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Shayo CS, Woodfield J, Shabhay ZA, Ikwuegbuenyi CA, Mtei J, Yonah B, Ndossi MY, Massawe SL, Magawa DG, Mndeme H, Kwelukilwa D, Bureta CA, Ngeregeza J, Hoffman C, Mangat HS, Mchome LL, Härtl R, Shabani HK. Neurosurgical Education in Tanzania: The Dar es Salaam Global Neurosurgery Course. World Neurosurg 2023; 180:42-51. [PMID: 37659749 DOI: 10.1016/j.wneu.2023.08.111] [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: 07/14/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Postgraduate neurosurgical training is essential to develop a neurosurgical workforce with the skills and knowledge to address patient needs for neurosurgical care. In Tanzania, the number of neurosurgeons and neurosurgical services offered have expanded in the past 40 years. Training opportunities within the country, however, are not sufficient to meet the needs of residents, specialists, and nurses in neurosurgery, forcing many to train outside the country incurring associated costs and burdens. We report on the Dar es Salaam Global Neurosurgery Course, which aims to provide local training to neurosurgical health care providers in Tanzania and surrounding countries. METHODS We report the experience of the Global Neurosurgery Course held in March 2023 in Dar es Salaam, Tanzania. We describe the funding, planning, organization, and teaching methods along with participant and faculty feedback. RESULTS The course trained 121 participants with 63 faculty-42 from Tanzania and 21 international faculty. Training methods included lectures, hands-on surgical teaching, webinars, case discussions, surgical simulation, virtual reality, and bedside teaching. Although there were challenges with equipment and Internet connectivity, participant feedback was positive, with overall improvement in knowledge reported in all topics taught during the course. CONCLUSIONS International collaboration can be successful in delivering topic-specific training that aims to address the everyday needs of surgeons in their local setting. Suggestions for future courses include increasing training on allied topics to neurosurgery and neurosurgical subspecialty topics, reflecting the growth in neurosurgical capacity and services offered in Tanzania.
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Affiliation(s)
- Consolata S Shayo
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania.
| | - Julie Woodfield
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania; Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Zarina A Shabhay
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Chibuikem Anthony Ikwuegbuenyi
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania; Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
| | - John Mtei
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Boaz Yonah
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Maxigama Y Ndossi
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Sylvia L Massawe
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Dorcas G Magawa
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Hadija Mndeme
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Donatila Kwelukilwa
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Costansia A Bureta
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Japhet Ngeregeza
- Department of Neurosurgery, Muhimbili National Hospital - Mloganzila, Dar es Salaam, Tanzania
| | - Caitlin Hoffman
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
| | - Halinder S Mangat
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA; Neurocritical Care Department, University of Kansas Medical Centre, Wichita, Kansas, USA
| | - Laurent Lemeri Mchome
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Roger Härtl
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA; New York-Presbyterian - Och Spine, New York, New York, USA
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
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Hawryluk GWJ, Lulla A, Bell R, Jagoda A, Mangat HS, Bobrow BJ, Ghajar J. Guidelines for Prehospital Management of Traumatic Brain Injury 3rd Edition: Executive Summary. Neurosurgery 2023; 93:e159-e169. [PMID: 37750693 PMCID: PMC10627685 DOI: 10.1227/neu.0000000000002672] [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: 05/07/2023] [Accepted: 07/29/2023] [Indexed: 09/27/2023] Open
Abstract
Prehospital care markedly influences outcome from traumatic brain injury, yet it remains highly variable. The Brain Trauma Foundation's guidelines informing prehospital care, first published in 2002, have sought to identify and disseminate best practices. Many of its recommendations relate to the management of airway, breathing and circulation, and infrastructure for this care. Compliance with the second edition of these guidelines has been associated with significantly improved survival. A working group developed evidence-based recommendations informing assessment, treatment, and transport decision-making relevant to the prehospital care of brain injured patients. A literature search spanning May 2005 to January 2022 supplemented data contained in the 2nd edition. Identified studies were assessed for quality and used to inform evidence-based recommendations. A total of 122 published articles formed the evidentiary base for this guideline update including 5 providing Class I evidence, 35 providing Class II evidence, and 98 providing Class III evidence for the various topics. Forty evidence-based recommendations were generated, 30 of which were strong and 10 of which were weak. In many cases, new evidence allowed guidelines from the 2nd edition to be strengthened. Development of guidelines on some new topics was possible including the prehospital administration of tranexamic acid. A management algorithm is also presented. These guidelines help to identify best practices for prehospital traumatic brain injury care, and they also identify gaps in knowledge which we hope will be addressed before the next edition.
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Affiliation(s)
- Gregory W. J. Hawryluk
- Neurological Institute, Cleveland Clinic, Akron General Hospital, Fairlawn, Ohio, USA
- Brain Trauma Foundation, Palo Alto, California, USA
| | - Al Lulla
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Randy Bell
- Uniformed Services University of Health Sciences, Avera Brain and Spine Institute, Sioux Falls, South Dakota, USA
| | - Andy Jagoda
- Department of Emergency Medicine, Mount Sinai, New York, New York, USA
| | - Halinder S. Mangat
- Brain Trauma Foundation, Palo Alto, California, USA
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Bentley J. Bobrow
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UT Health), Houston, Texas, USA
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Schenck HE, Joackim P, Lazaro A, Wu X, Gerber LM, Stieg PE, Härtl R, Shabani H, Mangat HS. Affordability impacts therapeutic intensity of acute management of severe traumatic brain injury patients: An exploratory study in Tanzania. Brain Spine 2023; 3:101738. [PMID: 37383438 PMCID: PMC10293321 DOI: 10.1016/j.bas.2023.101738] [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] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 06/30/2023]
Abstract
Introduction Quality health care in low and middle-income countries (LMICs) is constrained by financing of care. Research question What is the effect of ability to pay on critical care management of patients with severe traumatic brain injury (sTBI)? Material and Methods Data on sTBI patients admitted to a tertiary referral hospital in Dar-es-Salaam, Tanzania, were collected between 2016 and 2018, and included payor mechanisms for hospitalization costs. Patients were grouped as those who could afford care and those who were unable to pay. Results Sixty-seven patients with sTBI were included. Of those enrolled, 44 (65.7%) were able to pay and 15 (22.3%) were unable to pay costs of care upfront. Eight (11.9%) patients did not have a documented source of payment (unknown identity or excluded from further analysis). Overall mechanical ventilation rates were 81% (n=36) in the affordable group and 100% (n=15) in the unaffordable group (p=0.08). Computed tomography (CT) rates were 71.6% (n=48) overall, 100% (n=44) and 0% respectively (p<0.01); Surgical rates were 16.4% (n=11) overall, 18.2% (n=8) vs. 13.3% (n=2) (p=0.67) respectively. Two-week mortality was 59.7% overall (n=40), 47.7% (n=21) in the affordable group and 73.3% (n=11) in the unaffordable group (p=0.09) (adjusted OR 0.4; 95% CI: 0.07-2.41, p=0.32). Discussion and Conclusion Ability to pay appears to have a strong association with the use of head CT and a weak association with mechanical ventilation in the management of sTBI. Inability to pay increases redundant or sub-optimal care, and imposes a financial burden on patients and their relatives.
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Affiliation(s)
| | - Pascal Joackim
- Department of Neurosurgery, Muhimbili Orthopedic Institute, Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Albert Lazaro
- Department of Neurosurgery, Muhimbili Orthopedic Institute, Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Xian Wu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, USA
| | - Linda M. Gerber
- Department of Population Health Sciences, Weill Cornell Medicine, New York, USA
| | - Philip E. Stieg
- Department of Neurosurgery, Weill Cornell Brain & Spine Institute, USA
| | - Roger Härtl
- Department of Neurosurgery, Weill Cornell Brain & Spine Institute, USA
| | - Hamisi Shabani
- Department of Neurosurgery, Muhimbili Orthopedic Institute, Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Halinder S. Mangat
- Department of Neurosurgery, Weill Cornell Brain & Spine Institute, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
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Mangat HS, Rippon B, Reddy NT, Syed AA, Maruthanal JM, Luedtke S, Puthumana JJ, Srivatsa A, Bosman A, Kostkova P. Reported rates of all-cause serious adverse events following immunization with BNT-162b in 5-17-year-old children in the United States. PLoS One 2023; 18:e0281993. [PMID: 36800368 PMCID: PMC9937486 DOI: 10.1371/journal.pone.0281993] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
Vaccine development against COVID-19 has mitigated severe disease. However, reports of rare but serious adverse events following immunization (sAEFI) in the young populations are fuelling parental anxiety and vaccine hesitancy. With a very early season of viral illnesses including COVID-19, respiratory syncytial virus (RSV), influenza, metapneumovirus and several others, children are facing a winter with significant respiratory illness burdens. Yet, COVID-19 vaccine and booster uptake remain sluggish due to the mistaken beliefs that children have low rates of severe COVID-19 illness as well as rare but severe complications from COVID-19 vaccine are common. In this study we examined composite sAEFI reported in association with COVID-19 vaccines in the United States (US) amongst 5-17-year-old children, to ascertain the composite reported risk associated with vaccination. Between December 13, 2020, and April 13, 2022, a total of 467,890,599 COVID-19 vaccine doses were administered to individuals aged 5-65 years in the US, of which 180 million people received at least 2 doses. In association with these, a total of 177,679 AEFI were reported to the Vaccine Adverse Event reporting System (VAERS) of which 31,797 (17.9%) were serious. The rates of ED visits per 100,000 recipients were 2.56 (95% CI: 2.70-3.47) amongst 5-11-year-olds, 18.25 (17.57-18.95) amongst 12-17-year-olds and 33.74 (33.36-34.13) amongst 18-65-year olds; hospitalizations were 1.07 (95% CI 0.87-1.32) per 100,000 in 5-11-year-olds, 6.83 (6.42-7.26) in 12-17-year olds and 8.15 (7.96-8.35) in 18-65 years; life-threatening events were 0.14 (95% CI: 0.08-0.25) per 100,000 in 5-11-year olds, 1.22 (1.05-1.41) in 12-17-year-olds and 2.96 (2.85-3.08) in 18-65 year olds; and death 0.03 (95% CI 0.01-0.10) per 100,000 in 5-11 year olds, 0.08 (0.05-0.14) amongst 12-17-year olds and 0.76 (0.71-0.82) in 18-65 years age group. The results of our study from national population surveillance data demonstrate rates of reported serious AEFIs amongst 5-17-year-olds which appear to be significantly lower than in 18-65-year-olds. These low risks must be taken into account in overall recommendation of COVID-19 vaccination amongst children.
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Affiliation(s)
- Halinder S. Mangat
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, United States of America
- * E-mail:
| | - Brady Rippon
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, United States of America
| | - Nikita T. Reddy
- Department of Medical Sciences, Newcastle University, Great Britain, Newcastle upon Tyne, United Kingdom
| | - Akheel A. Syed
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Joel M. Maruthanal
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, United States of America
| | | | - Jyothy J. Puthumana
- Department of Cardiology, Northwestern Medicine, Chicago, Illinois, United States of America
| | - Abhinash Srivatsa
- Department of Pediatrics, Boston’s Children’s Hospital, Boston, Massachusetts, United States of America
| | - Arnold Bosman
- Transmissible BV, Public Health Learning Solutions, Utrecht, The Netherlands
| | - Patty Kostkova
- UCL Centre for Public Health in Emergencies (dPHE), University College London, London, United Kingdom
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LacKamp AN, Weber JM, Mac Grory B, Caye A, Stenuf C, Barkley T, Messe S, Alhanti B, Blanco RG, Fonarow GC, Xian Y, Mangat HS. Abstract TP116: Procoagulant Reversal Of Warfarin After Intracranial Hemorrhage Is Not Associated With Improved Functional Outcome When Coagulation Is Abnormal Without Full Anticoagulation. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Although the current guidelines recommend procoagulant reversal of elevated INR >= 2.0 (International Normalized Ratio) in patients with intracranial hemorrhage using warfarin, the benefit of procoagulant reversal is uncertain when patients have abnormal coagulation but are not fully anticoagulated.
Hypothesis:
For patients using warfarin (INR 1.5 to 1.9) who have intracranial hemorrhage the use of procoagulant reversal will improve functional outcome based upon dichotomized discharge mRS (modified Rankin scale) 0-3 vs 4-6.
Methods:
The Get With The Guidelines - Stroke registry was used to identify 239,681 patients with intracranial hemorrhage from hospitals using the comprehensive stroke center form between January 1, 2015 and January 4, 2022. Patients were excluded if they received thrombolytics, were using direct oral anticoagulants, if INR was not between 1.5 and 1.9, or if they were not using warfarin. To evaluate the association between procoagulant reversal and mRS at discharge, 1868 patients with non-missing mRS were analyzed for the primary outcome (mRS 0-3 vs. 4-6). Secondary outcomes that did not require mRS were analyzed among a possible 2569 patients. Propensity scores were estimated and overlap weighting was used to account for confounding. Logistic and negative binomial regression models were fit for binary and count variables, respectively.
Results:
There was an even distribution of patients into treatment and nontreatment (N=974 no reversal, N=894 reversal), and the groups were strikingly similar. Key outcomes are shown in the Table.
Conclusions:
Procoagulant reversal of warfarin for patients with acute intracranial hemorrhage and INR 1.5 - 1.9 was not associated with an improvement in functional outcome based upon mRS 0-3 vs 4-6. Patients that received a reversal agent had 25% lower odds of dying in the hospital or being discharged to hospice, but had a longer hospital stay and were less likely to be fully ambulatory at discharge.
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Affiliation(s)
- Aaron N LacKamp
- Anesthesiology and Neurology, The Univ of Kansas, Kansas City, KS
| | | | | | - Adrien Caye
- Sch of Medicine, The Univ of Kansas, Kansas City, KS
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Schenck HE, Mangat HS. Towards Improved Organizational Governance of Neurotrauma Surveillance Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries". Int J Health Policy Manag 2023; 12:7554. [PMID: 37579475 PMCID: PMC10125153 DOI: 10.34172/ijhpm.2022.7554] [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: 07/19/2022] [Accepted: 12/21/2022] [Indexed: 08/16/2023] Open
Abstract
Neurotrauma surveillance data on burden and severity of disease serves as a tool to define legislations, guide high-yield risk-specific prevention, and evaluate and monitor management strategies for adequate resource allocation. In this scoping review, Barthélemy and colleagues demonstrate the gap in neurotrauma surveillance in low- and middle-income countries (LMICs) and suggest strategies for governance in neurotrauma surveillance. We underline state accountability as well as the need for the close integration of academic and tertiary care clinical practitioners and policy-makers in addressing the public health crisis caused by neurotrauma. Additionally, multiple sources for surveillance must be included, especially in communities where victims may remain without access to formal healthcare. Finally, we offer insights into possible ways of increasing the visibility of neurotrauma on political agendas.
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Affiliation(s)
- Hanna E. Schenck
- School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Halinder S. Mangat
- Department of Neurology and Neurocritical Care, Kansas University Medical Center, Kansas City, KS, USA
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Leidinger A, Zuckerman SL, Feng Y, He Y, Chen X, Cheserem B, Gerber LM, Lessing NL, Shabani HK, Härtl R, Mangat HS. Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania. J Neurosurg Spine 2023; 38:503-511. [PMID: 36640104 DOI: 10.3171/2022.11.spine22763] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The burden of spinal trauma in low- and middle-income countries (LMICs) is immense, and its management is made complex in such resource-restricted settings. Algorithmic evidence-based management is cost-prohibitive, especially with respect to spinal implants, while perioperative care is work-intensive, making overall care dependent on multiple constraints. The objective of this study was to identify determinants of decision-making for surgical intervention, improvement in function, and in-hospital mortality among patients experiencing acute spinal trauma in resource-constrained settings. METHODS This study was a retrospective analysis of prospectively collected data in a cohort of patients with spinal trauma admitted to a tertiary referral hospital center in Dar es Salam, Tanzania. Data on demographic, clinical, and treatment characteristics were collected as part of a quality improvement neurotrauma registry. Outcome measures were surgical intervention, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement, and in-hospital mortality, based on existing treatment protocols. Univariate analyses of demographic and clinical characteristics were performed for each outcome of interest. Using the variables associated with each outcome, a machine learning algorithm-based regression nonparametric decision tree model utilizing a bootstrapping method was created and the accuracy of the three models was estimated. RESULTS Two hundred eighty-four consecutively admitted patients with acute spinal trauma were included over a period of 33 months. The median age was 34 (IQR 26-43) years, 83.8% were male, and 50.7% had experienced injury in a motor vehicle accident. The median time to hospital admission after injury was 2 (IQR 1-6) days; surgery was performed after a further median delay of 22 (IQR 13-39) days. Cervical spine injury comprised 38.4% of the injuries. Admission AIS grades were A in 48.9%, B in 16.2%, C in 8.5%, D in 9.5%, and E in 16.6%. Nearly half (45.1%) of the patients underwent surgery, 12% had at least one functional improvement in AIS grade, and 11.6% died in the hospital. Determinants of surgical intervention were age ≤ 30 years, spinal injury level, admission AIS grade, delay in arrival to the referral hospital, undergoing MRI, and type of insurance; admission AIS grade, delay to arrival to the hospital, and injury level for functional improvement; and delay to arrival, injury level, delay to surgery, and admission AIS grade for in-hospital mortality. The best accuracies for the decision tree models were 0.62, 0.34, and 0.93 for surgery, AIS grade improvement, and in-hospital mortality, respectively. CONCLUSIONS Operative intervention and functional improvement after acute spinal trauma in this tertiary referral hospital in an LMIC environment were low and inconsistent, which suggests that nonclinical factors exist within complex resource-driven decision-making frameworks. These nonclinical factors are highlighted by the authors' results showing clinical outcomes and in-hospital mortality were determined by natural history, as evidenced by the highest accuracy of the model predicting in-hospital mortality.
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Affiliation(s)
- Andreas Leidinger
- 1Department of Neurosurgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Scott L Zuckerman
- 2Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yueqi Feng
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | - Yitian He
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | - Xinrui Chen
- 3Biostatistics and Data Science, Cornell University, New York, New York
| | | | | | - Noah L Lessing
- 6School of Medicine, University of Maryland, Baltimore, Maryland
| | - Hamisi K Shabani
- 7Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania; and
| | - Roger Härtl
- 8Neurology and Neurological Surgery, Weill Cornell Medical College, New York, New York
| | - Halinder S Mangat
- 9Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center, Kansas City, Kansas
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Mangat HS, Musah A, Luedtke S, Syed AA, Maramattom BV, Maruthanal J, Bosman A, Kostkova P. Analyses of reported severe adverse events after immunization with SARS-CoV-2 vaccines in the United States: One year on. Front Public Health 2022; 10:972464. [PMID: 36311588 PMCID: PMC9610110 DOI: 10.3389/fpubh.2022.972464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/20/2022] [Indexed: 01/25/2023] Open
Abstract
Objective To analyze rates of reported severe adverse events after immunization (sAEFI) attributed to SARS-CoV-2 vaccines in the United States (US) using safety surveillance data. Methods Observational study of sAEFI reported to the vaccine adverse events reporting system (VAERS) between December 13, 2020, to December 13, 2021, and attributed to SARS-CoV-2 vaccination programs across all US states and territories. All sAEFI in conjunction with mRNA (BNT-162b2 or mRNA-1273) or adenovector (Ad26.COV2.S) vaccines were included. The 28-day crude cumulative rates for reported emergency department (ED) visits and sAEFI viz. hospitalizations, life-threatening events and deaths following SARS-CoV-2 vaccination were calculated. Incidence rate ratios (IRRs) of reported sAEFI were compared between mRNA and adenovector vaccines using generalized Poisson regression models. Results During the study period, 485 million SARS-CoV-2 vaccines doses were administered nationwide, and 88,626 sAEFI reported in VAERS. The 28-day crude cumulative reporting rates per 100,000 doses were 14.97 (95% confidence interval, 14.86-18.38) for ED visits, 5.32 (5.26-5.39) for hospitalizations, 1.72 (1.68-1.76) for life-threatening events, and 1.08 (1.05-1.11) for deaths. Females had two-fold rates for any reported AEFI compared to males, but lower adjusted IRRs for sAEFI. Cumulative rates per dose for reported sAEFI attributed to adenovector vaccine were 2-3-fold higher, and adjusted IRRs 1.5-fold higher than mRNA vaccines. Conclusions Overall cumulative rates for reported sAEFI following SARS-CoV-2 vaccination in the US over 1 year were very low; single-dose adenovector vaccine had 1.5-fold higher adjusted rates for reported sAEFI, which may however equate with multiple-doses mRNA vaccine regimens. These data indicate absence of high risks of sAEFI following SARS-CoV-2 vaccines and support safety equipoise between mRNA and adenovector vaccines. Public health messaging of these data is critical to overcome heuristic biases. Furthermore, these data may support ongoing adenovector vaccine use, especially in low- and middle-income countries due to affordability, logistical and cold chain challenges.
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Affiliation(s)
- Halinder S. Mangat
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States,*Correspondence: Halinder S. Mangat
| | - Anwar Musah
- UCL Centre for Public Health in Emergencies (dPHE), Institute for Risk & Disaster Reduction, Faculty of Mathematics & Physical Sciences, University College London, London, United Kingdom
| | - Susanne Luedtke
- Division of Infection Control, COVID-19 Management Group and Vaccine Implementation Team, Public Health Authority, Nuremberg, Germany
| | - Akheel A. Syed
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | | | - Joel Maruthanal
- Department of Neurology, Kansas University Medical Center, Kansas City, KS, United States
| | - Arnold Bosman
- Transmissible BV, Public Health Learning Solutions, Utrecht, Netherlands
| | - Patty Kostkova
- UCL Centre for Public Health in Emergencies (dPHE), Institute for Risk & Disaster Reduction, Faculty of Mathematics & Physical Sciences, University College London, London, United Kingdom
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Shammassian BH, Ronald A, Smith A, Sajatovic M, Mangat HS, Kelly ML. Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review. World Neurosurg 2022; 159:221-236.e4. [PMID: 34844010 DOI: 10.1016/j.wneu.2021.10.180] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage. METHODS A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH). RESULTS Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes. CONCLUSIONS Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.
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Affiliation(s)
- Berje H Shammassian
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
| | - Andrew Ronald
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arvin Smith
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Halinder S Mangat
- Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center Kansas City, Kansas, USA
| | - Michael L Kelly
- Metrohealth Medical Center, Department of Neurological Surgery, Cleveland, Ohio, USA
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10
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Lessing NL, Zuckerman SL, Lazaro A, Leech AA, Leidinger A, Rutabasibwa N, Shabani HK, Mangat HS, Härtl R. Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income Countries: A Preliminary Report From a Major East African Referral Center. Global Spine J 2022; 12:15-23. [PMID: 32799677 PMCID: PMC8965297 DOI: 10.1177/2192568220944888] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
STUDY DESIGN Retrospective cost-effectiveness analysis. OBJECTIVES While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting. METHODS At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. Cost/DALY averted was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life). RESULTS A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental cost/DALY averted for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences. CONCLUSIONS This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.
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Affiliation(s)
- Noah L. Lessing
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Scott L. Zuckerman
- Vanderbilt University Medical Center, Nashville, TN, USA,Weill Cornell Medicine, New York, NY, USA,Scott L. Zuckerman, Department of Neurological Surgery, Vanderbilt University Medical Center, Medical Center North T-4224, Nashville, TN 37212, USA.
| | - Albert Lazaro
- Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Ashley A. Leech
- Vanderbilt University School of Medicine, Nashville, TN, USA
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11
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Forgacs PB, Allen BB, Wu X, Gerber LM, Boddu S, Fakhar M, Stieg PE, Schiff ND, Mangat HS. Corticothalamic Connectivity in Aneurysmal Subarachnoid Hemorrhage: Relationship with Disordered Consciousness and Clinical Outcomes. Neurocrit Care 2021; 36:760-771. [PMID: 34669180 DOI: 10.1007/s12028-021-01354-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We present an exploratory analysis of the occurrence of early corticothalamic connectivity disruption after aneurysmal subarachnoid hemorrhage (SAH) and its correlation with clinical outcomes. METHODS We conducted a retrospective study of patients with acute SAH who underwent continuous electroencephalography (EEG) for impairment of consciousness. Only patients undergoing endovascular aneurysm treatment were included. Continuous EEG tracings were reviewed to obtain artifact-free segments. Power spectral analyses were performed, and segments were classified as A (only delta power), B (predominant delta and theta), C (predominant theta and beta), or D (predominant alpha and beta). Each incremental category from A to D implies greater preservation of corticothalamic connectivity. We dichotomized categories as AB for poor connectivity and CD for good connectivity. The modified Rankin Scale score at follow-up and in-hospital mortality were used as outcome measures. RESULTS Sixty-nine patients were included, of whom 58 had good quality EEG segments for classification: 28 were AB and 30 were CD. Hunt and Hess and World Federation of Neurological Surgeons grades were higher and the initial Glasgow Coma Scale score was lower in the AB group compared with the CD group. AB classification was associated with an adjusted odds ratio of 5.71 (95% confidence interval 1.61-20.30; p < 0.01) for poor outcome (modified Rankin Scale score 4-6) at a median follow-up of 4 months (interquartile range 2-6) and an odds ratio of 5.6 (95% confidence interval 0.98-31.95; p = 0.03) for in-hospital mortality, compared with CD. CONCLUSIONS EEG spectral-power-based classification demonstrates early corticothalamic connectivity disruption following aneurysmal SAH and may be a mechanism involved in early brain injury. Furthermore, the extent of this disruption appears to be associated with functional outcome and in-hospital mortality in patients with aneurysmal SAH and appears to be a potentially useful predictive tool that must be validated prospectively.
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Affiliation(s)
- Peter B Forgacs
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA
| | - Baxter B Allen
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA
| | - Xian Wu
- Department of Population Health Sciences, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Linda M Gerber
- Department of Population Health Sciences, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Srikanth Boddu
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Malik Fakhar
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA.,Department of Neurology, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA
| | - Nicholas D Schiff
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA
| | - Halinder S Mangat
- Department of Neurology, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, 525 E 68 Street, 610, New York, NY, 10065, USA. .,Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, NY, USA.
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12
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Maramattom BV, Krishnan P, Paul R, Padmanabhan S, Cherukudal Vishnu Nampoothiri S, Syed AA, Mangat HS. Guillain-Barré Syndrome following ChAdOx1-S/nCoV-19 Vaccine. Ann Neurol 2021; 90:312-314. [PMID: 34114256 DOI: 10.1002/ana.26143] [Citation(s) in RCA: 129] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/23/2021] [Accepted: 05/30/2021] [Indexed: 11/09/2022]
Abstract
As of April 22, 2021, around 1.5 million individuals in three districts of Kerala, India had been vaccinated with COVID-19 vaccines. Over 80% of these individuals (1.2 million) received the ChAdOx1-S/nCoV-19 vaccine. In this population, during this period of 4 weeks (mid-March to mid-April 2021), we observed seven cases of Guillain-Barre syndrome (GBS) that occurred within 2 weeks of the first dose of vaccination. All seven patients developed severe GBS. The frequency of GBS was 1.4- to 10-fold higher than that expected in this period for a population of this magnitude. In addition, the frequency of bilateral facial weakness, which typically occurs in <20% of GBS cases, suggests a pattern associated with the vaccination. While the benefits of vaccination substantially outweigh the risk of this relatively rare outcome (5.8 per million), clinicians should be alert to this possible adverse event, as six out of seven patients progressed to areflexic quadriplegia and required mechanical ventilatory support. ANN NEUROL 2021;90:312-314.
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Affiliation(s)
- Boby V Maramattom
- Department of Neurology, Aster Medcity, Kochi, India.,Department of Neurology, Indo-American Brain and Spine Center, Vaikom, India
| | | | - Reji Paul
- Department of Neurology, Aster Medcity, Kochi, India
| | | | | | - Akheel A Syed
- Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK
| | - Halinder S Mangat
- Department of Neurology, Division of Neurocritical Care, University of Kansas Medical Center, Kansas City, KS, USA
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13
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Mangat HS, Wu X, Gerber LM, Shabani HK, Lazaro A, Leidinger A, Santos MM, McClelland PH, Schenck H, Joackim P, Ngerageza JG, Schmidt F, Stieg PE, Hartl R. Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort. J Neurosurg 2021; 135:1190-1202. [PMID: 33482641 PMCID: PMC8295409 DOI: 10.3171/2020.8.jns201243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania. METHODS A neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model. RESULTS In total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model. CONCLUSIONS The 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.
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Affiliation(s)
- Halinder S. Mangat
- Department of Neurology, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Xian Wu
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Linda M. Gerber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Hamisi K. Shabani
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Albert Lazaro
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Andreas Leidinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Maria M. Santos
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Paul H. McClelland
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | | | - Pascal Joackim
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Japhet G. Ngerageza
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Franziska Schmidt
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Philip E. Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Roger Hartl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
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14
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Lessing NL, Mwesige S, Lazaro A, Cheserem JB, Zuckerman SL, Leidinger A, Rutabasibwa N, Shabani H, Mangat HS, Härtl R. Pressure Ulcers After Traumatic Spinal Injury in East Africa. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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15
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Lessing NL, Zuckerman SL, Lazaro A, Leech A, Leidinger A, Rutabasibwa N, Shabani H, Mangat HS, Härtl R. Cost-effectiveness of Operating on Traumatic Spinal Injuries in Low-middle Income Countries. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Mangat HS, Wu X, Gerber LM, Schwarz JT, Fakhar M, Murthy SB, Stieg PE, Ghajar J, Härtl R. Hypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury. Neurosurgery 2020; 86:221-230. [PMID: 30877299 DOI: 10.1093/neuros/nyz046] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 01/31/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously. OBJECTIVE To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI. METHODS We performed a case-control study using prospectively collected data from the New York State TBI-trac® database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (> 25 mm Hg) and CPPlow (< 60 mm Hg). RESULTS There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6 ± 0.8 vs 2.4 ± 2.3 d, P < .01), percentage of days with (8.8 ± 10.6 vs 28.1 ± 26.9%, P < .01), and the total duration of ICPhigh + CPPlow (11.12 ± 14.11 vs 30.56 ± 31.89 h, P = .01) were significantly lower. These results were replicated in the 1:2 match comparisons. CONCLUSION HTS bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.
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Affiliation(s)
- Halinder S Mangat
- Department of Neurology, Weill Cornell Medicine, New York, New York.,Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York
| | - Xian Wu
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Linda M Gerber
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Justin T Schwarz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York.,NewYork-Presbyterian Hospital, New York, New York
| | - Malik Fakhar
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Santosh B Murthy
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York
| | - Jamshid Ghajar
- Department of Neurological Surgery, Stanford University, Palo Alto, California.,Brain Trauma Foundation, New York, New York
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, Weill Cornell Medicine, New York, New York
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17
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Valand HA, Goyal A, Melendez DA, Matharu SS, Mangat HS, Tu RK. Lyme Disease: What the Neuroradiologist Needs to Know. AJNR Am J Neuroradiol 2019; 40:1998-2000. [PMID: 31672835 DOI: 10.3174/ajnr.a6301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 11/07/2022]
Abstract
Lyme disease is the most common tick-borne disease in Canada and the United States, caused by Borrelia burgdorferi, which affects multiple organ systems. Epidemiology, clinical presentation, and neuroimaging findings are reviewed.
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Affiliation(s)
- H A Valand
- From the American University of Integrative Sciences (H.A.V.), Brampton, Ontario, Canada
| | - A Goyal
- George Washington University (A.G., D.A.M.), Washington, DC
| | - D A Melendez
- George Washington University (A.G., D.A.M.), Washington, DC
| | - S S Matharu
- The Fischell Department of Bioengineering (S.S.M.), University of Maryland College Park, College Park, Maryland
| | - H S Mangat
- Germantown Medical Center (H.S.M.), Germantown, Maryland
| | - R K Tu
- Progressive Radiology (R.K.T.), George Washington University, United Medical Center, Washington, DC.
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18
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Allen BB, Forgacs PB, Fakhar MA, Wu X, Gerber LM, Boddu S, Murthy SB, Stieg PE, Mangat HS. Association of Seizure Occurrence with Aneurysm Treatment Modality in Aneurysmal Subarachnoid Hemorrhage Patients. Neurocrit Care 2019; 29:62-68. [PMID: 29484583 DOI: 10.1007/s12028-018-0506-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Data on new-onset seizures after treatment of aneurysmal subarachnoid hemorrhage (aSAH) patients are limited and variable. We examined the association between new-onset seizures after aSAH and aneurysm treatment modality, as well their relationship with initial clinical severity of aSAH and outcomes. METHODS This is a retrospective cohort study of all aSAH patients admitted to our institution over a 6-year period. 'Seizures' were defined as any observed clinical seizure or electrographic seizure on continuous electroencephalogram (cEEG) recordings, as determined by the reviewing neurophysiologist. Subgroup analyses were performed in low-grade (Hunt-Hess 1-3) and high-grade (Hunt-Hess 4-5) patients. Outcomes measures were Glasgow Coma Score (GCS) at intensive care unit (ICU) discharge and modified Rankin Scale (mRS) at outpatient follow-up. RESULTS There were 282 patients with aSAH; 203 (72.0%) suffered low-grade and 79 (28%) high-grade aSAH. Patients were treated with endovascular coiling (N = 194, 68.8%) or surgical clipping (N = 66, 23.4%). Eighteen (6.4%) patients had seizures, of whom 10 (5.5%) had aneurysm coiling and 7 (10.6%) underwent clipping (p = 0.15). In low-grade patients, seizures occurred less frequently (p = 0.016) and were more common after surgical clipping (p = 0.0089). Seizures correlated with lower GCS upon ICU discharge (p < 0.001), in clipped (p = 0.011) and coiled (p < 0.001) patients and in low-grade aSAH (p < 0.001). Seizures correlated with higher mRS on follow-up (p < 0.001), in clipped (p = 0.032) and coiled (p = 0.004) patients and in low-grade aSAH (p = 0.003). CONCLUSIONS New-onset seizures after aSAH occurred infrequently, and their incidence after aneurysm clipping versus coiling was not significantly different. However, in low-grade patients, new seizures were more frequently associated with clipping than coiling. Additionally, non-convulsive seizures did not occur in low-grade patients treated with coiling. These findings may explain, in part, previous work suggesting better outcomes in coiled patients and encourage physicians to have a lower threshold for cEEG utilization in low-grade patients suspected to have acute seizures after surgical clipping.
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Affiliation(s)
- Baxter B Allen
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,Department of Neurology, Weill Cornell Medicine, 525 East 68 Street, F-610, New York, NY, 10065, USA
| | - Peter B Forgacs
- Department of Neurology, Weill Cornell Medicine, 525 East 68 Street, F-610, New York, NY, 10065, USA.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.,The Rockefeller University, New York, NY, USA
| | - Malik A Fakhar
- Department of Neurology, Weill Cornell Medicine, 525 East 68 Street, F-610, New York, NY, 10065, USA.,Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Xian Wu
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Linda M Gerber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Srikanth Boddu
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
| | - Santosh B Murthy
- Department of Neurology, Weill Cornell Medicine, 525 East 68 Street, F-610, New York, NY, 10065, USA.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
| | - Halinder S Mangat
- Department of Neurology, Weill Cornell Medicine, 525 East 68 Street, F-610, New York, NY, 10065, USA. .,Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA.
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Santillan A, Mangat HS, Patsalides A. Isolated straight sinus thrombosis. J Clin Neurosci 2019. [DOI: 10.1016/j.jocn.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Aziz R, Colombe S, Mwakisambwe G, Ndezi S, Todd J, Kalluvya S, Mangat HS, Magleby R, Koebler A, Kenemo B, Peck RN, Downs JA. Pre-post effects of a tetanus care protocol implementation in a sub-Saharan African intensive care unit. PLoS Negl Trop Dis 2018; 12:e0006667. [PMID: 30161119 PMCID: PMC6116918 DOI: 10.1371/journal.pntd.0006667] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 03/14/2018] [Accepted: 07/09/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Tetanus is a vaccine-preventable, neglected disease that is life threatening if acquired and occurs most frequently in regions where vaccination coverage is incomplete. Challenges in vaccination coverage contribute to the occurrence of non-neonatal tetanus in sub-Saharan countries, with high case fatality rates. The current WHO recommendations for the management of tetanus include close patient monitoring, administration of immune globulin, sedation, analgesia, wound hygiene and airway support [1]. In response to these recommendations, our tertiary referral hospital in Tanzania implemented a standardized clinical protocol for care of patients with tetanus in 2006 and a subsequent modification in 2012. In this study we aimed to assess the impact of the protocol on clinical care of tetanus patients and their outcomes. METHODS AND FINDINGS We examined provision of care and outcomes among all patients admitted with non-neonatal tetanus to the ICU at Bugando Medical Centre between 2001 and 2016 in this retrospective cohort study. We compared three groups: the pre-protocol group (2001-2005), the Early protocol group (2006-2011), and the Late protocol group (2012-2016) and determined associations with mortality by univariable logistic regression. We observed a significant increase in provision of care as per protocol between the Early and Late groups. Patients in the Late group had a significantly higher utilization of mechanical ventilation (69.9% vs 22.0%, p< 0.0001), provision of surgical wound care (39.8% vs 20.3%, p = 0.011), and performance of tracheostomies (36.8% vs 6.7%, <0.0001) than patients in the Early group. Despite the increased provision of care, we found no significant decrease in overall mortality in the Early versus the Late groups (55.4% versus 40.3%, p = 0.069), or between the pre-protocol and post-protocol groups (60.7% versus 50.0%, p = 0.28). There was also no difference in 7-day ICU mortality (30.1% versus 27.8%, p = 0.70). Analysis of the causes of death revealed a decrease in deaths related to airway compromise (30.0% to 1.8%, p<0.001) but an increase in deaths due to presumed sepsis (15.0% to 44.6%, p = 0.018). CONCLUSION The overall mortality in patients suffering non-neonatal tetanus is high (>40%). Institution of a standardized tetanus management protocol, in accordance with WHO recommendations, decreased immediate mortality related to primary causes of death after tetanus. However, this was offset by an increase in death due to later ICU complications such as sepsis. Our results illustrate the complexity in achieving mortality reduction even in illnesses thought to require few critical care interventions. Improving basic ICU care and strengthening vaccination programs to prevent tetanus altogether are essential components of efforts to decrease the mortality caused by this lethal, neglected disease.
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Affiliation(s)
- Riaz Aziz
- Intensive Care Department, Bugando Medical Centre, Mwanza, Tanzania
- * E-mail:
| | - Soledad Colombe
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY, United States of America
| | | | - Solomon Ndezi
- Intensive Care Department, Bugando Medical Centre, Mwanza, Tanzania
| | - Jim Todd
- Department of Applied Biostatistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Samuel Kalluvya
- Department of Medicine, Bugando Medical Centre, Mwanza, Tanzania
| | - Halinder S. Mangat
- Department of Neurology, New York-Presbyterian Hospital/Weill Cornell Medical Centre, New York, NY, United States of America
| | - Reed Magleby
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY, United States of America
| | | | - Bernard Kenemo
- Intensive Care Department, Bugando Medical Centre, Mwanza, Tanzania
| | - Robert N. Peck
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY, United States of America
- Department of Medicine, Bugando Medical Centre, Mwanza, Tanzania
| | - Jennifer A. Downs
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY, United States of America
- Department of Medicine, Bugando Medical Centre, Mwanza, Tanzania
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21
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Mangat HS, Schöller K, Budohoski KP, Ngerageza JG, Qureshi M, Santos MM, Shabani HK, Zubkov MR, Härtl R, Stieg PE. Neurosurgery in East Africa: Foundations. World Neurosurg 2018; 113:411-424. [PMID: 29702965 DOI: 10.1016/j.wneu.2018.01.086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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] [Indexed: 11/19/2022]
Abstract
This article is the first in a series of 3 articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). We review the history and evolution of neurosurgery as a clinical specialty in East Africa. We also review Kenya, Uganda, and Tanzania in some detail and highlight contributions of individuals and local and regional organizations that helped to develop and shape neurosurgical care in East Africa. Neurosurgery has developed steadily as advanced techniques have been adopted by local surgeons who trained abroad, and foreign surgeons who have dedicated part of their careers in local hospitals. New medical schools and surgical training programs have been established through regional and international partnerships, and the era of regional specialty surgical training has just begun. As more surgical specialists complete training, a comprehensive estimation of disease burden facing the neurosurgical field is important. We present an overview with specific reference to neurotrauma and neural tube defects, both of which are of epidemiologic importance as they gain not only greater recognition, but increased diagnoses and demands for treatment. Neurosurgery in East Africa is poised to blossom as it seeks to address the growing needs of a growing subspecialty.
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Affiliation(s)
- Halinder S Mangat
- Department of Neurology, Division of Stroke and Critical Care, Weill Cornell Medicine, New York, New York, USA.
| | - Karsten Schöller
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Karol P Budohoski
- Department of Neurosurgery, Addenbrookes Hospital, University of Cambridge, United Kingdom
| | - Japhet G Ngerageza
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Mahmood Qureshi
- Department of Neurosurgery, Aga Khan University Hospital, Nairobi, Kenya
| | - Maria M Santos
- The Center for Global Health, Weill Cornell Medicine, New York, New York, USA; Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Micaella R Zubkov
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Philip E Stieg
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
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22
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Santos MM, Qureshi MM, Budohoski KP, Mangat HS, Ngerageza JG, Schöller K, Shabani HK, Zubkov MR, Härtl R. The Growth of Neurosurgery in East Africa: Challenges. World Neurosurg 2018; 113:425-435. [PMID: 29702966 DOI: 10.1016/j.wneu.2018.01.084] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/27/2022]
Abstract
As the second of 3 articles in this series, the aim of this article is to provide readers with an understanding of the development of neurosurgery in East Africa (foundations), the challenges that arise in providing neurosurgical care in developing countries (challenges), and an overview of traditional and novel approaches to overcoming these challenges and improving health care in the region (innovations). Recognizing the challenges that need to be addressed is the first step to implementing efficient and qualified surgery delivery systems in low- and middle-income countries. We reviewed the major challenges facing health care in East Africa and grouped them into 5 categories: 1) burden of surgical disease and workforce crisis; 2) global health view of surgery as "the neglected stepchild"; 3) need for recognizing the surgical system as an interdependent network and importance of organizational and equipment deficits; 4) lack of education in the community, failure of primary care systems, and net result of overwhelming tertiary care systems; 5) personal and professional burnout as well as brain drain of promising human resources from low- and middle-income countries in East Africa and similar regions across the world. Each major challenge was detailed and analyzed by authors who have worked or are currently working in the region, providing a personal perspective.
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Affiliation(s)
- Maria M Santos
- Center for Global Health, Weill Cornell Medicine, New York, New York, USA; Department of Neurosurgery, Muhimbili Orthopedic/Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Mubashir M Qureshi
- Department of Neurosurgery, Aga Khan University Hospital, Nairobi, Kenya
| | - Karol P Budohoski
- Department of Neurosurgery, Addenbrookes Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Halinder S Mangat
- Division of Stroke and Critical Care, Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Japhet G Ngerageza
- Department of Neurosurgery, Muhimbili Orthopedic/Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Karsten Schöller
- Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic/Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Micaella R Zubkov
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA.
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23
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Budohoski KP, Ngerageza JG, Austard B, Fuller A, Galler R, Haglund M, Lett R, Lieberman IH, Mangat HS, March K, Olouch-Olunya D, Piquer J, Qureshi M, Santos MM, Schöller K, Shabani HK, Trivedi RA, Young P, Zubkov MR, Härtl R, Stieg PE. Neurosurgery in East Africa: Innovations. World Neurosurg 2018; 113:436-452. [PMID: 29702967 DOI: 10.1016/j.wneu.2018.01.085] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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] [Indexed: 11/18/2022]
Abstract
In the last 10 years, considerable work has been done to promote and improve neurosurgical care in East Africa with the development of national training programs, expansion of hospitals and creation of new institutions, and the foundation of epidemiologic and cost-effectiveness research. Many of the results have been accomplished through collaboration with partners from abroad. This article is the third in a series of articles that seek to provide readers with an understanding of the development of neurosurgery in East Africa (Foundations), the challenges that arise in providing neurosurgical care in developing countries (Challenges), and an overview of traditional and novel approaches to overcoming these challenges to improve healthcare in the region (Innovations). In this article, we describe the ongoing programs active in East Africa and their current priorities, and we outline lessons learned and what is required to create self-sustained neurosurgical service.
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Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, United Kingdom
| | - Japhet G Ngerageza
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Benedict Austard
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Anthony Fuller
- Duke Global Neurosurgery and Neuroscience, Duke University, Durham, North Carolina, USA
| | - Robert Galler
- Department of Neurosurgery, Stony Brook Neuroscience Institute, New York, New York, USA
| | - Michael Haglund
- Duke Global Neurosurgery and Neuroscience, Duke University, Durham, North Carolina, USA
| | - Ronald Lett
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | | | - Halinder S Mangat
- Division of Stroke and Critical Care, Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Karen March
- University of Washington School of Nursing, Seattle, Washington, USA
| | - David Olouch-Olunya
- Department of Neurosurgery, Kenyatta Hospital, University of Nairobi, Nairobi, Kenya
| | - José Piquer
- Neurosurgical Unit, Hospital Universitario de la Ribera, Valencia, Spain
| | - Mahmood Qureshi
- Department of Neurosurgery, Aga Khan University Hospital, Nairobi, Kenya
| | - Maria M Santos
- Global Health, Weill Cornell Medicine, New York, New York, USA
| | - Karsten Schöller
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Rikin A Trivedi
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, United Kingdom
| | - Paul Young
- Department of Neurosurgery, University of St. Louis, St. Louis, Missouri, USA
| | - Micaella R Zubkov
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill-Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill-Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA.
| | - Philip E Stieg
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill-Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
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24
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Mangat HS. Hypertonic saline infusion for treating intracranial hypertension after severe traumatic brain injury. Crit Care 2018; 22:37. [PMID: 29463291 PMCID: PMC5820788 DOI: 10.1186/s13054-018-1963-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/24/2018] [Indexed: 12/21/2022]
Abstract
Traumatic brain injury (TBI) remains a major cause of mortality and disability. Post-traumatic intracranial hypertension (ICH) further complicates the care of patients. Hyperosmolar agents are recommended for the treatment of ICH, but no consensus or high-level data exist on the use of any particular agent or the route of administration. The two agents used commonly are hypertonic saline (HTS) and mannitol given as bolus therapy. Smaller studies suggest that HTS may be a superior agent in reducing the ICH burden, but neither agent has been shown to improve mortality or functional outcome. In a recently published analysis of pooled data from three prospective clinical trials, continuous infusion of HTS correlated with serum hypernatremia and reduced ICH burden in addition to improving 90-day mortality and functional outcome. This lays the foundation for the upcoming continuous hyperosmolar therapy for traumatic brain-injured patients (COBI) randomized controlled trial to study the outcome benefit of continuous HTS infusion to treat ICH after severe TBI. This is much anticipated and will be a high impact trial should the results be replicated. However, this would still leave a question over the use of mannitol bolus therapy which will need to be studied.
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Affiliation(s)
- Halinder S Mangat
- Department of Neurology & Neurological Surgery, Cornell University Joan and Sanford I Weill Medical College, 525 East 68 street, F-610, New York, NY, 10065, USA.
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25
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Murthy SB, Moradiya Y, Shah J, Merkler AE, Mangat HS, Iadacola C, Hanley DF, Kamel H, Ziai WC. Nosocomial Infections and Outcomes after Intracerebral Hemorrhage: A Population-Based Study. Neurocrit Care 2017; 25:178-84. [PMID: 27350549 DOI: 10.1007/s12028-016-0282-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infections after intracerebral hemorrhage (ICH) may be associated with worse outcomes. We aimed to evaluate the association between nosocomial infections (>48 h) and outcomes of ICH at a population level. METHODS We identified patients with ICH using ICD-9-CM codes in the 2002-2011 Nationwide Inpatient Sample. Demographics, comorbidities, surgical procedures, and hospital characteristics were compared between patients with and without concomitant nosocomial infections. Primary outcomes were in-hospital mortality and home discharge. Secondary outcome was permanent cerebrospinal shunt placement. Logistic regression analyses were used to analyze the association between infections and outcomes. RESULTS Among 509,516 ICH patients, infections occurred in 117,636 (23.1 %). Rates of infections gradually increased from 18.7 % in 2002-2003 to 24.1 % in 2010-2011. Pneumonia was the most common nosocomial infection (15.4 %) followed by urinary tract infection (UTI) (7.9 %). Patients with infections were older (p < 0.001), predominantly female (56.9 % vs. 47.9 %, p < 0.001), and more often black (15.0 % vs. 13.4 %, p < 0.001). Nosocomial infection was associated with longer hospital stay (11 vs. 5 days, p < 0.001) and a more than twofold higher cost of care (p < 0.001). In the adjusted regression analysis, patients with infection had higher odds of mortality [odds ratio (OR) 2.11, 95 % CI 2.08-2.14] and cerebrospinal shunt placement (OR 2.19, 95 % CI 2.06-2.33) and lower odds of home discharge (OR 0.49, 95 % CI 0.47-0.51). Similar results were observed in subgroup analyses of individual infections. CONCLUSIONS In a nationally representative cohort of ICH patients, nosocomial infection was associated with worse outcomes and greater resource utilization.
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Affiliation(s)
- Santosh B Murthy
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA. .,Clinical and Translational Neuroscience Unit, Feil Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.
| | - Yogesh Moradiya
- Department of Neurosurgery, Northwell Long Island Jewish School of Medicine, New York, NY, USA
| | - Jharna Shah
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander E Merkler
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA
| | - Halinder S Mangat
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA
| | - Costantino Iadacola
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA.,Clinical and Translational Neuroscience Unit, Feil Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hooman Kamel
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College, 525 E 68th Street, New York, NY, 10065, USA.,Clinical and Translational Neuroscience Unit, Feil Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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26
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Smart LR, Mangat HS, Issarow B, McClelland P, Mayaya G, Kanumba E, Gerber LM, Wu X, Peck RN, Ngayomela I, Fakhar M, Stieg PE, Härtl R. Severe Traumatic Brain Injury at a Tertiary Referral Center in Tanzania: Epidemiology and Adherence to Brain Trauma Foundation Guidelines. World Neurosurg 2017; 105:238-248. [PMID: 28559070 PMCID: PMC5575962 DOI: 10.1016/j.wneu.2017.05.101] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 03/07/2017] [Revised: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Severe traumatic brain injury (TBI) is a major cause of death and disability worldwide. Prospective TBI data from sub-Saharan Africa are sparse. This study examines epidemiology and explores management of patients with severe TBI and adherence to Brain Trauma Foundation Guidelines at a tertiary care referral hospital in Tanzania. METHODS Patients with severe TBI hospitalized at Bugando Medical Centre were recorded in a prospective registry including epidemiologic, clinical, treatment, and outcome data. RESULTS Between September 2013 and October 2015, 371 patients with TBI were admitted; 33% (115/371) had severe TBI. Mean age was 32.0 years ± 20.1, and most patients were male (80.0%). Vehicular injuries were the most common cause of injury (65.2%). Approximately half of the patients (47.8%) were hospitalized on the day of injury. Computed tomography of the brain was performed in 49.6% of patients, and 58.3% were admitted to the intensive care unit. Continuous arterial blood pressure monitoring and intracranial pressure monitoring were not performed in any patient. Of patients with severe TBI, 38.3% received hyperosmolar therapy, and 35.7% underwent craniotomy. The 2-week mortality was 34.8%. CONCLUSIONS Mortality of patients with severe TBI at Bugando Medical Centre, Tanzania, is approximately twice that in high-income countries. Intensive care unit care, computed tomography imaging, and continuous arterial blood pressure and intracranial pressure monitoring are underused or unavailable in the tertiary referral hospital setting. Improving outcomes after severe TBI will require concerted investment in prehospital care and improvement in availability of intensive care unit resources, computed tomography, and expertise in multidisciplinary care.
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Affiliation(s)
- Luke R Smart
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania; Center for Global Health, Weill Cornell Medicine, New York, New York, USA
| | - Halinder S Mangat
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA; Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA.
| | | | - Paul McClelland
- Center for Global Health, Weill Cornell Medicine, New York, New York, USA
| | - Gerald Mayaya
- Department of Neurosurgery, Bugando Medical Centre, Mwanza, Tanzania
| | - Emmanuel Kanumba
- Department of Neurosurgery, Bugando Medical Centre, Mwanza, Tanzania
| | - Linda M Gerber
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York, USA
| | - Xian Wu
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York, USA
| | - Robert N Peck
- Department of Internal Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania; Center for Global Health, Weill Cornell Medicine, New York, New York, USA
| | - Isidore Ngayomela
- Department of Orthopedic Surgery, Bugando Medical Centre, Mwanza, Tanzania
| | - Malik Fakhar
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Philip E Stieg
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
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27
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Gusdon AM, Gialdini G, Kone G, Baradaran H, Merkler AE, Mangat HS, Navi BB, Iadecola C, Gupta A, Kamel H, Murthy SB. Neutrophil-Lymphocyte Ratio and Perihematomal Edema Growth in Intracerebral Hemorrhage. Stroke 2017; 48:2589-2592. [PMID: 28698256 DOI: 10.1161/strokeaha.117.018120] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/05/2017] [Accepted: 06/21/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although preclinical studies have shown inflammation to mediate perihematomal edema (PHE) after intracerebral hemorrhage, clinical data are lacking. Leukocyte count, often used to gauge serum inflammation, has been correlated with poor outcome but its relationship with PHE remains unknown. Our aim was to test the hypothesis that leukocyte count is associated with PHE growth. METHODS We included patients with intracerebral hemorrhage admitted to a tertiary-care stroke center between 2011 and 2015. The primary outcome was absolute PHE growth during 24 hours, calculated using semiautomated planimetry. Linear regression models were constructed to study the relationship between absolute and differential leukocyte counts (monocyte count and neutrophil-lymphocyte ratio) and 24-hour PHE growth. RESULTS A total of 153 patients were included. Median hematoma and PHE volumes at baseline were 14.4 (interquartile range, 6.3-36.3) and 14.0 (interquartile range, 5.9-27.8), respectively. In linear regression analysis adjusted for demographics and intracerebral hemorrhage characteristics, absolute leukocyte count was not associated with PHE growth (β, 0.07; standard error, 0.15; P=0.09). In secondary analyses, neutrophil-lymphocyte ratio was correlated with PHE growth (β, 0.22; standard error, 0.08; P=0.005). CONCLUSIONS Higher neutrophil-lymphocyte ratio is independently associated with PHE growth. This suggests that PHE growth can be predicted using differential leukocyte counts on admission.
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Affiliation(s)
- Aaron M Gusdon
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Gino Gialdini
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Gbambele Kone
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Hediyeh Baradaran
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Alexander E Merkler
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Halinder S Mangat
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Babak B Navi
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Costantino Iadecola
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Ajay Gupta
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Hooman Kamel
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.)
| | - Santosh B Murthy
- From the Department of Neurology, Weill Cornell Medicine, New York (A.M.G., A.E.M., H.S.M., B.B.N., C.I., H.K., S.B.M.); Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York (A.M.G., G.G., G.K., A.E.M., B.B.N., C.I., A.G., H.K., S.B.M.); and Department of Radiology, Weill Cornell Medicine, New York (H.B., A.G.).
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Murthy SB, Merkler AE, Omran SS, Gialdini G, Gusdon A, Hartley B, Roh D, Mangat HS, Iadecola C, Navi BB, Kamel H. Outcomes after intracerebral hemorrhage from arteriovenous malformations. Neurology 2017; 88:1882-1888. [PMID: 28424275 DOI: 10.1212/wnl.0000000000003935] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare outcomes after intracerebral hemorrhage (ICH) from cerebral arteriovenous malformation (AVM) rupture and other causes of ICH. METHODS We performed a retrospective population-based study using data from the Nationwide Inpatient Sample. We used standard diagnosis codes to identify ICH cases from 2002 to 2011. Our predictor variable was cerebral AVM. Our primary outcomes were inpatient mortality and home discharge. We used logistic regression to compare outcomes between patients with ICH with and without AVM while adjusting for demographics, comorbidities, and hospital characteristics. In a confirmatory analysis using a prospective cohort of patients hospitalized with ICH at our institution, we additionally adjusted for hematoma characteristics and the Glasgow Coma Scale score. RESULTS Among 619,167 ICH hospitalizations, the 4,485 patients (0.7%, 95% confidence interval [CI] 0.6-0.8) with an AVM were younger and had fewer medical comorbidities than patients without AVM. After adjustment for confounders, patients with AVM had lower odds of death (odds ratio [OR] 0.5, 95% CI 0.4-0.7) and higher odds of home discharge (OR 2.0, 95% CI 1.4-3.0) than patients without AVM. In a confirmatory analysis of 342 patients with ICH at our institution, the 34 patients (9.9%, 95% CI 7.2-13.6) with a ruptured AVM had higher odds of ambulatory independence at discharge (OR 4.4, 95% CI 1.4-13.1) compared to patients without AVM. CONCLUSIONS Patients with ICH due to ruptured AVM have more favorable outcomes than patients with ICH from other causes.
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Affiliation(s)
- Santosh B Murthy
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY.
| | - Alexander E Merkler
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Setareh Salehi Omran
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Gino Gialdini
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Aaron Gusdon
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Benjamin Hartley
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - David Roh
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Halinder S Mangat
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Costantino Iadecola
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Babak B Navi
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Hooman Kamel
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
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Mangat HS, Ivanidze J, Mao X, Shungu D, Fakhar M, Gupta A, Stieg PE. Abstract 191: Selective Frontal Lobe Metabolic Dysfunction After Sub-arachnoid Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aneurysmal SAH results in high morbidity. Patients who make a good neurological recovery report significant neuropsychological impairment such as loss of motivation, interests, and concentration, all of which are commonly associated with frontal lobe dysfunction. We hypothesize that subclinical frontal lobe injury occurs in neurologically intact SAH patients and may be identified by measuring brain energy metabolism using regional N-acetyl aspartate (NAA) as an imaging marker of neuronal integrity and mitochondrial function, and CSF lactate, as a marker of anaerobic metabolism. We utilized MR Spectroscopy (MRS) to measure regional NAA in SAH patients who had suffered neither cerebral infarction nor neurological deficits. Only patients who underwent endovascular aneurysm coiling were included. Measurements were made in frontal, temporal, occipital lobes, lateral ventricles, and averaged in each hemisphere from 3 slices. Matching ROIs were placed on the most proximate CT perfusion maps to measure corresponding rCBF. MR spectra were compared to controls from our data library (7 subjects) and to rCBF. Average age was 58 years, Hunt Hess score was 2.43±1.09, modified Fisher score was 2.79±1.05. 3 patients had DCI and none had cerebral infarction. Median GCS at discharge was 15. MRS was done at 9.93±7.73 days from admission. 1 patient had no MRS data, 3 patients had no CT perfusion. SAH patients demonstrated significantly reduced NAA/RMS in frontal lobes (16.18±4.96 vs. 20.93±5.56, p=0.042) but not in temporal (16.49±4.37 vs. 19.37±4.38, p=0.09) or occipital lobes (20.62±4.50 vs. 21.05±4.23, p=0.41). CSF lactate was significantly higher in SAH patients (7.74±2.27 vs. 4.02±0.76, p=0.001). NAA/RMS did not correlate with CBF in pooled data (R
2
=0.02, p=0.40) or in frontal lobe rCBF (R
2
=0.001, p=0.92); nor with CSF lactate (R
2
=0.02, p=0.53). Total frontal lobe NAA is selectively reduced and CSF lactate is elevated in neurologically intact survivors after SAH. This preliminary data is suggestive of energy depletion and subclinical brain injury, which appears to be independent of cerebral blood flow. In addition to validating this pilot data, we will study the association with cognitive impairment in these patients.
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Affiliation(s)
| | | | | | | | | | - Ajay Gupta
- Radiology, Weill Cornell Medicine, New York, NY
| | - Philip E Stieg
- Neurological Surgery, Weill Cornell Medicine, New York, NY
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Grinspan ZM, Eldar YC, Gopher D, Gottlieb A, Lammfromm R, Mangat HS, Peleg N, Pon S, Rozenberg I, Schiff ND, Stark DE, Yan P, Pratt H, Kosofsky BE. Guiding Principles for a Pediatric Neurology ICU (neuroPICU) Bedside Multimodal Monitor: Findings from an International Working Group. Appl Clin Inform 2016; 7:380-98. [PMID: 27437048 DOI: 10.4338/aci-2015-12-ra-0177] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/29/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Physicians caring for children with serious acute neurologic disease must process overwhelming amounts of physiological and medical information. Strategies to optimize real time display of this information are understudied. OBJECTIVES Our goal was to engage clinical and engineering experts to develop guiding principles for creating a pediatric neurology intensive care unit (neuroPICU) monitor that integrates and displays data from multiple sources in an intuitive and informative manner. METHODS To accomplish this goal, an international group of physicians and engineers communicated regularly for one year. We integrated findings from clinical observations, interviews, a survey, signal processing, and visualization exercises to develop a concept for a neuroPICU display. RESULTS Key conclusions from our efforts include: (1) A neuroPICU display should support (a) rapid review of retrospective time series (i.e. cardiac, pulmonary, and neurologic physiology data), (b) rapidly modifiable formats for viewing that data according to the specialty of the reviewer, and (c) communication of the degree of risk of clinical decline. (2) Specialized visualizations of physiologic parameters can highlight abnormalities in multivariable temporal data. Examples include 3-D stacked spider plots and color coded time series plots. (3) Visual summaries of EEG with spectral tools (i.e. hemispheric asymmetry and median power) can highlight seizures via patient-specific "fingerprints." (4) Intuitive displays should emphasize subsets of physiology and processed EEG data to provide a rapid gestalt of the current status and medical stability of a patient. CONCLUSIONS A well-designed neuroPICU display must present multiple datasets in dynamic, flexible, and informative views to accommodate clinicians from multiple disciplines in a variety of clinical scenarios.
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Affiliation(s)
- Zachary M Grinspan
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY; Department of Pediatrics, Weill Cornell Medicine, New York, NY; New York-Presbyterian Hospital, New York, NY
| | - Yonina C Eldar
- Faculty of Electrical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Daniel Gopher
- Faculty of Industrial Engineering and Management, Technion Israel Institute of Technology , Haifa, Israel
| | - Amihai Gottlieb
- Faculty of Industrial Engineering and Management, Technion Israel Institute of Technology , Haifa, Israel
| | - Rotem Lammfromm
- Faculty of Industrial Engineering and Management, Technion Israel Institute of Technology , Haifa, Israel
| | - Halinder S Mangat
- New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Nimrod Peleg
- Faculty of Electrical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Steven Pon
- Department of Pediatrics, Weill Cornell Medicine, New York, NY; New York-Presbyterian Hospital, New York, NY
| | - Igal Rozenberg
- Faculty of Electrical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Nicholas D Schiff
- New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY; Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY
| | - David E Stark
- Departments of Medicine and Bioengineering, Stanford University , Stanford, CA
| | - Peter Yan
- New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Hillel Pratt
- Faculties of Medicine and Biomedical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Barry E Kosofsky
- Department of Pediatrics, Weill Cornell Medicine, New York, NY; New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY; Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY
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Murthy SB, Shah J, Mangat HS, Stieg P. Treatment of Intracranial Aneurysms With Pipeline Embolization Device: Newer Applications and Technical Advances. Curr Treat Options Neurol 2016; 18:16. [PMID: 26923606 DOI: 10.1007/s11940-016-0399-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OPINION STATEMENT Pipeline embolization device (PED) is a flow diverter used in the endovascular treatment of intracranial aneurysms, particularly those with unfavorable configurations. It works by causing progressive flow redirection leading to thrombosis within the aneurysm. PED was initially approved for adults with large or giant wide-necked (≥4 mm or no discernible neck) aneurysms of the internal carotid artery (ICA) from the petrous to the superior hypophyseal segments. Studies have shown a superior aneurysm occlusion rate of 85 % at 6 months for the PED and mortality ranging from 2.6 to 4 %. There appears to be a knowledge gap in terms of the duration of dual antiplatelet therapy and efficacy of assessing platelet inhibition. However, increasing operator experience and favorable longer-term outcome data have led to the exploration of PED for a wide array of off-label uses. Given the paucity of good-quality studies comparing PED with other endovascular/surgical treatment options, several multicenter randomized trials are currently underway to answer these important questions.
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Affiliation(s)
- Santosh B Murthy
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA. .,Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY, USA.
| | - Jharna Shah
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Halinder S Mangat
- Division of Stroke and Neurocritical Care, Department of Neurology, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA.,Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA
| | - Philip Stieg
- Department of Neurosurgery, Weill Cornell Medical College, New York, NY, USA
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Mangat HS. Erratum: Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. J Neurosurg 2016; 124:277. [DOI: 10.3171/2015.10.jns132545a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mangat HS. Erratum: Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. J Neurosurg 2016; 2016:277. [DOI: 10.3171/2015.10.jns132545a.test] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Hyperosmolar agents are commonly used as an initial treatment for the management of raised intracranial pressure (ICP) after severe traumatic brain injury (TBI). They have an excellent adverse-effect profile compared to other therapies, such as hyperventilation and barbiturates, which carry the risk of reducing cerebral perfusion. The hyperosmolar agent mannitol has been used for several decades to reduce raised ICP, and there is accumulating evidence from pilot studies suggesting beneficial effects of hypertonic saline (HTS) for similar purposes. An ideal therapeutic agent for ICP reduction should reduce ICP while maintaining cerebral perfusion (pressure). While mannitol can cause dehydration over time, HTS helps maintain normovolemia and cerebral perfusion, a finding that has led to a large amount of pilot data being published on the benefits of HTS, albeit in small cohorts. Prophylactic therapy is not recommended with mannitol, although it may be beneficial with HTS. To date, no large clinical trial has been performed to directly compare the two agents. The best current evidence suggests that mannitol is effective in reducing ICP in the management of traumatic intracranial hypertension and carries mortality benefit compared to barbiturates. Current evidence regarding the use of HTS in severe TBI is limited to smaller studies, which illustrate a benefit in ICP reduction and perhaps mortality.
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Affiliation(s)
- Halinder S Mangat
- Division of Stroke and Critical Care, Department of Neurology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Lahiri S, Navi B, Lapidus DM, Agarwal S, Mangat HS, Claassen J, Park S, Mayer SA, Kamel H. Abstract W MP61: Relationship Between Tracheostomy and Readmission Rates Among Mechanically Ventilated Patients with Stroke. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wmp61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Patients with ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) who undergo mechanical ventilation (MV) frequently require tracheostomy for management of persistent respiratory failure. Given the potential complications of chronic immobility and respiratory failure, these patients may be at high risk for hospital readmission.
Methods:
Using previously validated ICD-9-CM codes and statewide administrative claims data from California (2005-2011), Florida (2005-2012), and New York (2006-2011), we compared readmission rates among patients with a first-recorded stroke (IS, ICH, or SAH) who received MV and were discharged with or without a tracheostomy. Survival statistics and Poisson regression analyses with robust standard errors were used to report rates of hospital readmission and the association between tracheostomy and readmission rates.
Results:
Among 39,881 patients with stroke who underwent MV, 10,690 received a tracheostomy. The rate of any readmission was 21.1% (95% CI 20.3-21.9%) at 1 month and 45.1% (95% CI 44.2-46.1%) at 1 year among patients with tracheostomy versus 17.1% (95% CI 16.6-17.5%) and 35.3% (95% CI 34.8-35.9%) among those without a tracheostomy. The overall readmission rate throughout follow-up was 5.03 (95% CI 5.00-5.07) readmissions per 100 patients per month in those with tracheostomy versus 3.69 (95% CI 3.64-3.73) in those without tracheostomy. After adjustment for stroke type, demographic characteristics, vascular risk factors, Elixhauser comorbidities, stroke complications (e.g., seizures), and discharge disposition from the index hospitalization, tracheostomy was associated with a slightly increased readmission rate (incidence rate ratio, 1.04; 95% CI 1.00-1.08, p=0.04).
Conclusion:
Readmission rates among mechanically ventilated patients with stroke were not substantially higher than overall readmission rates seen in the general hospitalized population of elderly patients. There was a statistically significant but not clinically meaningful association between tracheostomy placement and readmission rates. These data may be helpful when counseling the families of patients with severe stroke.
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Affiliation(s)
- Shouri Lahiri
- Neurology, New York Presbyterian/Columbia and Weill Cornell Med Cntr, New York, NY
| | - Babak Navi
- Neurology, New York Presbyterian/Weill Cornell Med Cntr, New York, NY
| | - Daniel M Lapidus
- Neurology, New York Presbyterian/Columbia and Weill Cornell Med Cntr, New York, NY
| | - Sachin Agarwal
- Neurology, New York Presbyterian/Columbia Univ Med Cntr, New York, NY
| | - Halinder S Mangat
- Neurology, New York Presbyterian/Weill Cornell Med Cntr, New York, NY
| | - Jan Claassen
- Neurology, New York Presbyterian/Columbia Univ Med Cntr, New York, NY
| | - Soojin Park
- Neurology, New York Presbyterian/Columbia Univ Med Cntr, New York, NY
| | - Stephan A Mayer
- Neurology, Icahn Sch of Medicine at Mount Sinai, New York, NY
| | - Hooman Kamel
- Neurology, New York Presbyterian/Weill Cornell Med Cntr, New York, NY
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Mangat HS, Chiu YL, Gerber LM, Alimi M, Ghajar J, Härtl R. Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. J Neurosurg 2015; 122:202-10. [DOI: 10.3171/2014.10.jns132545] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECT
Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI.
METHODS
The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples.
RESULTS
A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56).
CONCLUSIONS
HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.
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Affiliation(s)
- Halinder S. Mangat
- Departments of 1Neurology and
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | | | - Linda M. Gerber
- Departments of 3Public Health and
- 4Medicine, Weill Cornell Medical College
| | - Marjan Alimi
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | - Jamshid Ghajar
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 6The Brain Trauma Foundation, New York, New York
| | - Roger Härtl
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
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Lahiri S, Mayer SA, Fink ME, Lord AS, Rosengart A, Mangat HS, Segal AZ, Claassen J, Kamel H. Mechanical Ventilation for Acute Stroke: A Multi-state Population-Based Study. Neurocrit Care 2014; 23:28-32. [DOI: 10.1007/s12028-014-0082-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Killeen RP, Gupta A, Delaney H, Johnson CE, Tsiouris AJ, Comunale J, Fink ME, Mangat HS, Segal AZ, Mushlin AI, Sanelli PC. Appropriate use of CT perfusion following aneurysmal subarachnoid hemorrhage: a Bayesian analysis approach. AJNR Am J Neuroradiol 2013; 35:459-65. [PMID: 24200901 DOI: 10.3174/ajnr.a3767] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE In recent years CTP has been used as a complementary diagnostic tool in the evaluation of delayed cerebral ischemia and vasospasm. Our aim was to determine the test characteristics of CTP for detecting delayed cerebral ischemia and vasospasm in SAH, and then to apply Bayesian analysis to identify subgroups for its appropriate use. MATERIALS AND METHODS Our retrospective cohort comprised consecutive patients with SAH and CTP performed between days 6 and 8 following aneurysm rupture. Delayed cerebral ischemia was determined according to primary outcome measures of infarction and/or permanent neurologic deficits. Vasospasm was determined by using DSA. The test characteristics of CTP and its 95% CIs were calculated. Graphs of conditional probabilities were constructed by using Bayesian techniques. Local treatment thresholds (posttest probability of delayed cerebral ischemia needed to initiate induced hypertension, hypervolemia, and hemodilution or intra-arterial therapy) were determined via a survey of 6 independent neurologists. RESULTS Ninety-seven patients with SAH were included in the study; 39% (38/97) developed delayed cerebral ischemia. Qualitative CTP deficits were seen in 49% (48/97), occurring in 84% (32/38) with delayed cerebral ischemia and 27% (16/59) without. The sensitivity, specificity, and positive and negative predictive values (95% CI) for CTP were 0.84 (0.73-0.96), 0.73 (0.62-0.84), 0.67 (0.51-0.79), and 0.88 (0.74-0.94), respectively. A subgroup of 57 patients underwent DSA; 63% (36/57) developed vasospasm. Qualitative CTP deficits were seen in 70% (40/57), occurring in 97% (35/36) with vasospasm and 23% (5/21) without. The sensitivity, specificity, and positive and negative predictive values (95% CI) for CTP were 0.97 (0.92-1.0), 0.76 (0.58-0.94), 0.88 (0.72-0.95), and 0.94 (0.69-0.99), respectively. Treatment thresholds were determined as 30% for induced hypertension, hypervolemia, and hemodilution and 70% for intra-arterial therapy. CONCLUSIONS Positive CTP findings identify patients who should be carefully considered for induced hypertension, hypervolemia, and hemodilution and/or intra-arterial therapy while negative CTP findings are useful in guiding a no-treatment decision.
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Affiliation(s)
- R P Killeen
- From the Departments of Radiology (R.P.K., A.G., H.D., C.E.J., A.J.T., J.C., P.C.S.)
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Abstract
PURPOSE OF REVIEW Although adherence to traumatic brain injury (TBI) guidelines has been associated with improved patient outcomes, guideline adherence remains suboptimal in practice. With neurologists becoming increasingly involved in specialized neurointensive care units and in the care of patients with severe TBI, familiarization with these guidelines is essential. RECENT FINDINGS Intracranial monitoring of different physiologic variables has increased in the past few years. Intracranial pressure (ICP)-driven therapy has been replaced by ICP-cerebral perfusion pressure (CPP)-driven therapy. More recently, the importance of brain oxygen optimization in addition to ICP-CPP has been recognized, and clinical trials are underway to study the effect of this approach. Surgical management of patients with TBI is also evolving rapidly with further studies on decompressive craniectomy. These are significant advances to improve TBI outcomes. SUMMARY This article summarizes the routine monitoring of patients with severe TBI and offers insight into some novel physiologic monitoring devices available. The guidelines for management of patients with severe TBI are summarized along with outcome measures.
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Affiliation(s)
- Halinder S Mangat
- Weill Cornell Medical College, Department of Neurology and Neuroscience, New York, NY 10021, USA.
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Velander AJ, Mangat HS. Patient Management Problem. Continuum (Minneap Minn) 2012; 18:708-713. [PMID: 22810260 DOI: 10.1212/01.con.0000415438.66222.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Velander AJ, Mangat HS. Patient Management Problem-Preferred Responses. Continuum (Minneap Minn) 2012; 18:714-726. [PMID: 22810261 DOI: 10.1212/01.con.0000415439.04340.9c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Fernandez A, Bond RL, Aziz-Sultan MA, Olvey SE, Mangat HS. Cerebral infarction secondary to vasospasm after perimesencephalic subarachnoid hemorrhage. J Clin Neurosci 2011; 18:994-6. [PMID: 21565507 DOI: 10.1016/j.jocn.2010.12.012] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 08/09/2010] [Accepted: 12/12/2010] [Indexed: 11/29/2022]
Abstract
Perimesencephalic subarachnoid hemorrhage (pSAH) has been described as a distinct form of subarachnoid hemorrhage (SAH) associated with good outcomes. We report a 48-year-old female who developed cerebral infarction due to severe diffuse vasospasm following pSAH. The patient presented with non-aneurysmal pSAH and was discharged home on day 5. However, one week later she developed an acute onset of right hemiparesis. A brain MRI showed acute infarctions on diffusion weighted imaging and her cerebral angiogram showed diffuse vasospasm. The patient received intra-arterial diltiazem and hypervolemic-hypertensive-hemodilution therapy with resulting resolution of the vasospasm and hemiparesis. While not as common as in SAH, there is a potential for the occurrence of cerebral infarction due to vasospasm after pSAH.
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Affiliation(s)
- A Fernandez
- Department of Neurology, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
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Abstract
Intravenous magnesium sulphate (MgSO4) has successfully been used in the treatment of acute asthma. The present study investigated the efficacy of nebulized MgSO4 as a bronchodilator in acute asthma as compared to nebulized salbutamol. This was a randomized, double-blind, controlled clinical trial. Asthmatics aged 12-60 yrs in acute exacerbation, with a peak expiratory flow (PEF) <300 L x min(-1), not having taken bronchodilators and not requiring assisted ventilation were included. Patients were randomized to receive treatment with serial nebulizations of either 3 mL (3.2% solution, 95 mg) MgSO4 solution or 3 mL (2.5 mg) salbutamol solution. All patients were also given 100 mg hydrocortisone i.v., and were monitored continuously for 2 h after which they were given supplemental treatment (if and when needed) and either discharged or admitted. Fischl index, PEF improvements (in % predicted) and admission rates were the outcome variables. Thirty-three patients were studied. Fischl score improvement was comparable and significant in both groups (4.31 to 0.43 in the MgSO4 group and 4.29 to 0.76 in the salbutamol group). The increase in PEF was statistically significant and comparable in both groups (by 35% pred in the MgSO4 and by 42% pred in the salbutamol group). Two patients warranted admission in the salbutamol group and one in the MgSO4 group. Nebulized MgSO4 had a significant bronchodilatory effect in acute asthma. This effect was not significantly different from that of nebulized salbutamol.
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Affiliation(s)
- H S Mangat
- Dept of Medicine, St John's Medical College Hospital, St John's National Academy of Health Sciences, Bangalore, Karnataka, India
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Abstract
The effect of long-term adrenalectomy on NMDA receptors in the rat hippocampus was studied. Hippocampal sections of control and adrenalectomized rats were incubated with [3H]MK-801, a radiolabeled non-competitive inhibitor of the NMDA receptor. Analysis by in vitro autoradiography showed a significant decrease in [3H]MK-801 binding in the dentate gyrus, CA1 and CA4 areas, as well as the temporal cortex. Results of this study suggest that glucocorticoids are vital for the regulation of the NMDA receptors.
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Affiliation(s)
- H S Mangat
- Department of Clinical Neurosciences and Family Medicine, Karolinska Institute, Huddinge University Hospital, Sweden
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Abstract
A 54-year-old man presented with an acute painless loss of vision. He had a three-month history of malaise, weight loss, and episodic sweating. Physical examination showed a thin, febrile man with a petechial rash over the lower legs. Cardiac auscultation revealed an apical thrill and pansystolic murmur. Dental hygiene was poor. The diagnosis, mechanisms and treatment of retinal artery occlusion associated with bacterial endocarditis are reviewed.
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Affiliation(s)
- H S Mangat
- Mercy Catholic Medical Center, Fitzgerald-Mercy Hospital, Darby, Pennsylvania
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