehabilitation for all the conditions considered. While some treatments could be different depending on pathology, a progressive approach to the pharmacological treatment of pain is advisable, starting with non-opioid analgesics (paracetamol) and nonsteroidal anti-inflammatory drugs as a first-line treatment, and opioid analgesics as a second-line treatment. In cases of pain secondary to spasticity, botulinum neurotoxin, and, in some cases, intrathecal baclofen infusion should be considered. Randomized controlled trials and prospective multicenter studies aimed at documenting the efficacy of pain treatment and their risk-benefit profile are recommended for these conditions.
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Affiliation(s)
- Michelangelo Bartolo
- Neurorehabilitation Unit, Department of Rehabilitation, HABILITA, Zingonia di Ciserano, Bergamo, Italy
| | - Adriano Chiò
- ALS Center, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Sergio Ferrari
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Cristina Tassorelli
- Neurorehabilitation Unit, "C. Mondino" National Neurological Institute, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Stefano Tamburin
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Micol Avenali
- Neurorehabilitation Unit, "C. Mondino" National Neurological Institute, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Eva Azicnuda
- Post-Coma Unit, Santa Lucia Foundation and Scientific Institute for Care and Research, Rome, Italy
| | - Andrea Calvo
- ALS Center, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Augusto T Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanni Defazio
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Roberto DE Icco
- Neurorehabilitation Unit, "C. Mondino" National Neurological Institute, Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Rita Formisano
- Post-Coma Unit, Santa Lucia Foundation and Scientific Institute for Care and Research, Rome, Italy
| | - Simone Franzoni
- Department of Geriatrics, "Poliambulanza" Foundation, Brescia, Italy
| | - Elena Greco
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Iwona Jedrychowska
- Oncological Rehabilitation Unit, Functional Recovery Unit, "Salvatore Maugeri" Foundation and Scientific Institute for Care and Research, Pavia, Italy
| | - Francesca Magrinelli
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Umberto Manera
- ALS Center, "Rita Levi Montalcini" Department of Neuroscience, University of Turin, Turin, Italy
| | - Enrico Marchioni
- Neurooncology Unit, "C. Mondino" National Neurological Institute, Pavia, Italy
| | - Sara Mariotto
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Salvatore Monaco
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Andrea Pace
- Neurooncology Unit, "Regina Elena" Scientific Institute for Care and Research, Rome, Italy
| | | | - Isabella Springhetti
- Oncological Rehabilitation Unit, Functional Recovery Unit, "Salvatore Maugeri" Foundation and Scientific Institute for Care and Research, Pavia, Italy
| | - Michele Tinazzi
- Section of Neurology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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15
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Koyama Y, Nitta K, Tochikura M, Kasahara T, Kametsu Y, Toyokura M, Masakado Y. Proposal for a New Exercise Method for Dysphagia with Velopharyngeal Inadequacy: A Case of Bickerstaff's Brainstem Encephalitis. Tokai J Exp Clin Med 2016; 41:143-146. [PMID: 27628607] [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] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/20/2016] [Indexed: 06/06/2023]
Abstract
Bickerstaff's brainstem encephalitis is an autoimmune disease with the primary lesion situated in the brainstem and three cardinal signs: ophthalmoplegia; ataxia; and impaired consciousness. A 68-year-old man was started on rehabilitation exercise 3 months after onset of Bickerstaff's brainstem encephalitis, due to remnant dysarthria and dysphagia (Functional Oral Intake Scale, level 5) after the cardinal signs of Bickerstaff's brainstem encephalitis resolved. Exercise involved using a straw in the anterior midline between the dorsal tongue and hard palate. While the patient was inhaling through the straw, the straw was blocked. After strengthening suction as much as possible, the patient was asked to immediately dry swallow at the same time that suction was stopped. Effects of exercise were examined using videofluorographic swallowing studies before and after 6 weeks of training to compare posterior and superior velar displacements and the presence of nasopharyngeal reflux. No adverse effects of exercise were encountered, and Functional Oral Intake Scale improved to level 7, with significant increases in posterior and superior velar displacement during swallowing compared with before training. In addition, nasopharyngeal reflux that had consistently been seen on swallowing before training was absent after 6 weeks of exercise. This exercise method may prove useful.
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Affiliation(s)
- Yuji Koyama
- Department of Rehabilitation Medicine, Tokai University Oiso Hospital, 21-2 Gakkyo, Oiso-machi, Naka-gun, Kanagawa 259-0198, Japan.
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16
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Lechinger J, Wielek T, Blume C, Pichler G, Michitsch G, Donis J, Gruber W, Schabus M. Event-related EEG power modulations and phase connectivity indicate the focus of attention in an auditory own name paradigm. J Neurol 2016; 263:1530-43. [PMID: 27216625 PMCID: PMC4971049 DOI: 10.1007/s00415-016-8150-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 11/28/2022]
Abstract
Estimating cognitive abilities in patients suffering from Disorders of Consciousness remains challenging. One cognitive task to address this issue is the so-called own name paradigm, in which subjects are presented with first names including the own name. In the active condition, a specific target name has to be silently counted. We recorded EEG during this task in 24 healthy controls, 8 patients suffering from Unresponsive Wakefulness Syndrome (UWS) and 7 minimally conscious (MCS) patients. EEG was analysed with respect to amplitude as well as phase modulations and connectivity. Results showed that general reactivity in the delta, theta and alpha frequency (event-related de-synchronisation, ERS/ERD, and phase locking between trials and electrodes) toward auditory stimulation was higher in controls than in patients. In controls, delta ERS and lower alpha ERD indexed the focus of attention in both conditions, late theta ERS only in the active condition. Additionally, phase locking between trials and delta phase connectivity was highest for own names in the passive and targets in the active condition. In patients, clear stimulus-specific differences could not be detected. However, MCS patients could reliably be differentiated from UWS patients based on their general event-related delta and theta increase independent of the type of stimulus. In conclusion, the EEG signature of the active own name paradigm revealed instruction-following in healthy participants. On the other hand, DOC patients did not show clear stimulus-specific processing. General reactivity toward any auditory input, however, allowed for a reliable differentiation between MCS and UWS patients.
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Affiliation(s)
- Julia Lechinger
- Laboratory for Sleep and Consciousness Research, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, 5020, Salzburg, Austria.
- Centre for Cognitive Neuroscience (CCNS), University of Salzburg, Salzburg, Austria.
| | - Tomasz Wielek
- Laboratory for Sleep and Consciousness Research, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, 5020, Salzburg, Austria
| | - Christine Blume
- Laboratory for Sleep and Consciousness Research, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, 5020, Salzburg, Austria
- Centre for Cognitive Neuroscience (CCNS), University of Salzburg, Salzburg, Austria
| | - Gerald Pichler
- Apallic Care Unit, Neurological Division, Albert-Schweitzer-Klinik, Graz, Austria
| | - Gabriele Michitsch
- Apallic Care Unit, Neurological Division, Sozialmedizinisches Zentrum Ost-Donauspital, Vienna, Austria
| | - Johann Donis
- Apallic Care Unit, Neurological Division, Sozialmedizinisches Zentrum Ost-Donauspital, Vienna, Austria
| | - Walter Gruber
- Centre for Cognitive Neuroscience (CCNS), University of Salzburg, Salzburg, Austria
| | - Manuel Schabus
- Laboratory for Sleep and Consciousness Research, Department of Psychology, University of Salzburg, Hellbrunnerstraße 34, 5020, Salzburg, Austria
- Centre for Cognitive Neuroscience (CCNS), University of Salzburg, Salzburg, Austria
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17
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Pascarella A, Trojano L, Loreto V, Bilo L, Moretta P, Estraneo A. Long-term outcome of patients with disorders of consciousness with and without epileptiform activity and seizures: a prospective single centre cohort study. J Neurol 2016; 263:2048-56. [PMID: 27416857 DOI: 10.1007/s00415-016-8232-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [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] [Received: 05/03/2016] [Revised: 07/03/2016] [Accepted: 07/05/2016] [Indexed: 11/26/2022]
Abstract
Brain-injured patients can experience epileptic seizures beyond 1 week from injury (unprovoked remote symptomatic epileptic seizures). In our longitudinal observational study, we analysed occurrence of unprovoked remote epileptic seizures and interictal epileptiform activity in 130 traumatic, vascular or anoxic inpatients with disorders of consciousness (DOC), with a clinical diagnosis of vegetative state (n = 97) or minimally conscious state (n = 33). We also investigated impact of epileptic seizures and epileptiform activity on clinical outcome (30 months post-onset). Epileptic seizures occurred in 35/130 patients (26.9 %), epileptiform activity in 61/130 (46.9 %) patients, without significant differences related to clinical diagnosis or aetiology. Among patients with epileptiform activity, only 26/61 (42.6 %) developed clinically evident seizures. Mortality at 30 months was not significantly influenced by the presence of seizures or epileptiform activity. The proportion of patients who recovered at long-term follow-up was higher in patients without than in patients with epileptic seizures, but was similar in patients with or without epileptiform activity. The presence of epileptic seizures but not of epileptiform activity, significantly affected the level of responsiveness at final outcome. In conclusion, seizures were detected in about one third of the whole sample, and in about a half of patients with epileptiform activity, regardless of clinical diagnosis or aetiology. Although epileptic seizures or epileptiform activity did not significantly affect mortality rate, we demonstrated that epileptic seizures could hamper recovery of consciousness. Epileptic seizures thus qualify as one of the factors largely undetermined at the moment which can influence prognosis in DOC patients.
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Affiliation(s)
- Angelo Pascarella
- Research Laboratory and Neurorehabilitation Unit for Disorder of Consciousness, Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Via Bagni Vecchi, 1, 82037, Telese Terme, BN, Italy
| | - Luigi Trojano
- Department of Psychology, Second University of Naples, Caserta, Italy
| | - Vincenzo Loreto
- Research Laboratory and Neurorehabilitation Unit for Disorder of Consciousness, Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Via Bagni Vecchi, 1, 82037, Telese Terme, BN, Italy
| | - Leonilda Bilo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Pasquale Moretta
- Research Laboratory and Neurorehabilitation Unit for Disorder of Consciousness, Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Via Bagni Vecchi, 1, 82037, Telese Terme, BN, Italy
| | - Anna Estraneo
- Research Laboratory and Neurorehabilitation Unit for Disorder of Consciousness, Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Via Bagni Vecchi, 1, 82037, Telese Terme, BN, Italy.
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18
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Chowdhury RA, Azad AK, Sardar H, Siddiqui MR, Saad S, Rahman S, Sikder AS. Pattern of Pulmonary Involvement and Outcome of Aspiration Pneumonia in Patients with Altered Consciousness Admitted in Dhaka Medical College Hospital. Mymensingh Med J 2016; 25:132-137. [PMID: 26931262] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Aspiration is well recognized as a cause of pulmonary disease and is not uncommon in patients with altered consciousness.The mortality rate of aspiration pneumonia is approximately 1% in outpatient setting and upto 25% in those requiring hospitalization. This study was done to see the pattern of pulmonary involvement and outcome of aspiration pneumonia in patients with altered consciousness admitted in medicine department of a tertiary care hospital in our country. This was a prospective observational study conducted among the 52 adult patients of aspiration pneumonia with altered consciousness admitted in the medicine department of Dhaka Medical College Hospital (DMCH), during June 2010 to December 2010. Aspiration pneumonia was confirmed by clinical examination and laboratory investigations. Hematologic measurements (TC of WBC, Hb%, ESR, platelet count), chest X-ray, blood gas analysis, blood urea, creatinine and random blood sugar, sputum for Gram staining, sputum for culture sensitivity and blood culture were done in all patients.Assessment of altered conscious patient was done by application of the Glasgow Coma Scale. Case record forms with appropriate questionnaire were filled for all patients. The mean±SD age was 57.42±13.63 years with ranged from 25 to 90 years. Out of 52 patients, 37(71.15%) patients were male and 15(28.85%) patients were female. Following aspiration 76.92% patients developed pneumonitis, 13.46% patients developed lung abscess and only 9.62% patients developed ARDS. Most (33) of the patients had opacity in right lower zone and 13 patients had opacity in the left lower zone, 6 patients had opacity in right mid zone. Only 10 patients had opacity in both lower zones. In this study overall mortality rate was 23%. If only one lobe was involved radiologically, mortality was 8.33%. If two or more lobes on one or both sides were involved, mortality was in the range of 25-91%.
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Affiliation(s)
- R A Chowdhury
- Dr Md Rashed Alam Chowdhury, Assistant Professor, Department of Medicine, Jahurul Islam Medical College Hospital, Bajitpur, Kishoregonj, Bangladesh
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Fan L, Su Y, Elmadhoun OA, Zhang Y, Zhang Y, Gao D, Ye H, Chen W. Protocol-directed weaning from mechanical ventilation in neurological patients: a randomised controlled trial and subgroup analyses based on consciousness. Neurol Res 2015; 37:1006-14. [PMID: 26311500 DOI: 10.1179/1743132815y.0000000092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES To assess whether a weaning protocol reduces the mechanical ventilation (MV) duration compared to physician's judgement-based weaning in neurological patients and to determine whether patient consciousness influences this reduction. METHODS A randomised controlled trial was conducted in a neurological intensive care unit (NCU) of a tertiary hospital; 144 patients requiring MV for more than 24 hours were randomly allocated to protocol-directed (intervention) (n = 71) or physician-directed (control) group (n = 73). RESULTS The intervention group displayed a significantly shorter median weaning time than the control group (2.00 vs 5.07 days, P < 0.05). The median MV duration tended to be shorter in the intervention group (10.8 vs 14.2 days, P = 0.106). The median length of NCU stay was 19.0 and 26.1 days in the intervention and control groups, respectively (P = 0.063). The median NCU cost was 9.26 × 10(4) and 12.24 × 10(4) ¥ in the intervention and control groups, respectively (P = 0.059). The unsuccessful weaning, ventilator-associated pneumonia (VAP) and mortality rates were similar between the groups. Among conscious patients, the median weaning time (2.00 vs 7.00 days, P < 0.05) and the median MV duration (8.8 vs 18.0 days, P = 0.017) were significantly reduced in the intervention group. Among unconscious patients, the intervention group displayed a reduced median weaning time (1.00 vs 3.10 days, P < 0.05), but not median MV duration (11.6 vs 11.1 days, P = 0.702), compared to the control group. CONCLUSION Protocol-directed weaning reduces weaning time, MV duration, length of NCU stay and NCU cost in neurological patients, and these effects are more significant in conscious patients than in unconscious patients.
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Bicego A, Lejoly K, Maudoux A, Lefebvre P, Laureys S, Schweizer V, Diserens K, Faymonville ME, Vanhaudenhuyse A. [Swallowing in disorders of consciousness]. Rev Neurol (Paris) 2014; 170:630-41. [PMID: 24952924 DOI: 10.1016/j.neurol.2014.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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] [Received: 09/11/2013] [Revised: 03/31/2014] [Accepted: 04/11/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Interest in studying swallowing disorders in patients with altered consciousness has increased over the past decade. Swallowing deficit is frequently encountered in severe brain-injured patients. STATE OF ART Results of studies have highlighted different factors such as the delay between the injury and the treatment and the level of consciousness of these patients, as well as the presence or not of tracheotomy, which will determine the feasibility of resuming oral feeding. Nowadays, very few valid and sensitive scales can be used to assess swallowing deficit in patients with disorders of consciousness. The Facial Oral Tract Therapy (FOTT) scale is an inter-professional multidisciplinary approach offering a structured way to evaluate and treat patients with swallowing disorders. In contrast with other scales, patients do not have to follow verbal instructions for the FOTT. PERSPECTIVES This paper presents a review of existing literature on the assessment and management of swallowing disorders in patients with altered state of consciousness, and a description of the FOTT method. CONCLUSION The FOTT seems to be an interesting assessment and rehabilitation tool for patients with disorders of consciousness. However, clinical studies are needed to confirm the validity and sensitivity of this technique.
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Affiliation(s)
- A Bicego
- Coma Science Group, centre de recherches du cyclotron, université de Liège, allée du 6-Août, Sart Tilman B30, 4000 Liège, Belgique
| | - K Lejoly
- Coma Science Group, centre de recherches du cyclotron, université de Liège, allée du 6-Août, Sart Tilman B30, 4000 Liège, Belgique
| | - A Maudoux
- Coma Science Group, centre de recherches du cyclotron, université de Liège, allée du 6-Août, Sart Tilman B30, 4000 Liège, Belgique; Service d'oto-rhino-laryngologie, hôpital universitaire de Liège, université de Liège, 13, avenue de l'Hôpital, 4000 Liège, Belgique
| | - P Lefebvre
- Service d'oto-rhino-laryngologie, hôpital universitaire de Liège, université de Liège, 13, avenue de l'Hôpital, 4000 Liège, Belgique
| | - S Laureys
- Coma Science Group, centre de recherches du cyclotron, université de Liège, allée du 6-Août, Sart Tilman B30, 4000 Liège, Belgique; Service de neurologie, hôpital universitaire de Liège, université de Liège, 13, avenue de l'Hôpital, 4000 Liège, Belgique
| | - V Schweizer
- Unité de phoniatrie, service d'oto-rhino-laryngologie, hôpital universitaire de Lausanne, 31, avenue Beaumont, 1011 Lausanne, Suisse
| | - K Diserens
- Unité de neurorééducation aiguë, département des neurosciences cliniques, hôpital universitaire de Lausanne, 46, rue du Bugnon, 1011 Lausanne, Suisse
| | - M-E Faymonville
- Service d'algologie-soins palliatifs, hôpital universitaire de Liège, université de Liège, CHU Sart Tilman, B35, 4000 Liège, Belgique
| | - A Vanhaudenhuyse
- Service d'algologie-soins palliatifs, hôpital universitaire de Liège, université de Liège, CHU Sart Tilman, B35, 4000 Liège, Belgique.
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Cunningham C, Chen WC, Shorten A, McClurkin M, Choezom T, Schmidt CP, Chu V, Bozik A, Best C, Chapman M, Furman M, Detyniecki K, Giacino JT, Blumenfeld H. Impaired consciousness in partial seizures is bimodally distributed. Neurology 2014; 82:1736-44. [PMID: 24727311 PMCID: PMC4032205 DOI: 10.1212/wnl.0000000000000404] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 01/27/2014] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To investigate whether impaired consciousness in partial seizures can usually be attributed to specific deficits in the content of consciousness or to a more general decrease in the overall level of consciousness. METHODS Prospective testing during partial seizures was performed in patients with epilepsy using the Responsiveness in Epilepsy Scale (n = 83 partial seizures, 30 patients). Results were compared with responsiveness scores in a cohort of patients with severe traumatic brain injury evaluated with the JFK Coma Recovery Scale-Revised (n = 552 test administrations, 184 patients). RESULTS Standardized testing during partial seizures reveals a bimodal scoring distribution, such that most patients were either fully impaired or relatively spared in their ability to respond on multiple cognitive tests. Seizures with impaired performance on initial test items remained consistently impaired on subsequent items, while other seizures showed spared performance throughout. In the comparison group, we found that scores of patients with brain injury were more evenly distributed across the full range in severity of impairment. CONCLUSIONS Partial seizures can often be cleanly separated into those with vs without overall impaired responsiveness. Results from similar testing in a comparison group of patients with brain injury suggest that the bimodal nature of Responsiveness in Epilepsy Scale scores is not a result of scale bias but may be a finding unique to partial seizures. These findings support a model in which seizures either propagate or do not propagate to key structures that regulate overall arousal and thalamocortical function. Future investigations are needed to relate these behavioral findings to the physiology underlying impaired consciousness in partial seizures.
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Affiliation(s)
- Courtney Cunningham
- From the Departments of Neurology (C.C., W.C.C., A.S., M.M., T.C., C.P.S., V.C., A.B., C.B., M.C., M.F., K.D., H.B.), Neurobiology (H.B.), and Neurosurgery (H.B.), Yale University School of Medicine, New Haven, CT; and Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
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Snyder SR, Kivlehan SM, Collopy KT. Acute alcohol poisoning: what can you do for the patient who's had too much? EMS World 2014; 43:36-42. [PMID: 24734396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Pistoia F, Sarà M, Sacco S, Franceschini M, Carolei A. Silencing the brain may be better than stimulating it. The GABA effect. Curr Pharm Des 2014; 20:4154-4166. [PMID: 24025066] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 09/05/2013] [Indexed: 06/02/2023]
Abstract
Cases of recovery from vegetative and minimally conscious state after the administration of various pharmacological agents have been recently reported. These agents include CNS depressants (zolpidem, baclofen, lamotrigine) and CNS stimulants (tricyclic antidepressants, selective serotonin reuptake inhibitors, dopaminergic agents, methylphenidate). The action of CNS depressants as awakening agents sounds paradoxical, as they are commonly prescribed to slow down brain activity in the management of anxiety, muscle tension, pain, insomnia and seizures. How these drugs may improve the level of consciousness in some brain-injured patients is the subject of intense debate. Here we hypothesize that CNS depressants may promote consciousness recovery by reversing a condition of GABA impairment in the injured brain, restoring the normal ratio between synaptic excitation and inhibition, which is the prerequisite for any transition from a resting state to goal-oriented activities (GABA impairment hypothesis). Alternative or complementary mechanisms underlying the improvement of consciousness may include the reversal of a neurodormant state within areas affected by diaschisis (diaschisis hypothesis) and the modulation of an informative overload to the cortex as a consequence of filter failure in the injured brain (informative overload hypothesis). A better understanding of how single agents act on neural networks, whose functioning is critical for recovery, may help to advance a tailored pharmacological approach in the treatment of severely brain injured patients.
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Affiliation(s)
| | | | | | | | - Antonio Carolei
- Neurorehabilitation, Department of Neurology, University of L'Aquila, 67100 L'Aquila, Italy.
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Nakatani R, Naba I, Kawasaki Y, Moriya M, Nakano M, Tatsumi C. [A case of possible neuro-Sweet disease with prolonged disturbance of consciousness and no dermal lesion during the course of dementia]. Rinsho Shinkeigaku 2014; 54:130-134. [PMID: 24583587 DOI: 10.5692/clinicalneurol.54.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The patient was a 58-year-old man with 1-year history of cognitive decline, which was diagnosed as Alzheimer's disease in another hospital. He was admitted to our hospital for extreme fatigue, weight loss, and dysphagia, subsequent to the left peripheral facial paresis. Brain magnetic resonance (MR) imaging showed bilateral diffuse white matter lesions and hippocampal atrophy. After admission, he presented with sudden high fever, recurrent exacerbations of consciousness, and increased C-reactive protein level with marked neutrophilia, with the result that he underwent mechanical ventilation. Routine cerebrospinal fluid findings at the exacerbation were normal i.e. 4.7 cells/mm(3), 40 mg/dl of protein, but IL-6 concentration was mildly elevated to 22.2 pg/ml. After confirming the positivity of HLA (human leukocyte antigen) B54 and Cw1, we administered steroid to him and his physical activity and state of consciousness significantly improved. During the course of treatment, dermal lesion characterisitic of Sweet disease was absent. We diagnosed this case was possible neuroSweet disease proposed by Hisanaga in 2005.
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Affiliation(s)
- Rie Nakatani
- Department of Neurology, Toyonaka Municipal Hospital
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Hyllienmark P, Brattström O, Larsson E, Martling CR, Petersson J, Oldner A. High incidence of post-injury pneumonia in intensive care-treated trauma patients. Acta Anaesthesiol Scand 2013; 57:848-54. [PMID: 23550742 DOI: 10.1111/aas.12111] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2013] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Trauma patients are susceptible to post-injury infections. We investigated the incidence, as well as risk factors for development of pneumonia in intensive care unit (ICU)-treated trauma patients. In addition, we report pathogens identified in patients that developed pneumonia. METHODS The study cohort consisted of 322 trauma patients admitted to the ICU at a level-one trauma centre following initial resuscitation. Patients 15 years or older with an ICU stay of more than 24 h were included. We investigated pre-hospital and hospital parameters during the first 24 h after admission and their possible association with pneumonia within 10 days of ICU admission. RESULTS Majority of the patients were male (78%) and the median age was 41 years. The overall degree of injury was high with a median Injury Severity Score (ISS) of 24. Overall 30-day mortality was 9%. Eighty-five (26%) patients developed pneumonia during their first 10 days in the ICU. Univariate logistic regression revealed that intubation in the field, shock, Glasgow Coma Scale (GCS) 3-8, major surgery within 24 h after admission, massive transfusion and ISS > 24 were all risk factors for subsequent development of pneumonia. In the multivariable model, only GCS 3-8 was identified as an independent risk factor. In 42 out of the 85 cases of pneumonia, the diagnosis was defined by significant growth of at least one pathogen where Enterobacteriaceae and Staphylococcus aureus were the most common. CONCLUSIONS Pneumonia is a common complication among ICU-treated trauma patients. Reduced consciousness is an independent risk factor for development of pneumonia after severe injury.
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Affiliation(s)
- P Hyllienmark
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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Ganesh S, Guernon A, Chalcraft L, Harton B, Smith B, Louise-Bender Pape T. Medical comorbidities in disorders of consciousness patients and their association with functional outcomes. Arch Phys Med Rehabil 2013; 94:1899-907. [PMID: 23735521 DOI: 10.1016/j.apmr.2012.12.026] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [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] [Received: 07/23/2012] [Revised: 10/17/2012] [Accepted: 12/13/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To identify, for patients in states of seriously impaired consciousness, comorbid conditions present during inpatient rehabilitation and their association with function at 1 year. DESIGN Abstracted data from a prospective cross-sectional observational study with data collection occurring January 1996 through December 2007. SETTING Four inpatient rehabilitation facilities in metropolitan areas. PARTICIPANTS The study sample of 68 participants is abstracted from a database of 157 patients remaining in states of seriously impaired consciousness for at least 28 days. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE One-year cognitive, motor, and total FIM score. RESULTS The most common medical complications during inpatient rehabilitation for the study sample are active seizures (46%), spasticity (57%), urinary tract infections (47%), and hydrocephalus with and without shunt (38%). Presence of ≥3 medical complications during inpatient rehabilitation, controlling for injury severity, is significantly (P<.05) associated with poorer total FIM and FIM motor scores 1 year after injury. The presence of hydrocephalus with and without shunt (r=-.20, -.21, -.18; P ≤.15), active seizures (r=-.31, -.22, -.42), spasticity (r=-.38, -.28, -.40), and urinary tract infections (r=-.25, -.24, -.26) were significantly (P<.10) associated with total FIM, FIM cognitive, and FIM motor scores, respectively. CONCLUSIONS Reported findings indicate that persons in states of seriously impaired consciousness with higher numbers of medical complications during inpatient rehabilitation are more likely to have lower functional levels 1-year postinjury. The findings indicate that persons with ≥3 medical complications during inpatient rehabilitation are at a higher risk for poorer functional outcomes at 1 year. It is, therefore, prudent to evaluate these patients for indications of these complications during inpatient rehabilitation.
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Affiliation(s)
- Shanti Ganesh
- Department of Veterans Affairs, Research Service and the Center for Management of Complex Chronic Care Center of Excellence, Edward Hines Jr Veterans Affairs Hospital, Hines, IL; Physical Medicine and Rehabilitation Service, Edward Hines Jr Veterans Affairs Hospital, Hines, IL
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Sugino T. [Impaired consciousness]. Nihon Rinsho 2013; 71:1004-1008. [PMID: 23855203] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Consciousness disorder is one of the common signs that clinicians treat every day. It is further more frequently found in elderly patients, but it is often difficult to make an exact diagnosis and to give a suitable treatment for each case. There are many kinds of diseases or systemic disorders which impair consciousness, and moreover, various backgrounds (e.g. their lifestyle, mental problems, etc.) characteristic for aged people often make the diagnosis unclear. Therefore, it is very important for every physician assigned to emergency room to have broad viewpoint and to make careful examinations approaching such patients. Needless to say, if the patient is facing crisis, more priority should be given to emergency treatment than to precise diagnosis.
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Affiliation(s)
- Tatsuya Sugino
- Emergency and Critical Care Center, Hyogo Prefectural Nishinomiya Hospital
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Collopy KT, Kivlehan S, Snyder SR. Acute altered mental status in elderly patients: what can cause geriatric AMS and delirium? EMS World 2013; 42:31-39. [PMID: 23469462] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Dolce G, Lucca LF, Quintieri M, Leto E, Rogano S, Riganello F, Pignolo L. Neurorehabilitation for severe disorder of consciousness: the S. Anna – RAN operational model. J Rehabil Med 2012; 44:512-6. [PMID: 22661002 DOI: 10.2340/16501977-0968] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Giuliano Dolce
- S. Anna Institute and RAN - Research in Advanced Neurorehabilitation, Crotone, Italy.
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Sániová B, Drobný M, Drobná E, Matloobi A. Acute consciousness disorders in intensive care medicine - value of its grading for prognostic conclusion. Neuro Endocrinol Lett 2012; 33:167-176. [PMID: 22592197] [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] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 04/25/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To understand consciousness we have to understand the mechanism of its function, which is to effectively organize sensory inputs from our environment. Consciousness is the basic, essential outcome of the process of organizing these sensory inputs, resulting in cognitive, mental, emotional, executive, instinctual or other marginally aware states. This reciprocal process of the CNS implies that organization is an act, which precedes consciousness, i.e. preconscious function. Most scientific explanations portray consciousness as an "emergent property" of classical computer-like activities in the brains neural networks. Doctors at ICU work daily with patients with altered human consciousness. Therefore, they must recognize and manage it skilfully and use adequate approaches for definite solutions. MATERIAL AND METHODS We observed a series of patients with traumatic and non traumatic brain injuries admitted to the ICU. The quality of life of these patients during the course of intensive care was very elementary and the final outcome GCS (oGCS) for future life was defined as a comatose state or apallic state, very rarely was it restored to premorbid condition as far as lucidity, attention, cognition, and executive functions. RESULTS We found that a significant oGCS increase in relation to condition at admission or intake GCS (iGCS) in the group with 184 patients total (p<0.00001), in cardio-pulmonary resuscitation (CPR), traumatic brain injury (TBI) subgroups (p<0.00001) and in spontaneous haemorrhage (SH) (p<0.05) represents the only basic prerequisite for further improvement. It is not easy to find good therapeutic approaches after traumatic and non traumatic brain injury. A statistically significant oGCS increase in relation to iGCS due to quite intense medical care and keeping disclosed the state of unconsciousness with further probable evolution through the following possible ways: death in fluent comatose state, delirium and awakening, delirium ending in death, direct awakening from comatose state. Therefore significantly increased oGCS is the only basic prerequisite for pragmatically optimal "quality of life" in the course of later life. CONCLUSION We raise general questions for both scientists and clinicians that will assist in their efforts to understand the basic endogenous conscious biological processes, their pathological changes and the links between them.
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Affiliation(s)
- Beata Sániová
- Department of Anaesthesiology and Intensive Care Medicine and Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Hospital Martin, Armed Forces Academy of General M. R. Štefánik, Liptovský Mikuláš, Slovak Republic.
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Machado C, Estevez M, Gutierrez J, Prez-Nellar J, Olivares A. A network approach to assessing cognition in disorders of consciousness. Neurology 2011; 77:511; author reply 511-2. [PMID: 21810702 DOI: 10.1212/wnl.0b013e31821ea0bd] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Chen CM, Hsu HC, Chuang YW, Chang CH, Lin CH, Hong CZ. Study on factors affecting the occurrence of upper gastrointestinal bleeding in elderly acute stroke patients undergoing rehabilitation. J Nutr Health Aging 2011; 15:632-6. [PMID: 21968857 DOI: 10.1007/s12603-011-0052-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate factors affecting upper gastrointestinal bleeding (UGIB) in elderly first-time acute stroke patients undergoing rehabilitation. PARTICIPANTS AND SETTING Three hundred and thirty-one elderly first-time acute stroke patients (age ≥65 years) transferred to our rehabilitative ward from July 2002 to June 2009 were included in the study. DESIGN We divided patients into UGIB and non-UGIB groups. Demographic data and possible precipitating factors were analyzed. RESULTS Sixty-eight (20.5%) patients experienced UGIB. The patients with UGIB were of older age (75.4 vs. 72.92 years, P = 0.003), had a longer rehabilitative ward stay (26.32 vs. 21 days, P = 0.002), more frequently had stroke-induced consciousness impairment (60.3 vs. 38%, P = 0.001), had a higher incidence of bilateral brain lesion (7.4 vs. 1.9%, P = 0.034), and more frequently used anticoagulants (17.6 vs. 9.1%, P = 0.044) than patients in the non-UGIB group. In multivariate logistic regression analysis, stroke-induced impaired consciousness (odds ratio: 2.806, 95% CI = 1.588-4.957, P = 0.000) was the most important risk factor for UGIB. CONCLUSIONS UGIB may prolong a patient's length of stay in a rehabilitative ward. These identified factors may help clinicians identify risks of UGIB before it develops.
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Affiliation(s)
- C-M Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chiayi, No.6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan, ROC
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Morrell GA. False reading of retained urine from a bladder scan. Urol Nurs 2010; 30:147-148. [PMID: 20469574] [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] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This case study describes bladder scan findings in an 88-year-old female patient with heart failure and decreased level of consciousness who experienced decreased urinary output. The actions of the nurse demonstrate how gaps between assessment findings and expected outcomes must be investigated further. This case provides an example of the daily need for critical thinking by nurses to promote positive patient outcomes.
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Affiliation(s)
- Gregory A Morrell
- Gregory A. Morrell, RN, is a Nurse, Cardiovascular Intensive Care Unit, Community Hospital Campus, University of Pittsburgh Medical Center--McKeesport, McKeesport, PA, USA
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Shaheen M. Severe congestive heart failure patient on amiodarone presenting with myxedemic coma: a case report. Indian Heart J 2009; 61:392-393. [PMID: 20635749] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
This is a case report of myxedema coma secondary to amiodarone-induced hypothyroidism in a patient with severe congestive heart failure (CHF). To our knowledge and after reviewing the literature there is one case report of myxedema coma during long term amiodarone therapy. Myxedema coma is a life threatening condition that carries a mortality reaching as high as 20% with treatment. The condition is treated with intravenous thyroxine (T4) or intravenous tri-iodo-thyronine (T3). Patients with CHF on amiodarone may suffer serious morbidity and mortality from hypothyroidism, and thus may deserve closer follow up for thyroid stimulating hormone (TSH) levels. This case report carries an important clinical application given the frequent usage of amiodarone among CHF patients. The myriad clinical presentation of myxedema coma and its serious morbidity and mortality stresses the need to suspect this clinical syndrome among CHF patients presenting with hypotension, weakness or other unexplained symptoms.
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Affiliation(s)
- Mazen Shaheen
- University of Cincinnati, College of Medicine, Department of Internal Medicine, Cincinnati, Ohio, USA.
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Siddiqui M, Jamil N, Malik A, Bano A, Khan FS, Siddiqui K. Frequency of non convulsive status epilepticus in patients with impaired level of consciousness. J PAK MED ASSOC 2009; 59:296-298. [PMID: 19438133] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To determine the frequency of Non Convulsive Status Epilepticus in patients admitted with impaired consciousness. METHODS All EEG's in patients with impaired level of consciousness over four years from 2002- 2006 were reviewed. All EEG's showing continuous epileptiform discharges were included. Findings of all these EEG's were divided into five groups; generalized spikes and wave, generalized sharp and wave, focal spike and wave, focal sharp and wave and periodic lateralized epileptiform discharges. RESULTS There were 785 EEG's recorded in patients with impaired level of consciousness. Only 12 (1.5%) patients were identified with NCSE on EEG. The commonest EEG findings in our patients with NCSE were: Continuous focal spike and wave seen in 4(33%), Continuous generalized spike and wave 3 (25%), Continuous generalized sharp and wave 3 (25%), Continuous focal sharp and wave 1 (8.3) and Continuous periodic lateralized epileptiform discharges (PLEDs) in 1 (8.3%) patient. CONCLUSION NCSE is an important treatable entity which can be easily recognized by doing an EEG.
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Affiliation(s)
- Maimoona Siddiqui
- Department of Clinical Neurophysiology & Neurology, Liaquat National Hospital, Institute of Postgraduate Medical Studies, Karachi, Pakistan
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Dimov GS, Karakolev ZT, Kalchev IY, Dobrev KD. Ventilator-associated pneumonia in patients with cerebral depression. Folia Med (Plovdiv) 2009; 51:56-60. [PMID: 19437899] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Bacterial nosocomial ventilator-associated pneumonias are common complications in critically-ill patients. The aim of the present study was to determine the significance of the quantitative changes of consciousness of various etiology as a risk factor for the development of this type of pneumonia. PATIENTS AND METHODS The present prospective study included 81 patients with depressed level of consciousness of different etiology who had developed bacterial nosocomial pneumonia. RESULTS Nosocomial pneumonia was diagnosed in 17 (20.98%) patients on mechanical ventilation. No evidence of pulmonary infection was found in the remaining 64 (79.02%) patients. In 2 (2.46%) cases which received thiopental we detected nosocomial pulmonary infection. Forty-six patients (56.79%) underwent neurosurgical interventions. Pneumonia was found in 11 cases (13.58%). CONCLUSIONS Suppression of brain activity and the ensuing depressed levels of consciousness as reasons for admission to an intensive-care unit cause a statistically significant increase of the risk of bacterial nosocomial pneumonia developing in patients on mechanical ventilation. Thiopental therapy did not affect the frequency of pulmonary infections. The neurosurgeries we conducted did not increase significantly the risk for nosocomial infections.
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Affiliation(s)
- Gospodin S Dimov
- Department of Anesthesiology, Emergency and Intensive-care medicine, University Hospital, Trakia University, Stara Zagora, Bulgaria.
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Abstract
BACKGROUND An important medical concern of the Iraq war is the potential long-term effect of mild traumatic brain injury, or concussion, particularly from blast explosions. However, the epidemiology of combat-related mild traumatic brain injury is poorly understood. METHODS We surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq. Validated clinical instruments were used to compare soldiers reporting mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), with soldiers who reported other injuries. RESULTS Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache. CONCLUSIONS Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems.
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Affiliation(s)
- Charles W Hoge
- Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, U.S. Army Medical Research and Materiel Command, Silver Spring, MD 20910, USA.
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de Castro P. [Patients with alteration of consciousness in the emergency department]. An Sist Sanit Navar 2008; 31 Suppl 1:87-97. [PMID: 18528446] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A subject is conscious when he is awake and with an adequate awareness of him and the environment. The term alteration of consciousness requires specification as to whether it defines alteration of arousal--when the patient might be confused, in a stupor or in some degree of coma (light, deep)--or alteration of awareness--that is, confused (spatio-temporally disoriented, with difficulty in maintaining his attention), with or without delirious ideation. The coma, in the strict sense, originates from structural (neurological) or functional (metabolic) dysfunction of the ascending reticular activator system, but it is accepted that it can derive also from diffuse bi-hemispheric cortical-subcortical damage. In the emergency department the starting point is the triad of situations that requires immediate treatment applying the normal protocol (ABC); next, pathologies involving risk to life, which might cause cerebral hypoxia, are ruled out: diminished cardiac output, shock and respiratory failure. Subsequently, a neurological evaluation is made, bearing in mind two situations of potential gravity: endocranial hypertension and diseases that might cause respiratory failure due to muscular fatigue. Neurological exploration will specify the respiratory, pupil and ocular patterns and motor responses. The depth of the coma is established through scales; a simplification of Jouvet's scale is proposed. The etiological diagnosis will on occasion require image tests and lumbar puncture.
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Affiliation(s)
- P de Castro
- Departamento de Neurología, Clínica Universitaria de Navarra, Pamplona, Spain
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Groopman J. Silent minds: what scanning techniques are revealing about vegetative patients. New Yorker 2007:38-43. [PMID: 17948338] [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] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Rohde V, Berns E, Rohde I, Gilsbach JM, Ryang YM. Experiences in the management of brainstem hematomas. Neurosurg Rev 2007; 30:219-23; discussion 223-4. [PMID: 17486379 DOI: 10.1007/s10143-007-0081-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [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: 11/28/2006] [Accepted: 03/04/2007] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to present our experience in the management of spontaneous brainstem hematomas (BSH). Records of 58 consecutive patients were reviewed, including demographic data, symptoms, Glasgow Coma Scale, treatment, intraoperative findings (in surgical cases), and outcome according to the Glasgow Outcome Scale. Fifteen patients were comatose (GCS 4 or less): 11/15 patients were treated conservatively. Four patients with accompanying acute occlusive hydrocephalus were treated by placement of an external ventricular drainage. None survived. In nine patients (60%), arteriosclerosis and/or long-standing arterial hypertension were known and arteriopathic BSH was suspected. Forty-three patients were not comatose: 37 patients showed no impairment of consciousness (GCS 15), 6 patients presented with mild disturbance of conscious state (GCS 13), progressing to coma (GCS 8) in 1. In the majority (36/43) of the non-comatose patients (83.7%) cavernoma could be revealed and removed surgically. In six patients (14%), an atypically located arteriopathic BSH was assumed and treated medically. One patient had an underlying brainstem arteriovenous malformation and was treated radiosurgically. Many arteriopathic BSH cause immediate coma indicating direct and irreversible damage of midpontine structures. Thus, we suggest not to proceed to surgery, even if the bleeding is accompanied by acute hydrocephalus. The majority of BSH not resulting in immediate coma are caused by underlying cavernomas. In these cases surgery should be considered.
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Affiliation(s)
- Veit Rohde
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany.
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Abstract
Aspiration syndromes are clinically and pathologically classified into three sets of disorders: (i) large airway mechanical obstruction caused by foreign bodies; (ii) aspiration pneumonitis; and (iii) aspiration pneumonia. In this article, we discuss the common clinical presentations, risk factors, radiographic features and methods of management of these disorders. We highlight recent recommendations and controversies surrounding the prevention of aspiration pneumonia in the critically ill patient. Finally, we review ethical dilemmas surrounding feeding and aspiration risk concerns in debilitated and demented patients.
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Affiliation(s)
- H S Paintal
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, and U.S. Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
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Greiner F, Rothrock J. Subacutely Progressive Epidural Hematoma in the Absence of a "Lucid Interval". Headache 2006; 46:808-9. [PMID: 16643585 DOI: 10.1111/j.1526-4610.2006.00456.x] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Frank Greiner
- Department of Radiology, University of South Alabama College of Medicine, Mobile, USA
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Abstract
OBJECT In patients with glioma, image-guided surgery helps to define the radiographic limits of the tumor to maximize safety and the extent of resection while minimizing damage to eloquent brain tissue. The authors hypothesize that image-guided resection (IGR) techniques are associated with improved outcomes in patients with malignant glioma. METHODS Data recorded in 486 patients enrolled in the Glioma Outcomes Project were analyzed in this study. Demographic data and outcomes in patients who underwent IGR were compared with those in patients who underwent resection without IGR. Univariate analysis performed with chi-square testing was used to compare patient presentation, tumor characteristics, and death rates. Multivariate logistic regression was used to predict various outcome parameters. Patients who underwent IGR were younger and had smaller, lower-grade tumors than those in whom IGR was not performed. They were more likely to present with seizure and normal consciousness. Unexpectedly, gross-total resection was performed in significantly fewer patients with IGR than in individuals without IGR. Patients with IGR were more likely to be discharged home with the ability to live independently, and they had a shorter duration of hospital stay than patients without IGR. Survival was significantly longer in patients who underwent IGR, but multivariate analysis showed that glioblastoma multiforme (GBM) and age accounted for these observations. CONCLUSIONS Selection bias occurs regarding patients who receive IGR; these biases include younger age, presentation with seizure and normal level of consciousness, tumor diameter less than 4 cm, and non-GBM on histopathological studies. Outcome appears to be improved in patients who undergo IGRs of high-grade gliomas. It is unclear if these improved outcomes are due to the selection of a more favorable patient population or to the IGR techniques themselves. It is likely that the full potential of image guidance in glioma surgery will not be realized until it is applied to a wider range of patients.
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Affiliation(s)
- N Scott Litofsky
- Division of Neurosurgery, University of Missouri-Columbia School of Medicine, Columbia, Missouri 65212, USA.
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Abstract
The coughing paroxysms of patients with cystic fibrosis may occasion neurological symptoms. Although cough syncope is well-known, and is associated with headache and paralysis, a migrainous mechanism has not been reported. We reviewed the medical records, autonomic testing results, and responses to treatment in two cystic fibrosis patients with similar presentations of cough-induced impairment of consciousness followed by headache and paralysis. A 24-year-old woman and an unrelated 38-year-old man, both with cystic fibrosis, developed post-tussive neurologic deficits. Both patients reported infrequent dramatic spells, always preceded by major hemoptysis, and associated with left-sided paralysis, transient blindness, nausea, and severe pulsating headaches. Autonomic testing demonstrated only postural tachycardia and a near-vasodepressor episode in the woman, and mild, generalized sympathetic dysfunction in the man. Treatment for presumptive migraine with aura with verapamil nearly eradicated symptoms in both patients. Discontinuation of verapamil in the woman was associated with symptom recurrence and a stroke, with significant persistent residual left hemiparesis. In conclusion, cough-induced neurologic deficits were previously reported with cystic fibrosis, without clear understanding of the mechanism of impairment of consciousness. Based on the hemiparesis, nausea, and throbbing headache, which repeatedly followed the events in both patients, and based on the response to verapamil, we hypothesize a migrainous mechanism in both of our patients. The pathophysiology that links the hemoptysis to the spells deserves further investigation.
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Affiliation(s)
- Dinesh S Rao
- Department of Neurology, Case Western Reserve University School of Medicine and University Hospitals of Cleveland, Cleveland, Ohio, USA
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Nicholas R, Pfeifer C. Failure of normal glycaemic regulation in a patient with severe hypothermia. Resuscitation 2005; 68:139-42. [PMID: 16216406 DOI: 10.1016/j.resuscitation.2005.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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: 12/31/2004] [Revised: 05/10/2005] [Accepted: 05/22/2005] [Indexed: 01/04/2023]
Abstract
This report describes the case of an 88-year-old non-diabetic female who presented to the emergency department following a presumed hypoglycaemic collapse due to self-neglect. Subsequent rewarming and resuscitation demonstrated a number of the significant consequences of severe hypothermia, including apparent secondary impairment of glycaemic autoregulation. The phenomenon of reversible inhibition of insulin secretion due to severe hypothermia has been documented previously in the field of cardiac surgery. The hyperglycaemia was not treated with any antihyperglycaemic agent, and her recovery was uneventful. Subsequent blood sugar level monitoring was normal. If insulin is administered to the hypothermic patient, intensive monitoring of blood glucose is essential due to the increase in endogenous insulin secretion on rewarming.
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Affiliation(s)
- Robert Nicholas
- Ochr, The Llawnt, Oswestry, Shropshire, SY10 7HY, The University of Queensland, Brisbane, Qld 4072, Australia
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Martín Navarro J, González Arias R, Molina Gay J, Cereceda Coto A. Hiponatremia aguda y síndrome de ogilvie por intoxicación accidental con desmopresina. Gastroenterología y Hepatología 2005; 28:435-6. [PMID: 16137482 DOI: 10.1157/13077767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Barbarito N, Nava S. Apnea while awake. Sleep Med 2005; 6:289-90. [PMID: 15854863 DOI: 10.1016/j.sleep.2005.01.005] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Revised: 01/17/2005] [Accepted: 01/21/2005] [Indexed: 11/23/2022]
Affiliation(s)
- N Barbarito
- Pneumologia, Fondazione Maugeri, Via Ferrata 8, 27100 Pavia, Italy
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