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Blood pressure (BP) is a dynamic measure that is frequently discussed in static terms. There exist many limitations in current documentation systems whereby documented BP values may not be reflective of the dynamic variability of BP. This study used an observational, prospective, non-randomized study design to examine the variability in BP response during intravenous vasoactive medication administration in an intensive care unit setting. Subjects admitted to a neuroscience intensive care unit were monitored continuously during a 12-hour period. The BP values include systolic BP, diastolic BP, and mean arterial pressure. Intermittent values from an intra-arterial figurecatheter (a-line) and continuously sampled values from an a-line obtained using continuous data acquisition (CDA) software, were compared to intermittently sampling of cuff-based BP measurements documented in the medical record. The 30 patients provided 1,220,511 BP observations from CDA, 944 from a-line documentation, and 416 from cuff-based BP documentation. The systolic BP was used as a goal parameter for 23 (77%) of the patients. Repeated measures models demonstrated that on average cuff-based differed from intermittent a-line and from CDA ( p  < .005) for all BP values. No differences between a-line and CDA were observed. Concordance correlation coefficients ranged from 0.56 to 0.72 for a-line, cuff-based BP, and CDA, indicating moderate agreement. Using intermittently documented BP values does not fully represent the dynamic nature of BP over time.

The pupillary light reflex (PLR) describes the response when light hits the retina and sends a signal (cranial nerve II) to the Edinger-Westphal Nucleus which via cranial nerve III results in pupillary constriction. The Neurological Pupil index TM (NPi) and pupil constriction velocity (CV) are two distinct variables that can be observed and measured using a pupillometer. We examine NPi and CV in 27,462 pupil readings (1,617 subjects). NPi values <3.0 and a CV < 0.8 mm/sec were considered abnormal. Regression was used to clarify the effect of pupil size and repeated measures. An odds ratio of abnormal CV given normal NPi (and vice versa) was computed using the glimmixed (SAS) regression. Of 27,462 readings, 49.2% revealed bilaterally normal NPi wtih brisk CV, and 10.8% revealed bilaterally abnormal NPi and slow CV; 9.1% with unilaterally normal NPi and brisk CV where the opposite pupil had an abnormal NPi and slow CV. The remaining 30.9% revealed that one or both PLR had either a normal NPi with slow CV, or abnormal NPi with brisk CV. Brisk CV does not rule out an abnormal PLR; slow CV does not rule in abnormal PLR. Practitioners should consider these implications when interpreting pupillometry readings.

Background Automated infrared pupillometry (AIP) and the Neurological Pupil index (NPi) provide an objective means of assessing and trending the pupillary light reflex (PLR) across a broad spectrum of neurological diseases. NPi quantifies the PLR and ranges from 0 to 5; in healthy individuals, the NPi of both eyes is expected to be ≥ 3.0 and symmetric. AIP values demonstrate emerging value as a prognostic tool with predictive properties that could allow practitioners to anticipate neurological deterioration and recovery. The presence of an NPi differential (a difference ≥ 0.7 between the left and right eye) is a potential sign of neurological abnormality. Methods We explored NPi differential by considering the modified Rankin Score at discharge (DC mRS) among patients admitted to neuroscience intensive care units (NSICU) of 4 U.S. and 1 Japanese hospitals and for two cohorts of brain injuries: stroke (including subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, and aneurysm, 1,200 total patients) and 185 traumatic brain injury (TBI) patients for a total of more than 54,000 pupillary measurements. Results Stroke patients with at least 1 occurrence of an NPi differential during their NSICU stay have higher DC mRS scores (3.9) compared to those without an NPi differential (2.7; P  < .001). Patients with TBI and at least 1 occurrence of an NPi differential during their NSICU stay have higher discharge modified Rankin Scale scores (4.1) compared to those without an NPi differential (2.9; P  < .001). When patients experience both abnormalities, abnormal (NPi < 3.0) and an NPi differential, the latter has an anticipatory relationship with respect to the former ( P  < .001 for z-score skewness analysis). Finally, our analysis confirmed ≥ 0.7 as the optimal cutoff value for the NPi differential (AUC = 0.71, P  < .001). Conclusion The NPi differential is an important factor that clinicians should consider when managing critically ill neurological injured patients admitted to the neurocritical care units. Trial registration NCT02804438 , Date of Registration: June 17, 2016.

Get With The Guidelines (GWTG)-Stroke is a national stroke registry and quality improvement program. We examined the accuracy and reliability of data entered in GWTG-Stroke. Data entered by sites in the GWTG-Stroke database were compared with that abstracted from de-identified medical records by trained auditors. Accuracy for each individual data element and a composite accuracy measure were calculated. Reliability was assessed using kappa (κ) statistics for categorical variables and intraclass correlation (ICC) for continuous variables. A random selection of 438 medical records from 147 GWTG-Stroke hospitals was obtained. Overall accuracy was above 90% for all variables abstracted except for weight (84.9%), serum creatinine (88.1%), deep venous thrombosis prophylaxis (79.0%), and date/time last known well (85.3%). Intermediate to good (κ or ICC 0.40-0.75) or excellent agreement (κ or ICC ≥0.75) was observed for nearly all audited variables, including time-related performance measures such as arrival within 2 hours of symptom onset (κ = 0.90) and door-to-needle time ≤60 minutes (κ = 0.72). The overall composite accuracy rate was 96.1%. The composite measure varied slightly by region and hospital academic status, but there were no significant differences in composite accuracy by bed size, ischemic stroke volume, primary stroke center certification, or Coverdell Registry participation. This audit establishes the reliability of GWTG-Stroke registry data. Individual data elements with suboptimal accuracy should be targeted for further data quality improvement.

ObjectivesThe purpose of this pilot study was to obtain baseline quantitative pupillometry (QP) measurements before and after catheter-directed cerebral angiography (DCA) to explore the hypothesis that cerebral angiography is an independent predictor of change in pupillary light reflex (PLR) metrics.DesignThis was a prospective, observational pilot study of PLR assessments obtained using QP 30 min before and after DCA. All patients had QP measurements performed with the NPi-300 (Neuroptics) pupillometer.SettingRecruitment was done at a single-centre, tertiary-care academic hospital and comprehensive stroke centre in Dallas, Texas.ParticipantsFifty participants were recruited undergoing elective or emergent angiography. Inclusion criteria were a physician-ordered interventional neuroradiological procedure, at least 18 years of age, no contraindications to PLR assessment with QP, and nursing transport to and from DCA. Patients with a history of eye surgery were excluded.Main outcome measuresDifference in PLR metric obtained from QP 30 min before and after DCA.ResultsStatistically significant difference was noted in the pre and post left eye readings for the minimum pupil size (a.k.a., pupil diameter on maximum constriction). The mean maximum constriction diameter prior to angiogram of 3.2 (1.1) mm was statistically larger than after angiogram (2.9 (1.0) mm; p<0.05); however, this was not considered clinically significant. Comparisons for all other PLR metrics pre and post angiogram demonstrated no significant difference. Using change in NPi pre and post angiogram (Δpre=0.05 (0.77) vs Δpost=0.08 (0.67); p=0.62), we calculated the effect size as 0.042. Hence, detecting a statistically significant difference in NPi, if a difference exists, would require a sample size of ~6000 patients.ConclusionsOur study provides supportive data that in an uncomplicated angiogram, even with intervention, there is no effect on the PLR.

Stroke is common and costly, annually depriving the lives and well-being of 800,000 Americans. Despite demonstrated efficacy in clinical trials, questions remain about the safety and clinical effectiveness of various treatment options given patient characteristics, conditions, preferences, and their desired outcomes. The Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) is a Patient-Centered Outcomes Research Institute–sponsored project designed to help patients, physicians, and other stakeholders make informed decisions regarding stroke care and improve outcomes through patient-centered comparative effectiveness research. The primary outcomes identified and prioritized by stroke patients are “home time” (time spent alive and outside a hospital) and major adverse cardiovascular events. With inputs from stroke patients themselves, a series of comparative safety and effectiveness analyses will be performed across 3 prioritized therapeutic areas identified as important by stroke survivors: oral anticoagulants, statin therapy, and antidepressants. We obtained data from Get With the Guidelines-Stroke linked with Medicare claims and follow-up telephone interviews. Our combined retrospective and prospective research strategy allows the evaluation of the safety and effectiveness of various treatment options and patient-centered longitudinal outcomes. To ensure the rapid translation of findings into clinical practice, results will be disseminated to stroke survivors, caregivers, and health care providers through traditional and social media, including an online decision aid tool. PROSPER is a patient-centered outcome research study guided by patients, caregivers, and the broader health care community. By addressing knowledge gaps in treatment uncertainties through comparative effectiveness research, PROSPER has the potential to improve decision making in stroke care and patient outcomes reflecting individual patient preferences, needs, and values.

The effect of intracranial pressure (ICP) and the role of ICP monitoring are best studied in traumatic brain injury (TBI). However, a variety of acute neurologic illnesses e.g., subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, meningitis/encephalitis, and select metabolic disorders, e.g., liver failure and malignant, brain tumors can affect ICP. The purpose of this paper is to review the literature about ICP monitoring in conditions other than TBI and to provide recommendations how the technique may be used in patient management. A PubMed search between 1980 and September 2013 identified 989 articles; 225 of which were reviewed in detail. The technique used to monitor ICP in non-TBI conditions is similar to that used in TBI; however, indications for ICP monitoring often are intertwined with the presence of obstructive hydrocephalus and hence the use of ventricular catheters is more frequent. Increased ICP can adversely affect outcome, particularly when it fails to respond to treatment. However, patients with elevated ICP can still have favorable outcomes. Although the influence of ICP-based care on outcome in non-TBI conditions appears less robust than in TBI, monitoring ICP and cerebral perfusion pressure can play a role in guiding therapy in select patients.

Background The 36-month Physical Medicine and Rehabilitation (PM&R) or Physiatry residency provides a number of multidisciplinary clinical experiences. These experiences often translate to novel research questions, which may not be pursued by residents due to several factors, including limited research exposure and uncertainty of how to begin a project. Limited resident participation in clinical research negatively affects the growth of Physiatry as a field and medicine as a whole. The two largest Physiatry organizations – the Association of Academic Physiatrists and the American Academy of Physical Medicine and Rehabilitation – participate in the Disability and Rehabilitation Research Coalition (DRRC), seeking to improve the state of rehabilitation and disability research through funding opportunities by way of the National Institutes of Health (NIH), the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) and the Patient-Centered Outcomes Research Institute (PCORI). A paucity of new Physiatry researchers neutralizes these efforts. Results This paper details the creation of a novel, multidisciplinary Rehabilitation Resident Research program that promotes resident research culture and production. Mirroring our collaborative clinical care paradigm, this program integrates faculty mentorship, institutional research collaborates (Neuroscience Nursing Research Center, Neuroscience Research Development Office) and departmental resources (Shark Tank competition) to provide resident-centric research support. Conclusions The resident-centric rehabilitation research team has formed a successful research program that was piloted from the resident perspective, facilitating academic productivity while respecting the clinical responsibilities of the 36-month PM&R residency. Resident research trainees are uniquely positioned to become future leaders of multidisciplinary and multispecialty collaborative teams, with a focus on patient function and health outcomes.

Background Subjective scoring of pupil reactivity is a fundamental element of the neurological examination for which the pupillometer provides an objective measure. Methods This single-blinded observational study examined interrater reliability of pupil exam findings between two practitioners and between practitioners and a pupillometer. Results From 2329 paired assessments, the interrater reliability between practitioners was only moderate for pupil size ( k = 0.54), shape ( k = 0.62), and reactivity ( k = 0.40). Only 33.3 % of pupils scored as non-reactive by practitioners were scored as non-reactive by pupillometry. Conclusions Despite the strong emphasis placed on the traditional pupil examination, especially for patients with a neurological illness, there is limited interrater reliability for subjective scoring of pupillary assessments. Thus, the use of automated pupillometers should be examined as a potential method to increase the reliability of measuring of pupil reactivity.

Purpose of ReviewThe purpose of this review is to examine the impact of pupillometer assessment on care and research of patients with neurological injury.Recent FindingsRecent studies demonstrate that automated pupillometry outperforms manual penlight pupil examination in neurocritical care populations. Further research has identified specific changes in the pupillary light reflex associated with pathologic conditions, and pupillometry has been used to successfully identify early changes in neurologic function, intracranial pressure, treatment response to osmotherapy, and prognosis after cardiac arrest.SummaryAutomated pupillometry is being increasingly adopted as a routine part of the neurologic examination, supported by a growing body of literature demonstrating its reliability, accuracy, and ease of use. Automated pupillometry allows rapid, non-invasive, reliable, and quantifiable assessment of pupillary function which may allow rapid diagnosis of intracranial pathology that affects clinical decision making.