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Background Coronavirus disease 2019 (COVID-19) is a global pandemic. The disease, typically characterized by bilateral pulmonary infiltrates and profound elevation of inflammatory markers, can range in severity from mild or asymptomatic illness to a lethal cytokine storm and respiratory failure. A number of recognized complications of COVID-19 infection are described in the literature. Common neurological complications include headache and anosmia. Guillain-Barré syndrome (GBS) is an uncommon complication described in isolated case reports. However, a causal relationship has yet to be established. This case report adds to the growing body of evidence that GBS is a potential COVID-19 complication. Case presentation A 70-year-old Caucasian woman with recently diagnosed COVID-19 infection presented to the emergency department with 4 days of gradually worsening ascending lower extremity weakness. Exam revealed bilateral lower extremity weakness, mute reflexes, and sensory loss. Soon after starting intravenous administration of immunoglobulin (IVIG), the patient developed respiratory distress, eventually requiring intubation. She remained intubated for the duration of her IVIG treatment. After five rounds of treatment, the patient was successfully extubated and transferred to acute rehab. Following 4 weeks of intense physical therapy, she was able to walk with assistance on room air. Conclusion At the present time, this is one of the few reports of acute inflammatory demyelinating polyneuropathy (AIDP) or GBS associated with COVID-19 in the United States. It is unclear whether a causal relationship exists given the nature of the syndrome. However, in light of the growing number of reported cases, physicians should be aware of this possible complication when evaluating COVID-19 patients.

Background Despite data indicating the importance of continuous video-electroencephalography (cvEEG) monitoring, adoption has been slow outside major academic centers. Barriers to adoption include the need for technologists, equipment, and cvEEG readers. Advancements in lower-cost lead placement templates and commercial systems with remote review may reduce barriers to allow community centers to implement cvEEG. Here, we report our experience, lessons learned, and financial impact of implementing a community hospital cvEEG-monitoring program. Methods We implemented an adult cvEEG service at Duke Regional Hospital (DRH), a community hospital affiliate, in June of 2012. Lead placement templates were used in the implementation to reduce the impact on technologists by using other bedside providers for EEG initiation. Utilization of the service, study quality, and patient outcomes were tracked over a 3-year period following initiation of service. Results Service was implemented at essentially no cost. Utilization varied from a number of factors: intensive care unit (ICU) attending awareness, limited willingness of bedside providers to perform lead placement, and variation in practice of the consulting neurologists. A total of 92 studies were performed on 88 patients in the first 3 years of the program, 24 in year one, 27 in year two, and 38 in year three, showing progressive adoption. Seizures were seen in 25 patients (27%), 19 were in status, of which 18 were successfully treated. Transfers to the main hospital, Duke University Medical Center, were prevented for 53 patients, producing an estimated cost savings of $145,750. The retained patients produced a direct contribution margin of about $75,000, and the margin was just over $100,000 for the entire monitored cohort. Conclusion ICU cvEEG service is feasible and practical to implement at the community hospital level. Service was initiated at little to no cost and clearly enhanced care, increased breadth of care, increased ICU census, and reduced transfers. The system allowed for successful management of ICU patients with underlying seizures and eliminated interfacility transfers, producing a savings of $145,750. The savings combined with the retained patient revenue produced a total revenue of over $250,000 with additional revenue in professional services as well. These results suggest expansion of cvEEG monitoring to community ICUs is practical, financially sustainable, improves the level and quality of care, and reduces costs.

Clopidogrel is a commonly prescribed antiplatelet drug in patients with stents and histories of arterial vascular disease. It generally has a favorable side effect profile with increasing bleeding risk as the main concern as an adverse event. A 19-year-old previously healthy male presented to the neurological intensive care unit with a subarachnoid hemorrhage requiring a flow diverting stent to secure the aneurysm. The patient was stable for 2 weeks and had no changes to management or medication within 48 h of antiplatelet therapy. Within hours of first-time dosing of clopidogrel, the patient experienced a syncopal episode and dyspnea. He was difficult to arouse and using accessory muscles to breath with an otherwise benign exam. He was hypoxic with bibasilar crackles requiring bilevel positive airway pressure (BiPap). Imaging showed bilateral pulmonary edema and he was diagnosed with moderate acute respiratory distress syndrome (ARDS). Infectious, cardiogenic, and contrast-induced ARDS were ruled out. Upon cessation of clopidogrel, his pulmonary function and mental status improved. This is the first reported case of a young and immunocompetent patient's severe pulmonary edema leading to acute respiratory distress syndrome in association with first- time dosing of clopidogrel.

Background Subarachnoid hemorrhage (SAH) has been associated with pronounced acute sympathetic activation. The purpose of this investigation is to identify demographic, clinical, radiological, and anatomical features of SAH that relate to sympathetic activation. Methods Observational study of consecutive Grades 3–5 SAH patients requiring ventriculostomy and undergoing endovascular aneurysmal obliteration. All patients underwent cerebrospinal fluid (CSF) sampling within 48 h of SAH onset, and samples were assayed for various catecholamine compounds and metabolites. Univariate analyses were performed to identify variables associated with catecholamine levels, and to correlate linearity among catecholamine compounds and metabolites. Variables demonstrating a possible association and variables of interest were entered into linear regression models to determine predictors of catecholamine elevations. Results Of the 102 patients, mean age was 58 years and 74% were female; 42% were Hunt–Hess (H/H) grade 4/5, 61% had a computed tomography (CT) score of 3/4, 57% had anterior cerebral or communicating artery (ACA/ACom) aneursysms, and 23% had aneurysms in the posterior circulation. In the univariate analysis, age, gender, H/H grade, CT score, and aneurysm location demonstrated various associations with catecholamine levels, and substantial positive correlations existed between the various catecholamine compounds and metabolites. Linear regression analyses revealed H/H grade to be an independent predictor of elevated CSF epinephrine (EPI), 3,4-dihydroxyphenylalanine (DOPA) and 3,4-dihydroxyphenyl acetic acid (DOPAC) levels, and of the norepinephrine/3,4-dihydroxyphenylglycol (NE/DHPG) ratio ( p  < 0.05 for all analyses). Female gender independently predicted increased dopamine (DA) and DOPAC levels ( p  < 0.05 for two analyses), as well as possibly DOPA levels ( p  < 0.1). Age, CT score and aneurysm location demonstrated only inconsistent associations and trends. Conclusions Central sympathetic activation relates to clinical severity and female gender. No definitive associations were found for age, hemorrhage amount, or aneurysm location.

Goal: Efficient patient flow is critical at Tampa General Hospital (TGH), a large academic tertiary care center and safety net hospital with more than 50,000 discharges and 30,000 surgical procedures per year. TGH collaborated with GE HealthCare Command Center to build a command center (called CareComm) with real-time artificial intelligence (AI) applications, known as tiles, to dynamically streamline patient care operations and throughput. To facilitate patient flow for our neuroscience service line, we partnered with the GE HealthCare Command Center team to configure a Downgrade Readiness Tile (DRT) to expedite patient transfers out of the neuroscience intensive care unit (NSICU) and reduce their length of stay (LOS). Methods: As part of an integrated NSICU performance improvement project, our LOS reduction workgroup identified the admission/discharge and transfer process as key metrics. Based on a 90%-plus average capacity, early identification of patients eligible for a downgrade to lower acuity units is critical to maintain flow from the operating rooms and emergency department. Our group identified clinical factors consistent with downgrade readiness as well as barriers preventing transition to the next phase of care. Configuration of an AI-powered model was identified as a mechanism to drive earlier downgrade and reduce LOS in the NSICU. A multidisciplinary ICU LOS reduction steering committee met to determine the criteria, design, and implementation of the AI-powered DRT. As opposed to identifying traditional clinical factors associated with stability for transfer, our working group asked, \"What are clinical barriers preventing downgrade?\" We identified more than 76 clinical elements from the electronic medical records that are programmed and displayed in real-time with a desired accuracy of over 95%. If no criteria are present, and no bed is requested or assigned, the DRT will report potential readiness for transfer. If three or more criteria are present, the DRT will suggest that the patient is not eligible for transfer. Principal Findings: The DRT was implemented in January 2022 and is used during multidisciplinary rounds (MDRs) and displayed on monitors positioned throughout the NSICU. During MDRs, the bedside nurses present each patient's key information in a standardized manner, after which the DRT is used to recommend or oppose patient transfer. Six months postimplementation period of the DRT and MDRs, the NSICU has seen a 7% or roughly eight-hour reduction in the ICU length of stay (4.15-3.88 days) with a more than three-hour earlier placement of a transfer order. Unplanned returns to the ICU (or bouncebacks) have remained low with no change in the preimplementation rate of 3% within 24 hours. As a result of this success, DRTs are being implemented in the medical ICUs. Practical Applications: This work is uniquely innovative as it shows AI can be integrated into traditional interdisciplinary rounds and enable accelerated decision-making, continuous monitoring, and real-time alerts. ICU throughput has traditionally relied on direct review of a patient's clinical course executed during clinical rounds. Our methodology adds a dynamic and technologically augmented touchpoint that is available in real time and can prompt a transfer request at any time throughout the day.

Traumatic brain injury (TBI) is common amongst Veterans and Military Service Members (V/SM), with 510,000 diagnosed with a TBI between 2000 and 2024, of which 82% were mild and 12% moderate. Hyperbaric oxygen therapy (HBOT) is considered a potential intervention for the management of mild/moderate TBI. However, the results from previous randomized controlled trials (RCTs) assessing the efficacy of HBOT for managing mild/moderate TBI are inconclusive due to several reasons, including lack of a priori power analyses, design considerations, and inappropriate comparators. The primary objective of this study is to assess the efficacy of HBOT compared to placebo/sham in reducing chronic neurobehavioral symptoms in participants with chronic mild to moderate TBI. This is a single-center blinded group sequential superiority randomized controlled trial (RCT). All consecutive United States (USA) V/SM with a history of mild or moderate TBI with persistent neurobehavioral symptoms (≥ 22 on the Neurobehavioral Symptom Inventory) at a year or more post-injury will be eligible for inclusion. HBOT medical grade oxygen pressurized to 2.0 Atmospheres Absolute (ATA) with Sechrist 3600H/HR monoplace hyperbaric chambers will be compared to a sham group of 1.0 ATA (normobaric) with oxygen delivered at 21% (normal oxygen concentration in room air) for approximately 60 min. The primary outcome is the post-intervention Neurobehavioral Symptom Inventory (NSI) score. Secondary outcomes are the number of HBOT dives needed to achieve a reduction in NSI score and to assess the impact of HBOT on post-traumatic stress disorder (PTSD) symptoms using the PTSD Checklist for DSM-5 (PCL-5). The study aims to enroll 420 subjects with an expected dropout rate of 20%. The study will determine the efficacy of HBOT at 2.0 ATA in reducing long-term neurobehavioral symptoms in V/SM with histories of mild to moderate TBI. This information will assist participants, providers, and policy members in managing chronic neurobehavioral symptoms after TBI. NCT06581003 (registered on 8/28/2024) https://clinicaltrials.gov/study/NCT06581003?term=NCT06581003&rank=1.

Background: Post-transplant lymphoproliferative disorders (PTLD) are rare immunosuppression complications affecting 5% of transplant patients. Isolated central nervous system (CNS)-PTLD without nodal or extra-nodal organ involvement is rarely reported and is difficult to diagnose due to the non-specific clinical manifestations and imaging features overlapping with other common CNS lesions. Case presentation: We present a case of a 72-year-old female subjected to a renal transplant 11 years ago with progressively worsening headaches and confusion. Imaging revealed vasogenic edema in the left frontal and bilateral temporal lobes. She was subjected to a craniotomy and excisional biopsy to obtain tissue for diagnostic and therapeutic interventions. Pathology examination showed atypical EBV-positive lymphoplasmacytic infiltrate, consistent with Polymorphic type PTLD. Conclusions: Patients diagnosed with PTLD need to have close monitoring of immunosuppressive medications while in the hospital. Early diagnosis is essential for patient survival with PTLD, as their health can deteriorate fast.

Background Dual antiplatelet therapy (DAPT) is commonly employed for neuroendovascular stenting due to the significant risk of thromboembolism. Clopidogrel and aspirin are most often selected as initial DAPTs; however, there is limited literature available to support guidance of DAPT in this setting. The objective of this study was to evaluate safety and efficacy in patients whose final regimen included either DAPT with aspirin and clopidogrel (DAPT-C) or DAPT with aspirin and ticagrelor (DAPT-T). Methods This was a multicenter, retrospective cohort of patients who underwent neuroendovascular stenting and received DAPT between July 1, 2017, and October 31, 2020. Study participants were allocated into groups based on discharge DAPT regimen. The primary outcome was incidence of stent thrombosis at 3–6 months on DAPT-C versus DAPT-T, as defined by the presence of thrombus on imaging or new onset stroke. Secondary outcomes included major and minor bleeding and death within 3–6 months after the procedure. Results Five hundred and seventy patients were screened across 12 sites. Of those, 486 were included (DAPT-C n  = 360, DAPT-T n  = 126). There was no difference in the primary outcome of stent thrombosis between the DAPT-C and DAPT-T groups (8% vs. 8%, p  = 0.97) and no difference in any of the secondary safety outcomes. Conclusions Using DAPT-C or DAPT-T regimens in a broad population of neuroendovascular stenting procedures appears to have similar safety and efficacy profiles. Further prospective evaluation is warranted to streamline the practice of DAPT selection and monitoring to determine the impact on clinical outcomes.