Myasthenic crisis in COVID-19 Delly, Fadi; Syed, Maryam J.; Lisak, Robert P. ...
Journal of the neurological sciences,
07/2020, Letnik:
414
Journal Article
Recenzirano
Odprti dostop
•Myasthenic crises is a potentially severe complication of COVID-19.•Hydroxychloroquine can aggravate myasthenia crises.•IVIg is a potential treatment for both Myasthenic crises and COVID-19.•IVIg ...treatment may cause thrombosis in susceptible patients.
Background
Non-convulsive status epilepticus (NCSE) is defined as status epilepticus (SE) with no obvious motor phenomenon and is diagnosed based on electroencephalogram (EEG). Refractory SE (RSE) is ...the persistence of seizures despite treatment with an adequately dosed first-line and second-line agents. Although guidelines for convulsive RSE include third-line agents such as intravenous anesthetic drugs (midazolam, propofol, or barbiturates), the therapeutic approach to NCSE is not well outlined. Treatment with traditional anesthetics invariably includes endotracheal intubation, which is associated with significant adverse events. Comparatively, ketamine, a non-competitive
N
-methyl-D-aspartate receptor antagonist is not associated with significant cardiorespiratory depression and may help in avoiding intubation.
Objective
In this case series, we describe our experience with the early use of intravenous ketamine as the first anesthetic agent in patients with refractory NCSE to avoid endotracheal intubation.
Methods
We present a case series of nine patients managed in the Neurointensive Care Unit at a university-affiliated tertiary care hospital. The study was approved by the hospital and university institutional review boards and the requirement for informed consent was waived for retrospective analysis of existing data, per institutional policy. All cases of SE were identified from a prospective database, and a subsequent retrospective chart review identified all patients with a diagnosis of refractory NCSE in whom ketamine was used as the first anesthetic agent. The primary endpoint was the avoidance of endotracheal intubation while on ketamine infusion. The secondary endpoint was defined as cessation of both clinical and electrographic seizures recorded on continuous EEG within 24 h of ketamine administration.
Results
A total of nine patients experiencing refractory NCSE were included in this case series, with a median age of 61 (range 26–72) years and seven patients were male. The primary endpoint, avoiding intubation, was achieved in five out of nine (55%) cases. Six patients experienced resolution of refractory NCSE with ketamine administration as the sole anesthetic agent. Four patients required endotracheal intubation and three patients had a failure of seizure cessation with ketamine. Hypersalivation and pneumonia were the most common ketamine associated adverse events. In non-intubated patients, no deaths occurred. One patient was discharged home, four to subacute rehabilitation, one to a long term acute care hospital, and one patient to hospice.
Conclusion
The use of ketamine as the primary anesthetic agent may be a reasonable option to avoid endotracheal intubation in a subset of patients with refractory NCSE. This study is limited by its small sample size, retrospective design, and reliance on information obtained from chart review.
An association between cerebral venous sinus thrombosis (CVST) and high altitude has been previously proposed, but limited published data exist to support this association. We investigated 28 cases ...of CVST occurring at high altitude and sought to describe patient demographics, altitude and acclimatization, hematological laboratory findings, neuroimaging, treatment, and prognosis in these cases.
Twenty-eight cases of symptomatic CVST occurring at high altitude were identified between the months of August 2017 and December 2018, in collaboration with Military Hospital, Rawalpindi and Combined Military Hospital, Skardu (Pakistan). Follow-up visits were performed at 1 and 6 months.
Twenty-seven (96%) of the patients were males, and the mean age was 33 years. In total, 32.1% were smokers. The mean NIHSS score on presentation was 5.5. 85.7% of the cases occurred at altitude higher than 8,000 feet. On average 107.8 days were spent at a high altitude prior to CVST. Totally, 71.4% had acclimatized for >2 weeks. The mean hemoglobin (Hb) value was 16.7 g/dL and 50% had d-dimer levels higher than 1,000 ng/mL. On MRI, 25% showed signs of hemorrhage and 14.3% showed infarcts. Treatments provided include low-molecular-weight heparin and Rivaroxaban and were associated with good outcomes.
CVST is not uncommon at high altitude (>8,000 feet). It is predominantly a male disease. Most patients have high Hb and high D-dimer levels. The overall outcome was good.
•Google Trends™ is a popular tool to analyze populations’ healthcare-seeking patterns.•Google Trends™ was used during the COVID-19 pandemic to assess risk communication.•No significant increase in ...seizure-related queries was observed using Google Trends™.
Google Trends™ is a popular tool for analyzing healthcare-seeking patterns based on observed changes in the relative search volume (RSV) of the queries made on the Google™ search engine. Google Trends™ was increasingly utilized during the pandemic to assess the impact on mental health, risk communication, the impact of media coverage, and preparedness prediction. The objective of this study was to evaluate the impact of the Coronavirus disease 2019 (COVID-19) pandemic on help-seeking behaviors for seizures and/or epilepsy by assessing the changes in seizure-related online queries in periods before and since the advent of the COVID-19 pandemic on Google Trends™. We compared the RSV volumes in the year prior to and during the COVID-19 pandemic against weekly COVID-19 positive cases for each state and US census regions Search terms were categorized according to seizure symptoms or seizure treatment. Our study showed no significant increase in the RSV for seizure and epilepsy-related searches during the COVID-19 pandemic via Google Trends™. Public health entities and medical systems may use Google Trends ™ as a way to predict national, regional, and local patient needs and drive resources to meet patient demands.
Stroke at Moderate and High Altitude Syed, Maryam J; Khatri, Ismail A; Alamgir, Wasim ...
High altitude medicine & biology,
03/2022, Letnik:
23, Številka:
1
Journal Article
Recenzirano
Syed, Maryam J., Ismail A. Khatri, Wasim Alamgir, and Mohammad Wasay. Stroke at moderate and high altitude.
. 23:1-7, 2022.
Stroke at high altitude is an understudied area in stroke research. With ...improvements in road infrastructure, access to high-altitude areas for recreation and living purposes has risen. Subsequently, it has been anticipated that due to normal physiological changes to high altitude the incidence of stroke is also likely to increase in these regions.
We searched PubMed for available literature about stroke at high altitude. Cross-referencing was done from available articles and through other scientific search engines. Relevant case series and case reports were included in this review of the topic.
Only one review article, eight case series (including review of literature), and seven case reports were identified that could be included in this review. Most of the available data come from moderate and high altitude.
There is limited available literature about stroke at high and extreme altitudes. Stroke at high altitude is likely to become an important subset of stroke population. Currently, there is inadequate knowledge about the incidence and prevalence, mechanisms, and stroke outcomes. Cerebral venous thrombosis is more common than arterial stroke. Stroke is probably secondary to conventional risk factors, polycythemia, and other coagulopathies. A case-control study may identify the at-risk population for stroke at moderate and high altitudes.
Background
Prior studies show hospital admission volume to be associated with poor outcomes following elective procedures and inpatient medical hospitalizations. However, it is unknown whether ...hospital volume impacts Inpatient outcomes for status epilepticus (SE) hospitalizations. In this study, we aimed to assess the impact of hospital volume on the outcome of patients with SE and related inpatient medical complications.
Methods
The 2005 to 2013 National Inpatient Sample database was queried using International Classification of Diseases 9th Edition diagnosis code 345.3 to identify patients undergoing acute hospitalization for SE. The National Inpatient Sample hospital identifier was used as a unique facility identifier to calculate the average volume of patients with SE seen in a year. The study cohort was divided into three groups: low volume (0–7 patients with SE per year), medium volume (8–22 patients with SE per year), and high volume (> 22 patients with SE per year). Multivariate logistic regression analyses were used to assess whether medium or high hospital volume had lower rates of inpatient medical complications compared with low-volume hospitals.
Results
A total of 137,410 patients with SE were included in the analysis. Most patients (
n
= 50,939; 37%) were treated in a low-volume hospital, 31% (
n
= 42,724) were treated in a medium-volume facility, and 18% (
n
= 25,207) were treated in a high-volume hospital. Patients undergoing treatment at medium-volume hospitals (vs. low-volume hospitals) had higher odds of pulmonary complications (odds ratio OR 1.18 95% confidence interval {CI} 1.12–1.25;
p
< 0.001), sepsis (OR 1.24 95% CI 1.08–1.43
p
= 0.002), and length of stay (OR 1.13 95% CI 1.0 –1.19
p
< 0.001). High-volume hospitals had significantly higher odds of urinary tract infections (OR 1.21 95% CI 1.11–1.33
p
< 0.001), pulmonary complications (OR 1.19 95% CI 1.10–1.28,
p
< 0.001), thrombosis (OR 2.13 95% CI 1.44–3.14,
p
< 0.001), and renal complications (OR 1.21 95% CI 1.07–1.37,
p
= 0.002). In addition, high-volume hospitals had lower odds of metabolic (OR 0.81 95% CI 0.72–0.91,
p
< 0.001), neurological complications (OR 0.80 95% CI 0.69–0.93,
p
= 0.004), and disposition to a facility (OR 0.89 95% CI 0.82–0.96,
p
< 0.001) compared with lower-volume hospitals.
Conclusions
Our study demonstrates certain associations between hospital volume and outcomes for SE hospitalizations. Further studies using more granular data about the type, severity, and duration of SE and types of treatment are warranted to better understand how hospital volume may impact care and prognosis of patients.
•Seizures, status epilepticus in COVID-19 had no correlation to functional outcomes.•21.8% of patients with COVID-19 who underwent EEG had clinical seizures.•7% had status epilepticus, majority of ...which (87.5%) had no epilepsy history.•No EEG pattern was associated with outcomes after adjusting for COVID-19 severity.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has a myriad of neurological manifestations and its effects on the nervous system are increasingly recognized. Seizures and status epilepticus (SE) are reported in the novel coronavirus disease (COVID-19), both new onset and worsening of existing epilepsy; however, the exact prevalence is still unknown. The primary aim of this study was to correlate the presence of seizures, status epilepticus, and specific critical care EEG patterns with patient functional outcomes in those with COVID-19.
This is a retrospective, multicenter cohort of COVID-19-positive patients in Southeast Michigan who underwent electroencephalography (EEG) from March 12th through May 15th, 2020. All patients had confirmed nasopharyngeal PCR for COVID-19. EEG patterns were characterized per 2012 ACNS critical care EEG terminology. Clinical and demographic variables were collected by medical chart review. Outcomes were divided into recovered, recovered with disability, or deceased.
Out of the total of 4100 patients hospitalized with COVID-19, 110 patients (2.68%) had EEG during their hospitalization; 64% were male, 67% were African American with mean age of 63 years (range 20–87). The majority (70%) had severe COVID-19, were intubated, or had multi-organ failure. The median length of hospitalization was 26.5 days (IQR = 15 to 44 days). During hospitalization, of the patients who had EEG, 21.8% had new-onset seizure including 7% with status epilepticus, majority (87.5%) with no prior epilepsy. Forty-nine (45%) patients died in the hospital, 46 (42%) recovered but maintained a disability and 15 (14%) recovered without a disability. The EEG findings associated with outcomes were background slowing/attenuation (recovered 60% vs recovered/disabled 96% vs died 96%, p < 0.001) and normal (recovered 27% vs recovered/disabled 0% vs died 1%, p < 0.001). However, these findings were no longer significant after adjusting for severity of COVID-19.
In this large multicenter study from Southeast Michigan, one of the early COVID-19 epicenters in the US, none of the EEG findings were significantly correlated with outcomes in critically ill COVID-19 patients. Although seizures and status epilepticus could be encountered in COVID-19, the occurrence did not correlate with the patients’ functional outcome.
The retrospective nature of most available epilepsy quality improvement (QI) tools focuses on changing health care provider (HCP) clinical habits and documentation practices rather than a focus on ...real-time patient interventions. Furthermore, patient-reported outcome data are often not available to determine the efficacy of these tools. Our primary objective was to demonstrate the improvement of HCPs' documentation and review of epilepsy quality measures (EQMs) during the patient visit with the implementation of a novel web application, NeuroMeasures. Our secondary objective was to improve the percentage of point-of-care counseling and interventions based on quality measures during the patient encounter based on the results of the NeuroMeasures tool.
Our QI study focused on comparing a preintervention and postintervention cohort of patients with epilepsy (PWE) before the implementation of NeuroMeasures, a web-based application that takes a self-guided patient survey through self-scoring algorithms focused on the American Academy of Neurology (AAN)'s 2017 EQMs. This e-tool then provides the HCP a tool to directly review the EQMs highlighted and perform any necessary counseling or interventions at the point-of-care visit. After intervention, EQMs were gained from the review of the NeuroMeasures HCP quality measures tool and a chart review for physician documentation. Patients with language barriers and severe cognitive disabilities were excluded from the study.
The preintervention cohort consisted of 150 unique PWE, and the postintervention cohort included 379 unique adult PWE and 515 total encounters. Overall percentages of review/adherence of EQMs were significantly improved between the preintervention and postintervention group for counseling for women of childbearing potential (91.7%), intractable epilepsy referral to a comprehensive epilepsy center (74%), quality of life assessment (80%), improvement of quality of life measurements (41.7%), and depression and anxiety screening (85.6%), demonstrating a significant increase when compared with the preintervention group (
< 0.00001).
A web-based point-of-care EQM application demonstrated significant improvement of the HCP's ability to perform and review EQMs at the point-of-care patient visit. Furthermore, the application was successful in creating opportunities for direct intervention based on the EQMs and chances for better patient education and provider-patient communication. Further considerations would include automated survey requests and expansion into other AAN QMs.
•Expanded Disability Status Scale (EDSS) is a commonly used tool to assess the extent of functional impairment in multiple sclerosis•This scale is traditionally conducted in face to face setting but ...recent reports suggest its use via telephone•This study is first validation of this tool in Urdu using telephone•Telephone EDSS may be useful and effective for MS patients•This could be an effective tool for MS patients in tele neurology clinics
Expanded Disability Status Scale (EDSS) is a commonly used tool to assess the extent of functional impairment in multiple sclerosis (MS) patients for clinical and research purposes. EDSS is traditionally conducted in a face-to-face setting, however, routine in-person EDSS assessments are often difficult to perform in developing countries due to the various reasons patients are unable to access healthcare and maintain clinic visits. Hence validating a locally translated telephone-based EDSS (T-EDSS) could be potentially useful to both physicians and patients by removing the need to commute to healthcare centers for disability assessment and could lead to overall improved care for MS patients.
Firstly, the EDSS scale was translated and culturally adapted into Urdu. On enrolment, EDSS was conducted during scheduled clinic visits and forty-seven subjects with MS were henceforth included in the study. Same patients were contacted via telephone following two weeks by a different neurologist to carry out the telephone-EDSS assessment. The patients’ baseline EDSS scores at enrolment were blinded to prevent interviewer bias.
Kappa value for agreement between the two assessments for EDSS scores of more than 6 was 0.73, whereas the kappa value for EDSS score of less than 4.5 was 0.35. The intraclass correlation coefficient (ICC) for T-EDSS score < 4.5 was 1.7, and for a score > 4.5 was 4.9, with the overall ICC being 0.64. Cronbach's alpha value for T-EDSS score < 4.5 was 0.59 and for the score > 4.5 was 0.79.
This study shows that there exists a positive correlation and substantial level of agreement between in-person EDSS and T-EDSS, especially in MS patients with higher baseline EDSS scores. Hence a locally translated T-EDSS can be used in Pakistani MS patients with reasonable confidence. T-EDSS may be more useful in MS patients with moderate to severe disability.
PDF
