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Hwang DY, Kim KS, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Madzar D, Mahanes D, Mainali S, Sakowitz OW, Varelas PN, Weimar C, Westermaier T, Meixensberger J. Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage. Neurocrit Care 2024; 40:395-414. [PMID: 37923968 PMCID: PMC10959839 DOI: 10.1007/s12028-023-01854-7] [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: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication. METHODS A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format. RESULTS Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication-aside from the most clinically devastated patients-for at least the first 48-72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality. CONCLUSIONS These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Kliniken Dachau, University of Wuerzburg, Würzburg, Germany
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Mahanes D, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mainali S, Meixensberger J, Varelas PN, Weimar C, Westermaier T, Sakowitz OW. Guidelines for neuroprognostication in adults with traumatic spinal cord injury. Neurocrit Care 2024; 40:415-437. [PMID: 37957419 PMCID: PMC10959804 DOI: 10.1007/s12028-023-01845-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/17/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Traumatic spinal cord injury (tSCI) impacts patients and their families acutely and often for the long term. The ability of clinicians to share prognostic information about mortality and functional outcomes allows patients and their surrogates to engage in decision-making and plan for the future. These guidelines provide recommendations on the reliability of acute-phase clinical predictors to inform neuroprognostication and guide clinicians in counseling adult patients with tSCI or their surrogates. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of an appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Timing/Setting question was framed as "When counseling patients or surrogates of critically ill patients with traumatic spinal cord injury, should < predictor, with time of assessment if appropriate > be considered a reliable predictor of < outcome, with time frame of assessment >?" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four Grading of Recommendations Assessment, Development, and Evaluation criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. Good practice recommendations addressed essential principles of neuroprognostication that could not be framed in the Population/Intervention/Comparator/Outcome/Timing/Setting format. Throughout the guideline development process, an individual living with tSCI provided perspective on patient-centered priorities. RESULTS Six candidate clinical variables and one prediction model were selected. Out of 11,132 articles screened, 369 met inclusion criteria for full-text review and 35 articles met eligibility criteria to guide recommendations. We recommend pathologic findings on magnetic resonance imaging, neurological level of injury, and severity of injury as moderately reliable predictors of American Spinal Cord Injury Impairment Scale improvement and the Dutch Clinical Prediction Rule as a moderately reliable prediction model of independent ambulation at 1 year after injury. No other reliable or moderately reliable predictors of mortality or functional outcome were identified. Good practice recommendations include considering the complete clinical condition as opposed to a single variable and communicating the challenges of likely functional deficits as well as potential for improvement and for long-term quality of life with SCI-related deficits to patients and surrogates. CONCLUSIONS These guidelines provide recommendations about the reliability of acute-phase predictors of mortality, functional outcome, American Spinal Injury Association Impairment Scale grade conversion, and recovery of independent ambulation for consideration when counseling patients with tSCI or their surrogates and suggest broad principles of neuroprognostication in this context.
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Affiliation(s)
- Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, University of Virginia, Charlottesville, VA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Klinikum Dachau, Dachau, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany.
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Muehlschlegel S, Rajajee V, Wartenberg KE, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Weimar C, Westermaier T. Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury. Neurocrit Care 2024; 40:448-476. [PMID: 38366277 PMCID: PMC10959796 DOI: 10.1007/s12028-023-01902-2] [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: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Moderate-severe traumatic brain injury (msTBI) carries high morbidity and mortality worldwide. Accurate neuroprognostication is essential in guiding clinical decisions, including patient triage and transition to comfort measures. Here we provide recommendations regarding the reliability of major clinical predictors and prediction models commonly used in msTBI neuroprognostication, guiding clinicians in counseling surrogate decision-makers. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we conducted a systematic narrative review of the most clinically relevant predictors and prediction models cited in the literature. The review involved framing specific population/intervention/comparator/outcome/timing/setting (PICOTS) questions and employing stringent full-text screening criteria to examine the literature, focusing on four GRADE criteria: quality of evidence, desirability of outcomes, values and preferences, and resource use. Moreover, good practice recommendations addressing the key principles of neuroprognostication were drafted. RESULTS After screening 8125 articles, 41 met our eligibility criteria. Ten clinical variables and nine grading scales were selected. Many articles varied in defining "poor" functional outcomes. For consistency, we treated "poor" as "unfavorable". Although many clinical variables are associated with poor outcome in msTBI, only the presence of bilateral pupillary nonreactivity on admission, conditional on accurate assessment without confounding from medications or injuries, was deemed moderately reliable for counseling surrogates regarding 6-month functional outcomes or in-hospital mortality. In terms of prediction models, the Corticosteroid Randomization After Significant Head Injury (CRASH)-basic, CRASH-CT (CRASH-basic extended by computed tomography features), International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-core, IMPACT-extended, and IMPACT-lab models were recommended as moderately reliable in predicting 14-day to 6-month mortality and functional outcomes at 6 months and beyond. When using "moderately reliable" predictors or prediction models, the clinician must acknowledge "substantial" uncertainty in the prognosis. CONCLUSIONS These guidelines provide recommendations to clinicians on the formal reliability of individual predictors and prediction models of poor outcome when counseling surrogates of patients with msTBI and suggest broad principles of neuroprognostication.
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Affiliation(s)
- Susanne Muehlschlegel
- Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Saint Luke's Health System, Kansas City, MO, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper Klinikum Dachau, Dachau, Germany.
- Faculty of Medicine, University of Würzburg, Würzburg, Germany.
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Hwang DY, Bannon SM, Meurer K, Kubota R, Baskaran N, Kim J, Zhang Q, Reichman M, Fishbein NS, Lichstein K, Motta M, Muehlschlegel S, Reznik ME, Jaffa MN, Creutzfeldt CJ, Fehnel CR, Tomlinson AD, Williamson CA, Vranceanu AM. Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma. Neurocrit Care 2024; 40:674-688. [PMID: 37523110 DOI: 10.1007/s12028-023-01804-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma. METHODS Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24 h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7 days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences. RESULTS We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress. CONCLUSIONS In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Sarah M Bannon
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kate Meurer
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Rina Kubota
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nithyashri Baskaran
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Jisoo Kim
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Qiang Zhang
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - Mira Reichman
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Nathan S Fishbein
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kaitlyn Lichstein
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Melissa Motta
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Michael E Reznik
- Department of Neurology, Alpert Medical School, Brown University, Providence, RI, USA
| | - Matthew N Jaffa
- Department of Neurointensive Care, Hartford Hospital, Hartford, CT, USA
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington and Harborview Medical Center, Seattle, WA, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Amanda D Tomlinson
- Department of Critical Care Medicine, College of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Ana-Maria Vranceanu
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Yoo A, Guterman EL, Hwang DY, Holloway RG, George BP. Impact of the COVID-19 Pandemic on Inpatient Utilization for Acute Neurologic Disease. Neurohospitalist 2024; 14:13-22. [PMID: 38235034 PMCID: PMC10790622 DOI: 10.1177/19418744231196984] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Background and Objective: The initial months of the Corona Virus 2019 (COVID-19) pandemic resulted in decreased hospitalizations. We aimed to describe differences in hospitalizations and related procedures across neurologic disease. Methods: In our retrospective observational study using the California State Inpatient Database and state-wide population-level estimates, we calculated neurologic hospitalization rates for a control period from January 2019 to February 2020 and a COVID-19 pandemic period from March to December 2020. We calculated incident rate ratios (IRR) for neurologic hospitalizations using negative binomial regression and compared relevant procedure rates over time. Results: Population-based neurologic hospitalization rates were 29.1 per 100,000 (95% CI 26.9-31.3) in April 2020 compared to 43.6 per 100,000 (95% CI 40.4-46.7) in January 2020. Overall, the pandemic period had 13% lower incidence of neurologic hospitalizations per month (IRR 0.87, 95% CI 0.86-0.89). The smallest decreases were in neurotrauma (IRR 0.92, 95% CI 0.89-0.95) and neuro-oncologic cases (IRR 0.93, 95% CI 0.87-0.99). Headache admissions experienced the greatest decline (IRR 0.62, 95% CI 0.58-0.66). For ischemic stroke, greater rates of endovascular thrombectomy (5.6% vs 5.0%; P < .001) were observed in the pandemic. Among all neurologic disease, greater rates of gastrostomy (4.0% vs 3.5%; P < .001), intubation/mechanical ventilation (14.3% vs 12.9%, P < .001), and tracheostomy (1.4 vs 1.2%; P < .001) were observed during the pandemic. Conclusions: During the first months of the COVID-19 pandemic there were fewer hospitalizations to varying degrees for all neurologic diagnoses. Rates of procedures indicating severe disease increased. Further study is needed to determine the impact on triage, patient outcomes, and cost consequences.
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Affiliation(s)
- Alexander Yoo
- Department of Medicine, University of Pennsylvania Perlman School of Medicine, Philadelphia, PA, USA
| | - Elan L. Guterman
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - David Y. Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Robert G. Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin P. George
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
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Mikhaiel JP, Parasram M, Manning T, Al-Dulaimi MW, Barnes EC, Falcone GJ, Hwang DY, Prust ML. Sporadic Creutzfeldt-Jakob Disease Initially Presenting With Posterior Reversible Encephalopathy Syndrome: A Case Report. Neurologist 2024; 29:14-16. [PMID: 37582680 DOI: 10.1097/nrl.0000000000000519] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Sporadic Creutzfeldt-Jakob disease (sCJD) is a fatal neurodegenerative condition caused by prion proteins. Cortical and subcortical diffusion-weighted imaging restriction on magnetic resonance imaging (MRI) is associated with sCJD. Posterior reversible encephalopathy syndrome (PRES) results from impaired vessel autoregulation due to an identifiable trigger, which is associated with subcortical fluid-attenuated inversion recovery changes on MRI. We report a case of sCJD initially presenting with PRES. CASE REPORT A 70-year-old woman presented to an outside hospital with progressive confusion and difficulty in managing activities of daily living. Initial examination revealed stuporous mental state and stimulus-induced myoclonus. MRI revealed bilateral subcortical occipital lobe T2-fluid-attenuated inversion recovery hyperintensities without contrast enhancement suggestive of PRES. Electroencephalogram (EEG) revealed frequent generalized periodic discharges meeting criteria for nonconvulsive status epilepticus. Clinical examination and EEG did not improve despite escalating antiseizure medications. Initial lumbar puncture was unremarkable. She was transferred to our hospital with a presumptive diagnosis of PRES, although there was no clear trigger. Continuous EEG revealed ongoing generalized periodic discharges with myoclonic activity meeting criteria for myoclonic seizures that were refractory to multiple antiseizure medications. Repeat MRI showed resolution of PRES but revealed subtle diffuse cortical diffusion-weighted imaging restriction. Repeat lumbar puncture was performed and 14-3-3 and real-time quaking-induced conversion returned positive, confirming sCJD. CONCLUSIONS This case reports highlights that sCJD can present with neuroimaging consistent with PRES. The diagnosis of sCJD should be considered in patients with PRES who continue to show neurological decline despite optimal management and radiographic improvement of PRES on MRI. Further research is needed to identify a pathophysiological relationship between these clinical phenotypes.
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Affiliation(s)
- John P Mikhaiel
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Melvin Parasram
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Thomas Manning
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Erin C Barnes
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Morgan L Prust
- Department of Neurology, Yale School of Medicine, New Haven, CT
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Busl KM, Fried H, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Westermaier T, Weimar C. Author Correction: Guidelines for Neuroprognostication in Adults with Guillain-Barré Syndrome. Neurocrit Care 2023; 39:752. [PMID: 37726550 PMCID: PMC10689509 DOI: 10.1007/s12028-023-01830-1] [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: 09/21/2023]
Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen and BDH-Clinic Elzach, Essen, Germany.
- BDH-Clinic Elzach, Elzach, Germany.
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8
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Zhang L, Albert GP, Pieters TA, McHugh DC, Asemota AO, Roberts DE, Hwang DY, Bender MT, George BP. Association of Do-Not-Resuscitate orders and in-hospital mortality among patients undergoing cranial neurosurgery. J Clin Neurosci 2023; 118:26-33. [PMID: 37857061 DOI: 10.1016/j.jocn.2023.10.006] [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: 08/13/2023] [Revised: 09/21/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Previous studies identified pre-existing DNR orders as a predictor of mortality after surgery. We sought to evaluate mortality of patients receiving cranial neurosurgery with DNR orders placed at the time of, or within 24 h of admission. METHODS We performed a retrospective cohort study using the California State Inpatient Database, January 2018 to December 2020. We used International Classification of Diseases, 10th Revision (ICD-10) codes to identify emergent hospitalizations with principal diagnosis of brain injury, including traumatic brain injury [TBI], ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], or malignant brain tumor [mBT]. We used procedure and Diagnosis Related Group codes to identify cranial neurosurgery. Patients with DNR were one-to-one matched to non-DNR controls based on diagnosis (exact matching), age, sex, Elixhauser comorbidity index, and organ failure (coarsened matching). The primary outcome was inpatient mortality. RESULTS In California, 30,384 patients underwent cranial neurosurgery, 2018-2020 (n = 3,112, 10% DNR). DNR patients were older, more often female, more often White, with greater comorbidity and organ system dysfunction. There were 2,505 patients with DNR orders 1:1 matched to controls. Patients with DNR had greater inpatient mortality (56% vs. 23%, p < 0.001; Hazard Ratio 3.11, 95% CI 2.50-3.86), received tracheostomy (Odds Ratio [OR] 0.37, 95% CI 0.24-0.57) and gastrostomy less (OR 0.48, 95% CI 0.39-0.58) compared to controls. Multivariable analysis of the unmatched cohort demonstrated similar results. CONCLUSION Patients undergoing cranial neurosurgery with early or pre-existing DNR have high inpatient mortality compared to clinically similar non-DNR patients; 1 in 2 died during their hospitalization.
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Affiliation(s)
- Lan Zhang
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - George P Albert
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Thomas A Pieters
- University of Massachusetts Memorial Health, Department of Neurosurgery, Worcester, MA, United States
| | - Daryl C McHugh
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Anthony O Asemota
- University of Texas Southwestern Medical Center, Department of Neurosurgery, Dallas, TX, United States
| | - Debra E Roberts
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - David Y Hwang
- University of North Carolina School of Medicine, Department of Neurology, Chapel Hill, NC, United States
| | - Matthew T Bender
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Benjamin P George
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States.
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9
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Jaffa MN, Kirsch HL, Creutzfeldt CJ, Guanci M, Hwang DY, LeTavec D, Mahanes D, Natarajan G, Steinberg A, Zahuranec DB, Muehlschlegel S. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-Care and Family/Surrogate Decision-Maker Data. Neurocrit Care 2023; 39:600-610. [PMID: 37704937 DOI: 10.1007/s12028-023-01796-0] [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: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND To facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDEs) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC. METHODS To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the National Institutes of Health/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core", "basic", "exploratory", or "supplemental", as well as their use for studying the acute or chronic phase of DoC, or both. RESULTS We identified 32 relevant preexisting National Institutes of Health CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup. CONCLUSIONS Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.
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Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Hannah L Kirsch
- Department of Neurology, Stanford University School of Medicine, 453 Quarry Road, MC 5235, Palo Alto, CA, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, Division of Stroke and Palliative Care, University of Washington, Seattle, WA, USA
| | - Mary Guanci
- Department of Neuroscience Nursing, Massachusetts General Hospital, Boston, MA, USA
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Detroit, MI, USA
| | - Alexis Steinberg
- Department of Neurology, Critical Care Medicine, and Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Darin B Zahuranec
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
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10
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Threlkeld ZD, Hwang DY. The Severely Wounded Brain Healed: Outcome Prognostication in Neurology. Semin Neurol 2023; 43:662-663. [PMID: 37918443 DOI: 10.1055/s-0043-1775794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Affiliation(s)
- Zachary D Threlkeld
- Division of Neurocritical Care, Department of Neurology, Stanford University School of Medicine, Stanford, California
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina
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11
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Albert GP, McHugh DC, Hwang DY, Creutzfeldt CJ, Holloway RG, George BP. National Cost Estimates of Invasive Mechanical Ventilation and Tracheostomy in Acute Stroke, 2008-2017. Stroke 2023; 54:2602-2612. [PMID: 37706340 DOI: 10.1161/strokeaha.123.043176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/09/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Patients with stroke receiving invasive mechanical ventilation (IMV) and tracheostomy incur intense treatment and long hospitalizations. We aimed to evaluate US hospitalization costs for patients with stroke requiring IMV, tracheostomy, or no ventilation. METHODS We performed a retrospective observational study of US hospitalizations for acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage receiving IMV, tracheostomy, or none using the National Inpatient Sample, 2008 to 2017. We calculated hospitalization costs using cost-to-charge ratios adjusted to 2017 US dollars for inpatients with stroke by ventilation status (no IMV, IMV alone, tracheostomy). RESULTS Of an estimated 5.2 million (95% CI, 5.1-5.3) acute stroke hospitalizations, 2008 to 2017; 9.4% received IMV alone and 1.4% received tracheostomy. Length of stay for patients without IMV was shorter (median, 4 days; interquartile range [IQR], 2-6) compared with IMV alone (median, 6 days; [IQR, 2-13]), and tracheostomy (median, 25 days; [IQR, 18-36]; P<0.001). Mortality for patients without IMV was 3.2% compared with 51.2% for IMV alone and 9.8% for tracheostomy (P<0.001). Median hospitalization costs for patients without IMV was $9503 (IQR, $6544-$14 963), compared with $23 774 (IQR, $10 900-$47 735) for IMV alone and $95 380 (IQR, $63 921-$144 019) for tracheostomy. Tracheostomy placement in ≤7 days had lower costs compared with placement in >7 days (median, $71 470 [IQR, $47 863-$108 250] versus $102 979 [IQR, $69 563-$152 543]; P<0.001). Each day awaiting tracheostomy was associated with a 2.9% cost increase (95% CI, 2.6%-3.1%). US hospitalization costs for patients with acute stroke were $8.7 billion/y (95% CI, $8.5-$8.9 billion). For IMV alone, costs were $1.8 billion/y (95% CI, $1.7-$1.9 billion) and for tracheostomy $824 million/y (95% CI, $789.7-$858.3 million). CONCLUSIONS Patients with acute stroke who undergo tracheostomy account for 1.4% of stroke admissions and 9.5% of US stroke hospitalization costs. Future research should focus on the added value to society and patients of IMV and tracheostomy, in particular after 7 days for the latter procedure given the increased costs incurred and poor outcomes in stroke.
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Affiliation(s)
- George P Albert
- Department of Neurology, University of Rochester Medical Center, NY (G.P.A., D.C.M., R.G.H., B.P.G.)
| | - Daryl C McHugh
- Department of Neurology, University of Rochester Medical Center, NY (G.P.A., D.C.M., R.G.H., B.P.G.)
| | - David Y Hwang
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill (D.Y.H.)
| | | | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, NY (G.P.A., D.C.M., R.G.H., B.P.G.)
| | - Benjamin P George
- Department of Neurology, University of Rochester Medical Center, NY (G.P.A., D.C.M., R.G.H., B.P.G.)
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12
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Jaffa MN, Hwang DY. Goals of Care for Severe Acute Brain Injury Patients: When a Choice Is Not a Choice. Crit Care Med 2023; 51:978-980. [PMID: 37318295 DOI: 10.1097/ccm.0000000000005879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC
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13
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Jaffa MN, Kirsch HL, Creutzfeldt CJ, Guanci M, Hwang DY, LeTavec D, Mahanes D, Steinberg A, Natarajan G, Zahuranec DB, Muehlschlegel S. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-care and Family/Surrogate Decision-Maker Data. Res Sq 2023:rs.3.rs-3084539. [PMID: 37461521 PMCID: PMC10350109 DOI: 10.21203/rs.3.rs-3084539/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
INTRODUCTION In order to facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDE) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC. METHODS To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the NIH/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core," "basic," "exploratory," or "supplemental," as well as their utility for studying the acute or chronic phase of DoC, or both. RESULTS We identified 32 relevant pre-existing NIH CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup. CONCLUSIONS Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.
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Affiliation(s)
| | | | | | | | - David Y Hwang
- The University of North Carolina at Chapel Hill School of Medicine
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14
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Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN. Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocrit Care 2023; 38:533-563. [PMID: 36949360 PMCID: PMC10241762 DOI: 10.1007/s12028-023-01688-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurology and Neurosurgery, 3552 Taubman Health Care Center, SPC 5338, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sherry H Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
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15
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Busl KM, Fried H, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Westermaier T, Weimar C. Guidelines for Neuroprognostication in Adults with Guillain-Barré Syndrome. Neurocrit Care 2023; 38:564-583. [PMID: 36964442 PMCID: PMC10241707 DOI: 10.1007/s12028-023-01707-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/23/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Guillain-Barré syndrome (GBS) often carries a favorable prognosis. Of adult patients with GBS, 10-30% require mechanical ventilation during the acute phase of the disease. After the acute phase, the focus shifts to restoration of motor strength, ambulation, and neurological function, with variable speed and degree of recovery. The objective of these guidelines is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling adult patients with GBS and/or their surrogates. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Time frame/Setting (PICOTS) question was framed as follows: "When counseling patients or surrogates of critically ill patients with Guillain-Barré syndrome, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of [outcome, with time frame of assessment]?" Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eight candidate clinical variables and six prediction models were selected. A total of 45 articles met our eligibility criteria to guide recommendations. We recommend bulbar weakness (the degree of motor weakness at disease nadir) and the Erasmus GBS Respiratory Insufficiency Score as moderately reliable for prediction of the need for mechanical ventilation. The Erasmus GBS Outcome Score (EGOS) and modified EGOS were identified as moderately reliable predictors of independent ambulation at 3 months and beyond. Good practice recommendations include consideration of both acute and recovery phases of the disease during prognostication, discussion of the possible need for mechanical ventilation and enteral nutrition during counseling, and consideration of the complete clinical condition as opposed to a single variable during prognostication. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of the need for mechanical ventilation, poor functional outcome, and independent ambulation following GBS in the context of counseling patients and/or surrogates and suggest broad principles of neuroprognostication. Few predictors were considered moderately reliable based on the available body of evidence, and higher quality data are needed.
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Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen and BDH-Clinic Elzach, Essen, Germany.
- BDH-Clinic Elzach, Elzach, Germany.
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16
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Busl KM, Fried H, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Westermaier T, Weimar C. Correction to: Guidelines for Neuroprognostication in Adults with Guillain-Barré Syndrome. Neurocrit Care 2023:10.1007/s12028-023-01726-0. [PMID: 37100978 DOI: 10.1007/s12028-023-01726-0] [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: 04/28/2023]
Affiliation(s)
- Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | | | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen and BDH-Clinic Elzach, ,Essen, Germany.
- BDH-Clinic Elzach, Elzach, Germany.
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17
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Ammar AA, Elsamadicy AA, Ammar MA, Reeves BC, Koo AB, Falcone GJ, Hwang DY, Petersen N, Kim JA, Beekman R, Prust M, Magid-Bernstein J, Acosta JN, Herbert R, Sheth KN, Matouk CC, Gilmore EJ. Emergent external ventricular drain placement in patients with factor Xa inhibitor-associated intracerebral hemorrhage after reversal with andexanet alfa. Clin Neurol Neurosurg 2023; 226:107621. [PMID: 36791588 DOI: 10.1016/j.clineuro.2023.107621] [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: 12/01/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Andexanet alfa (AA), a factor Xa-inhibitor (FXi) reversal agent, is given as a bolus followed by a 2-hour infusion. This long administration time can delay EVD placement in intracerebral hemorrhage (ICH) patients. We sought to evaluate the safety of EVD placement immediately post-AA bolus compared to post-AA infusion. METHODS We conducted a retrospective study that included adult patients admitted with FXi-associated ICH who received AA and underwent EVD placement The primary outcome was the occurrence of a new hemorrhage (tract, extra-axial, or intraventricular hemorrhage). Secondary outcomes included mortality, intensive care unit and hospital length of stay, and discharge modified Rankin Score. The primary safety outcome was documented thrombotic events. RESULTS Twelve patients with FXi related ICH were included (EVD placement post-AA bolus, N = 8; EVD placement post-AA infusion, N = 4). Each arm included one patient with bilateral EVD placed. There was no difference in the incidence of new hemorrhages, with one post-AA bolus patient had small, focal, nonoperative extra-axial hemorrhage. Morbidity and mortality were higher in post-AA infusion patients (mRS, post-AA bolus, 4 [4-6] vs. post-AA infusion 6 [5,6], p = 0.24 and post-AA bolus, 3 (37.5 %) vs. post-AA infusion, 3 (75 %), p = 0.54, respectively). One patient in the post-AA bolus group had thrombotic event. There was no difference in hospital LOS (post-AA bolus, 19 days [12-26] vs. post-AA infusion, 14 days [9-22], p = 0.55) and ICU LOS (post-AA bolus, 10 days [6-13] vs. post-AA infusion, 11 days [5-21], p = 0.86). CONCLUSION We report no differences in the incidence of tract hemorrhage, extra-axial hemorrhage, or intraventricular hemorrhage post-AA bolus versus post-AA infusion. Larger prospective studies to validate these results are warranted.
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Affiliation(s)
- Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA; Department of Pharmacy, New York Presbyterian/Weill Cornell, 525 East 68th Street, New York, NY 10065, USA.
| | - Aladine A Elsamadicy
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Mahmoud A Ammar
- Department of Pharmacy, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA
| | - Benjamin C Reeves
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Andrew B Koo
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, Chapel Hill, NC 27599, USA
| | - Nils Petersen
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Jennifer A Kim
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Rachel Beekman
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Morgan Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Jessica Magid-Bernstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Julián N Acosta
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Ryan Herbert
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Charles C Matouk
- Departments of Neurosurgery, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 20 York Street, New Haven, CT 06510, USA
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Waseem H, Keegan J, Farrell K, Hwang DY, Oliver B, Olm-Shipman C, Pepin R, Mecchella J. Implementation of a Standardized Shared Decision-making Bundle to Improve Communication Practices in the Neurocritical Care Unit. Neurol Clin Pract 2023; 13:e200120. [PMID: 36865641 PMCID: PMC9973293 DOI: 10.1212/cpj.0000000000200120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/01/2022] [Indexed: 01/19/2023]
Abstract
Background and Objective Shared decision-making (SDM) aligns patient preferences with health care team treatment goals. This quality improvement initiative implemented a standardized SDM bundle within a neurocritical care unit (NCCU), where unique demands make existing, provider-driven SDM practices challenging. Methods An interprofessional team defined key issues, identified barriers, and created change ideas to drive implementation of an SDM bundle using the Institute for Healthcare Improvement Model for Improvement framework incorporating Plan-Do-Study-Act cycles. The SDM bundle included (1) a health care team huddle pre-SDM and post-SDM conversation; (2) a social worker-driven SDM conversation with the patient family, including core standardized communication elements to ensure consistency and quality; and (3) an SDM documentation tool within the electronic medical record to ensure the SDM conversation was accessible to all health care team members. The primary outcome measure was percentage of SDM conversations documented. Results Documentation of SDM conversations improved by 56%, from 27% to 83% pre/postintervention. Average time to documentation decreased by 4 days, from day 9 preintervention to day 5 postintervention. There was no significant change in NCCU length of stay, nor did palliative care consultation rates increase. Postintervention, SDM team huddle compliance was 94.3%. Discussion A team-driven, standardized SDM bundle that integrates with health care team workflows enabled SDM conversations to occur earlier and resulted in improved documentation of SDM conversations. Team-driven SDM bundles have the potential to improve communication and promote early alignment with patient family goals, preferences, and values.
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Affiliation(s)
- Hena Waseem
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Joshua Keegan
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Kelly Farrell
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - David Y Hwang
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Brant Oliver
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Casey Olm-Shipman
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - Renee Pepin
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
| | - John Mecchella
- Dartmouth-Hitchcock Medical Center (HW, JK, KF, BO, RP, JM); The Dartmouth Institute for Health Policy and Clinical Practice (HW, BO), Geisel School of Medicine at Dartmouth; Yale School of Medicine (DYH); and University of North Carolina Medical Center (CO-S)
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19
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Muehlschlegel S, Goostrey K, Flahive J, Zhang Q, Pach JJ, Hwang DY. Pilot Randomized Clinical Trial of a Goals-of-Care Decision Aid for Surrogates of Patients With Severe Acute Brain Injury. Neurology 2022; 99:e1446-e1455. [PMID: 35853748 PMCID: PMC9576301 DOI: 10.1212/wnl.0000000000200937] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/19/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Breakdowns in clinician-family communication in neurologic intensive care units (neuroICUs) are common, particularly for goals-of-care decisions to continue or withdraw life-sustaining treatments while considering long-term prognoses. Shared decision-making interventions (decision aids [DAs]) may prevent this problem and increase patient-centered care, yet none are currently available. We assessed the feasibility, acceptability, and perceived usefulness of a DA for goals-of-care communication with surrogate decision makers for critically ill patients with severe acute brain injury (SABI) after hemispheric acute ischemic stroke, intracerebral hemorrhage, or traumatic brain injury. METHODS We conducted a parallel-arm, unblinded, patient-level randomized, controlled pilot trial at 2 tertiary care US neuroICUs and randomized surrogate participants 1:1 to a tailored paper-based DA provided to surrogates before clinician-family goals-of-care meetings or usual care (no intervention before clinician-family meetings). The primary outcomes were feasibility of deploying the DA (recruitment, participation, and retention), acceptability, and perceived usefulness of the DA among surrogates. Exploratory outcomes included outcome of surrogate goals-of-care decision, code status changes during admission, patients' 3-month functional outcome, and surrogates' 3-month validated psychological outcomes. RESULTS We approached 83 surrogates of 58 patients and enrolled 66 surrogates of 41 patients (80% consent rate). Of 66 surrogates, 45 remained in the study at 3 months (68% retention). Of the 33 surrogates randomized to intervention, 27 were able to receive the DA, and 25 subsequently read the DA (93% participation). Eighty-two percent rated the DA's acceptability as good or excellent (median acceptability score 2 [IQR 2-3]); 96% found it useful for goals-of-care decision making. In the DA group, there was a trend toward fewer comfort care decisions (27% vs 56%, p = 0.1) and fewer code status changes (no change, 73% vs 44%, p = 0.02). At 3 months, fewer patients in the DA group had died (33% vs 69%, p = 0.05; median Glasgow Outcome Scale 3 vs1, p = 0.05). Regardless of intervention, 3-month psychological outcomes were significantly worse among surrogates who had chosen continuation of care. DISCUSSION A goals-of-care DA to support ICU shared decision making for patients with SABI is feasible to deploy and well perceived by surrogates. A larger trial is feasible to conduct, although surrogates who select continuation of care deserve additional psychosocial support. CLINICAL TRIALS REGISTRATION Clinicaltrials.gov NCT03833375. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that the use of a DA explaining the goals-of-care decision and the treatment options is acceptable and useful to surrogates of incapacitated critically ill patients with ischemic stroke, intracerebral hemorrhage, or traumatic brain injury.
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Affiliation(s)
- Susanne Muehlschlegel
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT.
| | - Kelsey Goostrey
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Julie Flahive
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Qiang Zhang
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Jolanta J Pach
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
| | - David Y Hwang
- From the Departments of Neurology (S.M., K.G.), Anesthesiology (S.M.), Surgery (S.M.), and Population and Quantitative Health Sciences (J.F.), University of Massachusetts Chan Medical School, Worcester; and Division of Neurocritical Care and Emergency Neurology (Q.Z., J.J.P., D.Y.H.), Department of Neurology, Yale School of Medicine, New Haven, CT
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20
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Steinberg A, Hudoba C, Hwang DY, Kramer NM, Mehta AK, Muehlschlegel S, Jones CA, Besbris J. Top Ten Tips Palliative Care Clinicians Should Know About Disorders of Consciousness: A Focus on Traumatic and Anoxic Brain Injury. J Palliat Med 2022; 25:1571-1578. [PMID: 35639356 DOI: 10.1089/jpm.2022.0202] [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] [Indexed: 11/13/2022] Open
Abstract
Palliative care (PC) teams commonly encounter patients with disorders of consciousness (DOC) following anoxic or traumatic brain injury (TBI). Primary teams may consult PC to help surrogates in making treatment choices for these patients. PC clinicians must understand the complexity of predicting neurologic outcomes, address clinical nihilism, and appropriately guide surrogates in making decisions that are concordant with patients' goals. The purpose of this article was to provide PC providers with a better understanding of caring for patients with DOC, specifically following anoxic or TBI. Many of the tips acknowledge the uncertainty of DOC and provide strategies to help tackle this dilemma.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christine Hudoba
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Neha M Kramer
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA.,Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Department of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Department of Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine and Palliative Care Program, Duke University Hospital, Durham, North Carolina, USA
| | - Jessica Besbris
- Department of Internal Medicine and Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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21
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Bösel J, Niesen WD, Salih F, Morris NA, Ragland JT, Gough B, Schneider H, Neumann JO, Hwang DY, Kantamneni P, James ML, Freeman WD, Rajajee V, Rao CV, Nair D, Benner L, Meis J, Klose C, Kieser M, Suarez JI, Schönenberger S, Seder DB. Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA 2022; 327:1899-1909. [PMID: 35506515 PMCID: PMC9069344 DOI: 10.1001/jama.2022.4798] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Many patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation. OBJECTIVE To test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020. INTERVENTIONS Patients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194). MAIN OUTCOMES AND MEASURES The primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death). RESULTS Among 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, -3.6% [95% CI, -14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy. CONCLUSIONS AND RELEVANCE Among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02377167.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, Freiburg University Hospital, Freiburg im Breisgau, Germany
| | - Farid Salih
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Jeremy T. Ragland
- Department of Neurosurgery, University of Texas Health Science Center, Houston
| | - Bryan Gough
- Department of Neurology, Ohio State University, Wexner Medical Center, Columbus
| | - Hauke Schneider
- Department of Neurology, Dresden University Hospital, Dresden, Germany
- Now with the Department of Neurology, Augsburg University Hospital Augsburg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Phani Kantamneni
- Department of Medicine, Kadlec Regional Medical Center, Richland, Washington
| | - Michael L. James
- Departments of Anesthesiology and Neurology, Duke University Hospital, Durham, North Carolina
| | - William D. Freeman
- Departments of Neurology, Neurologic Surgery, and Critical Care, Mayo Clinic, Jacksonville, Florida
| | | | - Chethan Venkatasubba Rao
- Department of Neurology, Neurosurgery and Center for Space Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Laura Benner
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - José I. Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David B. Seder
- Department of Critical Care Services, Maine Medical Center, Portland, Maine
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22
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Hwang DY. Patients' Families, Physicians, and Nurses: Trying to See Eye-to-Eye Regarding Prognosis in Neurocritical Care. Neurocrit Care 2022; 37:10-11. [PMID: 35476246 DOI: 10.1007/s12028-022-01503-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA. .,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
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23
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Yuen MM, Prabhat AM, Mazurek MH, Chavva IR, Crawford A, Cahn BA, Beekman R, Kim JA, Gobeske KT, Petersen NH, Falcone GJ, Gilmore EJ, Hwang DY, Jasne AS, Amin H, Sharma R, Matouk C, Ward A, Schindler J, Sansing L, de Havenon A, Aydin A, Wira C, Sze G, Rosen MS, Kimberly WT, Sheth KN. Portable, low-field magnetic resonance imaging enables highly accessible and dynamic bedside evaluation of ischemic stroke. Sci Adv 2022; 8:eabm3952. [PMID: 35442729 PMCID: PMC9020661 DOI: 10.1126/sciadv.abm3952] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/08/2022] [Indexed: 05/26/2023]
Abstract
Brain imaging is essential to the clinical management of patients with ischemic stroke. Timely and accessible neuroimaging, however, can be limited in clinical stroke pathways. Here, portable magnetic resonance imaging (pMRI) acquired at very low magnetic field strength (0.064 T) is used to obtain actionable bedside neuroimaging for 50 confirmed patients with ischemic stroke. Low-field pMRI detected infarcts in 45 (90%) patients across cortical, subcortical, and cerebellar structures. Lesions as small as 4 mm were captured. Infarcts appeared as hyperintense regions on T2-weighted, fluid-attenuated inversion recovery and diffusion-weighted imaging sequences. Stroke volume measurements were consistent across pMRI sequences and between low-field pMRI and conventional high-field MRI studies. Low-field pMRI stroke volumes significantly correlated with stroke severity and functional outcome at discharge. These results validate the use of low-field pMRI to obtain clinically useful imaging of stroke, setting the stage for use in resource-limited environments.
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Affiliation(s)
- Matthew M. Yuen
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Anjali M. Prabhat
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Mercy H. Mazurek
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Isha R. Chavva
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Anna Crawford
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bradley A. Cahn
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Jennifer A. Kim
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin T. Gobeske
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nils H. Petersen
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Guido J. Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Emily J. Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - David Y. Hwang
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Adam S. Jasne
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Hardik Amin
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Adrienne Ward
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, USA
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Ani Aydin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Charles Wira
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gordon Sze
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Matthew S. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - W. Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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24
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Sheth KN, Yuen MM, Mazurek MH, Cahn BA, Prabhat AM, Salehi S, Shah JT, By S, Welch EB, Sofka M, Sacolick LI, Kim JA, Payabvash S, Falcone GJ, Gilmore EJ, Hwang DY, Matouk C, Gordon-Kundu B, Rn AW, Petersen N, Schindler J, Gobeske KT, Sansing LH, Sze G, Rosen MS, Kimberly WT, Kundu P. Bedside detection of intracranial midline shift using portable magnetic resonance imaging. Sci Rep 2022; 12:67. [PMID: 34996970 PMCID: PMC8742125 DOI: 10.1038/s41598-021-03892-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 12/02/2021] [Indexed: 12/17/2022] Open
Abstract
Neuroimaging is crucial for assessing mass effect in brain-injured patients. Transport to an imaging suite, however, is challenging for critically ill patients. We evaluated the use of a low magnetic field, portable MRI (pMRI) for assessing midline shift (MLS). In this observational study, 0.064 T pMRI exams were performed on stroke patients admitted to the neuroscience intensive care unit at Yale New Haven Hospital. Dichotomous (present or absent) and continuous MLS measurements were obtained on pMRI exams and locally available and accessible standard-of-care imaging exams (CT or MRI). We evaluated the agreement between pMRI and standard-of-care measurements. Additionally, we assessed the relationship between pMRI-based MLS and functional outcome (modified Rankin Scale). A total of 102 patients were included in the final study (48 ischemic stroke; 54 intracranial hemorrhage). There was significant concordance between pMRI and standard-of-care measurements (dichotomous, κ = 0.87; continuous, ICC = 0.94). Low-field pMRI identified MLS with a sensitivity of 0.93 and specificity of 0.96. Moreover, pMRI MLS assessments predicted poor clinical outcome at discharge (dichotomous: adjusted OR 7.98, 95% CI 2.07–40.04, p = 0.005; continuous: adjusted OR 1.59, 95% CI 1.11–2.49, p = 0.021). Low-field pMRI may serve as a valuable bedside tool for detecting mass effect.
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Affiliation(s)
- Kevin N Sheth
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA.
| | - Matthew M Yuen
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Mercy H Mazurek
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Bradley A Cahn
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Anjali M Prabhat
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | - Jill T Shah
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | | | | | | | - Jennifer A Kim
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Barbara Gordon-Kundu
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Adrienne Ward Rn
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, USA
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Kevin T Gobeske
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Gordon Sze
- Department of Neuroradiology, Yale School of Medicine, New Haven, CT, USA
| | - Matthew S Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Strohm TA, Hwang DY. Response to Mroz et al., Applying the Care and Communication Bundle to Promote Palliative Care in a Neuro-Intensive Care Unit: Why and How (DOI: 10.1089/jpm.2020.0730). J Palliat Med 2021; 24:1755-1756. [PMID: 34851193 DOI: 10.1089/jpm.2021.0470] [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: 11/12/2022] Open
Affiliation(s)
- Tamara A Strohm
- Division of Cerebrovascular Disease and Neurocritical Care, Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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Garg A, Soto AL, Knies AK, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data. Neurocrit Care 2021; 35:468-479. [PMID: 33619667 PMCID: PMC8380750 DOI: 10.1007/s12028-021-01200-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 10/06/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with a severe acute brain injury admitted to the intensive care unit often have a poor neurological prognosis. In these situations, a clinician is responsible for conducting a goals-of-care conversation with the patient's surrogate decision makers. The diversity in thought and background of surrogate decision makers can present challenges during these conversations. For this reason, our study aimed to identify predictive characteristics of US surrogate decision makers' favoring life-sustaining treatment (LST) over comfort measures only for patients with severe acute brain injury. METHODS We analyzed data from a cross-sectional survey study that had recruited 1588 subjects from an online probability-based US population sample. Seven hundred and ninety-two subjects had randomly received a hypothetical scenario regarding a relative intubated with severe acute brain injury with a prognosis of severe disability but with the potential to regain some consciousness. Seven hundred and ninety-six subjects had been randomized to a similar scenario in which the relative was projected to remain vegetative. For each scenario, we conducted univariate analyses and binary logistic regressions to determine predictors of LST selection among available respondent characteristics. RESULTS 15.0% of subjects selected LST for the severe disability scenario compared to 11.4% for the vegetative state scenario (p = 0.07), with those selecting LST in both groups expressing less decisional certainty. For the severe disability scenario, independent predictors of LST included having less than a high school education (adjusted OR = 2.87, 95% CI = 1.23-6.76), concern regarding prognostic accuracy (7.64, 3.61-16.15), and concern regarding the cost of care (4.07, 1.80-9.18). For the vegetative scenario, predictors included the youngest age group (30-44 years, 3.33, 1.02-10.86), male gender (3.26, 1.75-6.06), English as a second language (2.94, 1.09-7.89), Evangelical Protestant (3.72, 1.28-10.84) and Catholic (4.01, 1.72-9.36) affiliations, and low income (< $25 K). CONCLUSION Several demographic and decisional characteristics of US surrogate decision makers predict LST selection for patients with severe brain injury with varying degrees of poor prognosis. Surrogates concerned about the cost of medical care may nevertheless be inclined to select LST, albeit with high levels of decisional uncertainty, for patients projected to have severe disabilities.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
| | - Andrea K Knies
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
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Abstract
Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.
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Affiliation(s)
- Lucy Gao
- Yale School of Medicine, New Haven, CT, United States
| | | | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
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Abstract
Coma trajectories are characterized by quick awakening or protracted awakening. Outcome is bookended by restored functionality or permanent cognitively and physically debilitated states. Given the stakes, prognostication cannot be easily questioned as a judgment call, and a scientific underpinning is elemental. Conventional wisdom in determining coma-outcome trajectories posits that (1) predictive models are better than personal experiences, (2) self-fulfilling prophesy is unchecked and driven by nihilism, with little regard for prior probability outcomes, and (3) recovery is impacted by patients’ prior wishes and preexisting medical conditions—but also by what families are told about the patient’s state and anticipated clinical course. Moreover, a predicted good outcome can be offset by a major subsequent complication, or a predicted poor outcome can be offset by aggressive care. This article examines some of these concepts, including how we decide on aggressiveness of care, how we judge quality of life, and the impact on outcome. Most patients who awaken quickly do well and can resume their pretrauma injury lives. In worse off, slow-to-awaken patients, outcomes are a mixed bag of limited innate resilience, depleted cognitive and physical reserves, and adjusted quality of life. Bias and noise are factors not easily measured in outcome prediction, but their influence on recovery trajectories raises some troubling issues.
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Affiliation(s)
- Eelco F M Wijdicks
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA. .,Yale New Haven Hospital, New Haven, CT, USA. .,Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David Y Hwang
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA.,Yale New Haven Hospital, New Haven, CT, USA
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29
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Weber U, Zhang Q, Ou D, Garritano J, Johnson J, Anderson N, Knies AK, Nhundu B, Bautista C, Huang KB, Vranceanu AM, Rosand J, Hwang DY. Predictors of Family Dissatisfaction with Support During Neurocritical Care Shared Decision-Making. Neurocrit Care 2021; 35:714-722. [PMID: 33821402 PMCID: PMC8021441 DOI: 10.1007/s12028-021-01211-6] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is a critical need to improve support for families making difficult shared decisions about patient care with clinicians in the neuroscience ICU (neuro-ICU). The aim of this study is to identify patient- and family-related factors associated with dissatisfaction with shared decision-making support among families of neuro-critically ill patients. METHODS We conducted a retrospective observational cohort study using survey data that had been collected from a consecutive sample of family members of patients in the neuro-ICU (one family member per patient) at two US academic centers. Satisfaction with shared decision-making support on ICU discharge had been measured among family members using one specific Likert scale item on the Family Satisfaction in the ICU 24 survey, a validated survey instrument for families of patients in the ICU. We dichotomized top-box responses for this particular item as an outcome variable and identified available patient- and family-related covariates associated with dissatisfaction (i.e., less than complete satisfaction) via univariate and multivariate analyses. RESULTS Among 355 surveys, 180 (49.5%) of the surveys indicated dissatisfaction with support during decision-making. In a multivariate model, no preexisting characteristics of families or patients ascertainable on ICU admission were predictive of dissatisfaction. However, among family factors determined during the ICU course, experiencing three or fewer formal family meetings (odds ratio 1.93 [confidence interval 1.13-3.31]; p = 0.01) was significantly predictive of dissatisfaction with decisional support in this cohort with an average patient length of stay of 8.6 days (SD 8.4). There was also a trend toward a family's decision to keep a patient as full code, without treatment limitations, being predictive of dissatisfaction (odds ratio 1.80 [confidence interval 0.93-3.51]; p = 0.08). CONCLUSIONS Family dissatisfaction with neuro-ICU shared decision-making support is not necessarily predicted by any preexisting family or patient variables but appears to correlate with participating in fewer formal family meetings during ICU admission. Future studies to improve family satisfaction with neurocritical care decision-making support should have broad inclusion criteria for participants and should consider promoting frequency of family meetings as a core strategy.
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Affiliation(s)
- Urs Weber
- Yale School of Medicine, Yale University, New Haven, CT, USA.,Yale New Haven Hospital, New Haven, CT, USA
| | - Qiang Zhang
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Derek Ou
- Donald and Barbara Zucker School of Medicine At Hofstra/Northwell, Long Island, NY, USA
| | - James Garritano
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | | | | | - Andrea K Knies
- Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Belinda Nhundu
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Cynthia Bautista
- School of Nursing and Health Studies, Fairfield University, Fairfield, CT, USA
| | - Kevin B Huang
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Ana-Maria Vranceanu
- Harvard Medical School, Harvard University, Boston, MA, USA.,Division of Neurocritical Care and the Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA.,Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- Harvard Medical School, Harvard University, Boston, MA, USA.,Division of Neurocritical Care and the Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - David Y Hwang
- Yale New Haven Hospital, New Haven, CT, USA. .,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, Yale University, New Haven, CT, USA. .,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, CT, USA.
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Albert GP, Hwang DY, George BP. Abstract P273: Hospitalization Costs for United States Stroke Patients Receiving Tracheostomy. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p273] [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:
Stroke patients who receive tracheostomy often undergo prolonged ventilation and have long, complicated ICU stays. Little is known about the hospitalization costs for these patients.
Methods:
We used the National Inpatient Sample from 2008-2017 to identify patients with a primary diagnosis of acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. We identified individuals who received tracheostomy based on procedure codes. We used cost-to-charge ratios to calculate hospitalization costs for each patient and adjusted costs to 2017 US dollars using the Medical Consumer Price Index. We examined differences in hospitalization costs based on age, sex, race, Elixhauser score, length of stay, and early tracheostomy placement (≤7 days). We calculated overall average annual hospitalization costs for all patients with stroke and tracheostomy in the US and compared to the total US acute stroke population inpatient costs.
Results:
We identified an estimated 61,322 acute stroke patients in the US receiving tracheostomy from 2008 to 2017, representing 1.1% of all US acute stroke patients. Stroke patients with tracheostomy had a mean age of 61 years (SD=13.8); 46% were female, 29% black, 12% Hispanic, and 13% rural. Among tracheostomy patients, the mean Elixhauser score was 4.7 (SD=2). The mean hospitalization cost for tracheostomy patients was $117,492 (median $97,063; IQR $64,887-$145,419). Costs were greater for younger patients, females, and those from urban locations. There was no difference in costs for white compared to minority patients. Each additional hospital day accounted for $2,023 in hospitalization costs, and those with early tracheostomy (22% of tracheostomy patients) had lower hospitalization costs (mean $89,811 vs. $125,318; p<0.001). Total US hospitalization costs for acute stroke patients receiving tracheostomy are estimated at $720.4 million per year, which represents 8.1% of total acute stroke hospitalization costs in the US.
Conclusion:
Acute stroke patients who receive tracheostomy account for 1% of all stroke patients, but 8% of all hospitalization costs for stroke in the US.
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Yuen M, Mazurek M, Cahn B, Prabhat A, By S, Hu HH, Welch EB, Sacolick L, O’Halloran R, Ward A, Timario N, Falcone GJ, Gilmore EJ, Hwang DY, Kim J, Kaddouh F, Sharma R, Amin H, Schindler JL, Matouk C, Hebert R, Wira CR, Sze G, Rosen M, Kimberly WT, Sheth KN. Abstract 33: Qualitative Description of Ischemic Stroke Appearance on Low-Field, Point-Of-Care Magnetic Resonance Imaging. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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
Background and Aims:
Advances in low-field MRI have enabled image acquisition at the point-of-care (POC). We aim to characterize ischemic lesions in low-field, POC MRI and assess its relationship with stroke severity in ischemic stroke patients.
Methods:
We performed POC MRI exams on ischemic stroke patients. T2-weighted (T2W), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI) exams were acquired with a 64mT, portable bedside MRI system. Three raters computed signal intensity ratios (SIR) for each sequence. For every slice showing an infarct, an SIR was generated by dividing the mean signal intensity of the lesion by the mean signal intensity of the contralateral hemisphere. Infarct volumes were obtained by multiplying the lesion area of each slice by the slice thickness (5mm) and summing the cross-sectional areas. Volumes were correlated with National Institutes of Health Stroke Scale (NIHSS) scores at the time of scan.
Results:
We studied 18 ischemic stroke patients (50% women; ages 30-95 years). Two patients were studied at two and three serial timepoints, respectively. POC exams were obtained 2.7 ± 2.2 days after symptom onset. A total of 18 T2W, 17 FLAIR, and 18 DWI exams were obtained. Three exams (1 T2W; 1 FLAIR; 1 DWI) were excluded due to motion degradation. High field MRI exams (19 ± 16 hours from POC exams) demonstrated ischemic infarcts in 15 of the 18 patients. All POC T2W and FLAIR exams revealed infarcts in these patients, and 14 of the 17 DWI exams showed infarcts. Ischemic infarcts were seen as hyperintense lesions (SIR: T2W = 1.19 ± 0.10, FLAIR = 1.15 ± 0.08, DWI = 1.36 ± 0.17). Infarct volume significantly correlated with NIHSS scores (T2W: r = 0.71, p < 0.01; FLAIR: r = 0.65, p < 0.05; DWI: r = 0.65, p < 0.05).
Conclusions:
These preliminary data suggest that low-field, POC MRI may be useful in the clinical evaluation of ischemic stroke. Further work in larger cohorts is needed to elucidate the appearance of infarction on low-field imaging.
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Hwang DY. Ventriculostomy Without Decompressive Suboccipital Craniectomy for a Devastating Posterior Fossa Mass Lesion: Doing "Everything" for the Family. Neurocrit Care 2020; 34:8-9. [PMID: 33263145 PMCID: PMC7707899 DOI: 10.1007/s12028-020-01156-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 12/03/2022]
Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
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33
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Reznik ME, Moody S, Murray K, Costa S, Grory BM, Madsen TE, Mahta A, Wendell LC, Thompson BB, Rao SS, Stretz C, Sheth KN, Hwang DY, Zahuranec DB, Schrag M, Daiello LA, Asaad WF, Jones RN, Furie KL. The impact of delirium on withdrawal of life-sustaining treatment after intracerebral hemorrhage. Neurology 2020; 95:e2727-e2735. [PMID: 32913011 PMCID: PMC7734724 DOI: 10.1212/wnl.0000000000010738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/12/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To determine the impact of delirium on withdrawal of life-sustaining treatment (WLST) after intracerebral hemorrhage (ICH) in the context of established predictors of poor outcome, using data from an institutional ICH registry. METHODS We performed a single-center cohort study on consecutive patients with ICH admitted over 12 months. ICH features were prospectively adjudicated, and WLST and corresponding hospital day were recorded retrospectively. Patients were categorized using DSM-5 criteria as never delirious, ever delirious (either on admission or later during hospitalization), or persistently comatose. We determined the impact of delirium on WLST using Cox regression models adjusted for demographics and ICH predictors (including Glasgow Coma Scale score), then used logistic regression with receiver operating characteristic curve analysis to compare the accuracy of ICH score-based models with and without delirium category in predicting WLST. RESULTS Of 311 patients (mean age 70.6 ± 15.6, median ICH score 1 [interquartile range 1-2]), 50% had delirium. WLST occurred in 26%, and median time to WLST was 1 day (0-6). WLST was more frequent in patients who developed delirium (adjusted hazard ratio 8.9 [95% confidence interval (CI) 2.1-37.6]), with high rates of WLST in both early (occurring ≤24 hours from admission) and later delirium groups. An ICH score-based model was strongly predictive of WLST (area under the curve [AUC] 0.902 [95% CI 0.863-0.941]), and the addition of delirium category further improved the model's accuracy (AUC 0.936 [95% CI 0.909-0.962], p = 0.004). CONCLUSION Delirium is associated with WLST after ICH regardless of when it occurs. Further study on the impact of delirium on clinician and surrogate decision-making is warranted.
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Affiliation(s)
- Michael E Reznik
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN.
| | - Scott Moody
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Kayleigh Murray
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Samantha Costa
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Brian Mac Grory
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Tracy E Madsen
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Ali Mahta
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Linda C Wendell
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Bradford B Thompson
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Shyam S Rao
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Christoph Stretz
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Kevin N Sheth
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Y Hwang
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Darin B Zahuranec
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Matthew Schrag
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Lori A Daiello
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Wael F Asaad
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Richard N Jones
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Karen L Furie
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
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34
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Sheth KN, Mazurek MH, Yuen MM, Cahn BA, Shah JT, Ward A, Kim JA, Gilmore EJ, Falcone GJ, Petersen N, Gobeske KT, Kaddouh F, Hwang DY, Schindler J, Sansing L, Matouk C, Rothberg J, Sze G, Siner J, Rosen MS, Spudich S, Kimberly WT. Assessment of Brain Injury Using Portable, Low-Field Magnetic Resonance Imaging at the Bedside of Critically Ill Patients. JAMA Neurol 2020; 78:2769858. [PMID: 32897296 PMCID: PMC7489395 DOI: 10.1001/jamaneurol.2020.3263] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/17/2020] [Indexed: 01/17/2023]
Abstract
IMPORTANCE Neuroimaging is a key step in the clinical evaluation of brain injury. Conventional magnetic resonance imaging (MRI) systems operate at high-strength magnetic fields (1.5-3 T) that require strict, access-controlled environments. Limited access to timely neuroimaging remains a key structural barrier to effectively monitor the occurrence and progression of neurological injury in intensive care settings. Recent advances in low-field MRI technology have allowed for the acquisition of clinically meaningful imaging outside of radiology suites and in the presence of ferromagnetic materials at the bedside. OBJECTIVE To perform an assessment of brain injury in critically ill patients in intensive care unit settings, using a portable, low-field MRI device at the bedside. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, single-center cohort study of 50 patients admitted to the neuroscience or coronavirus disease 2019 (COVID-19) intensive care units at Yale New Haven Hospital in New Haven, Connecticut, from October 30, 2019, to May 20, 2020. Patients were eligible if they presented with neurological injury or alteration, no contraindications for conventional MRI, and a body habitus not exceeding the scanner's 30-cm vertical opening. Diagnosis of COVID-19 was determined by positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction nasopharyngeal swab result. EXPOSURES Portable MRI in an intensive care unit room. MAIN OUTCOMES AND MEASURES Demographic, clinical, radiological, and treatment data were collected and analyzed. Brain imaging findings are described. RESULTS Point-of-care MRI examinations were performed on 50 patients (16 women [32%]; mean [SD] age, 59 [12] years [range, 20-89 years]). Patients presented with ischemic stroke (n = 9), hemorrhagic stroke (n = 12), subarachnoid hemorrhage (n = 2), traumatic brain injury (n = 3), brain tumor (n = 4), and COVID-19 with altered mental status (n = 20). Examinations were acquired at a median of 5 (range, 0-37) days after intensive care unit admission. Diagnostic-grade T1-weighted, T2-weighted, T2 fluid-attenuated inversion recovery, and diffusion-weighted imaging sequences were obtained for 37, 48, 45, and 32 patients, respectively. Neuroimaging findings were detected in 29 of 30 patients who did not have COVID-19 (97%), and 8 of 20 patients with COVID-19 (40%) demonstrated abnormalities. There were no adverse events or complications during deployment of the portable MRI or scanning in an intensive care unit room. CONCLUSIONS AND RELEVANCE This single-center series of patients with critical illness in an intensive care setting demonstrated the feasibility of low-field, portable MRI. These findings demonstrate the potential role of portable MRI to obtain neuroimaging in complex clinical care settings.
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Affiliation(s)
- Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Mercy H. Mazurek
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew M. Yuen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Bradley A. Cahn
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Jill T. Shah
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Adrienne Ward
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, Connecticut
| | - Jennifer A. Kim
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Emily J. Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin T. Gobeske
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Firas Kaddouh
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - David Y. Hwang
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph Schindler
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Rothberg
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
- Hyperfine Research Inc, Guilford, Connecticut
| | - Gordon Sze
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan Siner
- Division of Pulmonology and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew S. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown
| | - Serena Spudich
- Division of Neurology Infections & Global Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - W. Taylor Kimberly
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston
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Jasne AS, Chojecka P, Maran I, Mageid R, Eldokmak M, Zhang Q, Nystrom K, Vlieks K, Askenase M, Petersen N, Falcone GJ, Wira CR, Lleva P, Zeevi N, Narula R, Amin H, Navaratnam D, Loomis C, Hwang DY, Schindler J, Hebert R, Matouk C, Krumholz HM, Spudich S, Sheth KN, Sansing LH, Sharma R. Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic. Stroke 2020; 51:2664-2673. [PMID: 32755347 PMCID: PMC7446978 DOI: 10.1161/str.0000000000000347] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [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] [Indexed: 01/26/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic. Methods: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic. Results: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 (P=0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city (P<0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale. Conclusions: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.
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Affiliation(s)
- Adam S Jasne
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Pola Chojecka
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Ilavarasy Maran
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Razaz Mageid
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Mohamed Eldokmak
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Qiang Zhang
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Karin Nystrom
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Kelsey Vlieks
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Michael Askenase
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Nils Petersen
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Guido J Falcone
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Charles R Wira
- Department of Emergency Medicine (C.R.W.), Yale University School of Medicine, New Haven, CT
| | - Paul Lleva
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Neer Zeevi
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Reshma Narula
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Hardik Amin
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Dhasakumar Navaratnam
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Caitlin Loomis
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - David Y Hwang
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Joseph Schindler
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Departments of Neurosurgery and of Radiology and Biomedical Imaging (R.H., C.M.), Yale University School of Medicine, New Haven, CT
| | - Charles Matouk
- Departments of Neurosurgery and of Radiology and Biomedical Imaging (R.H., C.M.), Yale University School of Medicine, New Haven, CT
| | - Harlan M Krumholz
- Department of Cardiology (H.M.K.), Yale University School of Medicine, New Haven, CT
| | - Serena Spudich
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Lauren H Sansing
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Richa Sharma
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
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Wartenberg KE, Hwang DY, Haeusler KG, Muehlschlegel S, Sakowitz OW, Madžar D, Hamer HM, Rabinstein AA, Greer DM, Hemphill JC, Meixensberger J, Varelas PN. Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society. Neurocrit Care 2020; 31:231-244. [PMID: 31368059 PMCID: PMC6757096 DOI: 10.1007/s12028-019-00769-6] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background/Objective Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many different conditions. However, there are concerns about significant gaps in knowledge regarding optimal methods of prognostication. Methods As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prognostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain–Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines. Results Prognostic models exist for all of the conditions presented. However, there are significant gaps in prognostication in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifically, the self-fulfilling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identified as major gaps in most prognostic models. Conclusions Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
| | - Susanne Muehlschlegel
- Department of Neurology, Anesthesiology and Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Oliver W Sakowitz
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord St, Boston, MA, 02118, USA
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Juergen Meixensberger
- Department of Neurosurgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Panayiotis N Varelas
- Department of Neurology and Neurosurgery, Henry Ford Hospital, 2799 W. Grand Blvd Neurosurgery - K-11, Detroit, MI, 48202, USA
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Muehlschlegel S, Hwang DY, Flahive J, Quinn T, Lee C, Moskowitz J, Goostrey K, Jones K, Pach JJ, Knies AK, Shutter L, Goldberg R, Mazor KM. Goals-of-care decision aid for critically ill patients with TBI: Development and feasibility testing. Neurology 2020; 95:e179-e193. [PMID: 32554766 DOI: 10.1212/wnl.0000000000009770] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 12/17/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To develop and demonstrate early feasibility of a goals-of-care decision aid for surrogates of patients who are critically ill with traumatic brain injury (ciTBI) that meets accepted international decision aid guidelines. METHODS We developed the decision aid in 4 stages: (1) qualitative study of goals-of-care communication and decision needs of 36 stakeholders of ciTBI (surrogates and physicians), which informed (2) development of paper-based decision aid with iterative revisions after feedback from 52 stakeholders; (3) acceptability and usability testing in 18 neurologic intensive care unit (neuroICU) family members recruited from 2 neuroICU waiting rooms using validated scales; and (4) open-label, randomized controlled feasibility trial in surrogates of ciTBI. We performed an interim analysis of 16 surrogates of 12 consecutive patients who are ciTBI to confirm early feasibility of the study protocol and report recruitment, participation, and retention rates to date. RESULTS The resultant goals-of-care decision aid achieved excellent usability (median System Usability Scale 87.5 [possible range 0-100]) and acceptability (97% graded the tool's content as "good" or "excellent"). Early feasibility of the decision aid and the feasibility trial protocol was demonstrated by high rates of recruitment (73% consented), participation (100%), and retention (100% both after the goals-of-care clinician-family meeting and at 3 months) and complete data for the measurements of all secondary decision-related and behavioral outcomes to date. CONCLUSIONS Our systematic development process resulted in a novel goals-of-care decision aid for surrogates of patients who are ciTBI with excellent usability, acceptability, and early feasibility in the neuroICU environment, and meets international decision aid standards. This methodology may be a development model for other decision aids in neurology to promote shared decision-making.
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Affiliation(s)
- Susanne Muehlschlegel
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA.
| | - David Y Hwang
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Julie Flahive
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Thomas Quinn
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Christopher Lee
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Jesse Moskowitz
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Kelsey Goostrey
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Kelsey Jones
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Jolanta J Pach
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Andrea K Knies
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Lori Shutter
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Robert Goldberg
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
| | - Kathleen M Mazor
- From the Departments of Neurology (S.M., C.L., K.G., K.J.), Anesthesiology/Critical Care (S.M.), Surgery (S.M.), Population and Quantitative Health Sciences (J.F., R.G.), Meyers Primary Care Institute (K.M.M.), and Internal Medicine (K.M.M.), University of Massachusetts Medical School, Worcester; Center for Neuroepidemiology and Clinical Neurological Research (D.Y.H.) and Department of Neurology (D.Y.H., J.J.P., A.K.K.), Yale School of Medicine, New Haven, CT; Department of Medicine (T.Q.), Beth Israel Deaconess Hospital, Harvard Medical School, Boston, MA; Department of Psychiatry (J.M.), Brown Medical School, Providence, RI; and Departments of Critical Care Medicine and Neurology (L.S.), University of Pittsburgh School of Medicine, PA
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Zubair AS, Landreneau M, Witsch J, Fulbright RK, Huttner A, Sheth KN, Hwang DY. A Critically Ill Patient With Central Nervous System Tuberculosis and Negative Initial Workup. Front Neurol 2020; 11:430. [PMID: 32595583 PMCID: PMC7304250 DOI: 10.3389/fneur.2020.00430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/17/2020] [Accepted: 04/22/2020] [Indexed: 11/29/2022] Open
Abstract
Empiric anti-tuberculous therapy should not be delayed in patients with a strong clinical suspicion for TB. Because confirmatory TB testing may be difficult to obtain, early and empiric treatment, when there is concern for central nervous system TB, may result in improved outcomes for patients. GeneXpert is currently an area of active research, and the test returns diagnostic results within hours, which would make it the preferred test for investigating TB meningitis.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Mark Landreneau
- Department of Neurology, Stamford Hospital, Stamford, CT, United States
| | - Jens Witsch
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Robert K Fulbright
- Department of Radiology, Yale School of Medicine, New Haven, CT, United States
| | - Anita Huttner
- Department of Pathology, Yale School of Medicine, New Haven, CT, United States
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States.,Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States.,Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, CT, United States
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Neal JB, Pearlman RA, White DB, Tolchin B, Sheth KN, Bernat JL, Hwang DY. Policies for Mandatory Ethics Consultations at U.S. Academic Teaching Hospitals: A Multisite Survey Study. Crit Care Med 2020; 48:847-853. [PMID: 32317595 PMCID: PMC10765238 DOI: 10.1097/ccm.0000000000004343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the number of top-ranked U.S. academic institutions that require ethics consultation for specific adult clinical circumstances (e.g., family requests for potentially inappropriate treatment) and to detail those circumstances and the specific clinical scenarios for which consultations are mandated. DESIGN Cross-sectional survey study, conducted online or over the phone between July 2016 and October 2017. SETTING We identified the top 50 research medical schools through the 2016 U.S. News and World Report rankings. The primary teaching hospital for each medical school was included. SUBJECTS The chair/director of each hospital's adult clinical ethics committee, or a suitable alternate representative familiar with ethics consultation services, was identified for study recruitment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A representative from the adult ethics consultation service at each of the 50 target hospitals was identified. Thirty-six of 50 sites (72%) consented to participate in the study, and 18 (50%) reported having at least one current mandatory consultation policy. Of the 17 sites that completed the survey and listed their triggers for mandatory ethics consultations, 20 trigger scenarios were provided, with three sites listing two distinct clinical situations. The majority of these triggers addressed family requests for potentially inappropriate treatment (9/20, 45%) or medical decision-making for unrepresented patients lacking decision-making capacity (7/20, 35%). Other triggers included organ donation after circulatory death, initiation of extracorporeal membrane oxygenation, denial of valve replacement in patients with subacute bacterial endocarditis, and posthumous donation of sperm. Twelve (67%) of the 18 sites with mandatory policies reported that their protocol(s) was formally documented in writing. CONCLUSIONS Among top-ranked academic medical centers, the existence and content of official policies regarding situations that mandate ethics consultations are variable. This finding suggests that, despite recent critical care consensus guidelines recommending institutional review as standard practice in particular scenarios, formal adoption of such policies has yet to become widespread and uniform.
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Affiliation(s)
- Jonathan B Neal
- University of Connecticut School of Medicine, Farmington, CT
| | - Robert A Pearlman
- National Center for Ethics in Health Care, Veterans Health Administration, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, CT
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - David Y Hwang
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
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Hwang DY, Knies AK, Mampre D, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L. Concerns of surrogate decision makers for patients with acute brain injury: A US population survey. Neurology 2020; 94:e2054-e2068. [PMID: 32341190 PMCID: PMC7282883 DOI: 10.1212/wnl.0000000000009406] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 12/03/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether groups of surrogates for patients with severe acute brain injury (SABI) with poor prognosis can be identified based on their prioritization of goals-of-care (GOC) decisional concerns, an online survey of 1,588 adults recruited via a probability-based panel representative of the US population was conducted. METHODS Participants acted as a surrogate for a GOC decision for a hypothetical patient with SABI and were randomized to 1 of 2 prognostic scenarios: the patient likely being left with a range of severe functional disability (SD) or remaining in a vegetative state (VS). Participants prioritized a list of 12 decisional concerns via best-worst scaling. Latent class analysis (LCA) was used to discover decisional groups. RESULTS The completion rate was 44.6%; data weighting was conducted to mitigate nonresponse bias. For 792 SD respondents, LCA revealed 4 groups. All groups shared concerns regarding respecting patient wishes and minimizing suffering. The 4 groups were otherwise distinguished by unique concerns that their members highlighted: an older adult remaining severely disabled (34.4%), family consensus (26.4%), doubt regarding prognostic accuracy (20.7%), and cost of long-term care (18.6%). For the 796 VS respondents, LCA revealed 5 groups. Four of the 5 groups had similar concern profiles to the 4 SD groups. The largest (29.0%) expressed the most prognostic doubt. An additional group (15.8%) prioritized religious concerns. CONCLUSIONS Although surrogate decision makers for patients with SABI are concerned with respecting patient wishes and minimizing suffering, certain groups highly prioritize other specific decisional factors. These data can help inform future interventions for supporting decision makers.
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Affiliation(s)
- David Y Hwang
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT.
| | - Andrea K Knies
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - David Mampre
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Stanislav Kolenikov
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Marci Schalk
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Heather Hammer
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Douglas B White
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Robert G Holloway
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Kevin N Sheth
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
| | - Liana Fraenkel
- From the Yale School of Medicine (DYH, AKK, KNS), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, New Haven, CT; Johns Hopkins School of Medicine (DM), Baltimore, MD; Abt Associates (SK), Columbia, MO; Abt Associates (MS), Chicago, IL; Booz Allen Hamilton (HH), Social Science Group, Washington, DC; Department of Critical Care Medicine (DBW), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (RGH), University of Rochester Medical Center, Rochester, NY; and Yale School of Medicine (LF), Department of Internal Medicine, New Haven, CT
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Junn A, Hwang DY. Practice Variability in Determination of Death by Neurologic Criteria for Adult Patients. Yale J Biol Med 2019; 92:719-724. [PMID: 31866786 PMCID: PMC6913831] [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] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 2010, the American Academy of Neurology (AAN) published updated official guidelines for specific practices involved in the determination of death by neurologic criteria for adult patients, otherwise known as brain death. Most states, however, do not have laws mandating the standard adoption of the AAN guidelines. The responsibilities for creating and implementing brain death determination policies thus falls on individual hospitals. As a result, significant variability in practice exists between hospitals and even between providers. This review highlights the ways in which and the extent to which adult brain death determination varies across the US, while also making the case that such persistent levels of heterogeneity call for improvements in standardizing training in brain death determination.
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Affiliation(s)
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Department of Neurology, Yale School of Medicine, New Haven, CT,To whom all correspondence should be addressed: David Y. Hwang, MD, FAAN, FCCM, FNCS, Associate Professor, Division of Neurocritical Care and Emergency Neurology, Division of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520; Tel: 203-785-7171, Fax: 203-737-4419,
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Hwang DY. Is Post-Neurointensive Care Syndrome Actually a Thing? Neurocrit Care 2019; 31:453-454. [PMID: 31420783 DOI: 10.1007/s12028-019-00827-z] [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: 10/26/2022]
Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520, USA.
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Feler J, Tan A, Sammann A, Matouk C, Hwang DY. Decision Making Among Patients with Unruptured Aneurysms: A Qualitative Analysis of Online Patient Forum Discussions. World Neurosurg 2019; 131:e371-e378. [DOI: 10.1016/j.wneu.2019.07.161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
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Weber U, Johnson J, Anderson N, Knies AK, Nhundu B, Bautista C, Huang KB, Hamza M, White J, Coppola A, Akgün KM, Greer DM, Marcolini EG, Gilmore EJ, Petersen NH, Timario N, Poskus K, Sheth KN, Hwang DY. Dedicated Afternoon Rounds for ICU Patients' Families and Family Satisfaction With Care. Crit Care Med 2019; 46:602-611. [PMID: 29300237 DOI: 10.1097/ccm.0000000000002963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE It was hypothesized that adding dedicated afternoon rounds for patients' families to supplement standard family support would improve overall family satisfaction with care in a neuroscience ICU. DESIGN Pre- and postimplementation (pre-I and post-I) design. SETTING Single academic neuroscience ICU. PATIENTS Patients in the neuroscience ICU admitted for longer than 72 hours or made comfort measures only at any point during neuroscience ICU admission. INTERVENTION The on-service attending intensivist and a neuroscience ICU nursing leader made bedside visits to families to address concerns during regularly scheduled, advertised times two afternoons each week. MEASUREMENTS AND MAIN RESULTS One family member per patient during the pre-I and post-I periods was recruited to complete the Family Satisfaction in the ICU 24 instrument. Post-I respondents indicated whether they had participated in the afternoon rounds. For primary outcome, the mean pre-I and post-I composite Family Satisfaction in the ICU 24 scores (on a 100-point scale) were compared. A total of 146 pre-I (March 2013 to October 2014; capture rate, 51.6%) and 141 post-I surveys (October 2014 to December 2015; 47.2%) were collected. There was no difference in mean Family Satisfaction in the ICU 24 score between groups (pre-I, 89.2 ± 11.2; post-I, 87.4 ± 14.2; p = 0.6). In a secondary analysis, there was also no difference in mean Family Satisfaction in the ICU 24 score between the pre-I respondents and the 39.0% of post-I respondents who participated in family rounds. The mean Family Satisfaction in the ICU 24 score of the post-I respondents who reported no participation trended lower than the mean pre-I score, with fewer respondents in this group reporting complete satisfaction with emotional support (75% vs. 54%; p = 0.002), coordination of care (82% vs. 68%; p = 0.03), and frequency of communication by physicians (60% vs. 43%; p = 0.03). CONCLUSIONS Dedicated afternoon rounds for families twice a week may not necessarily improve an ICU's overall family satisfaction. Increased dissatisfaction among families who do not or cannot participate is possible.
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Affiliation(s)
- Urs Weber
- Yale School of Medicine, New Haven, CT
| | | | | | | | | | | | | | | | | | | | - Kathleen M Akgün
- Department of Internal Medicine, Pulmonary, Critical Care and Sleep Medicine Section, VA Connecticut Healthcare System and Yale University School of Medicine, West Haven, CT
| | - David M Greer
- Yale-New Haven Hospital, New Haven, CT.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Evie G Marcolini
- Yale-New Haven Hospital, New Haven, CT.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Emily J Gilmore
- Yale-New Haven Hospital, New Haven, CT.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT.,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
| | - Nils H Petersen
- Yale-New Haven Hospital, New Haven, CT.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT.,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
| | | | | | - Kevin N Sheth
- Yale-New Haven Hospital, New Haven, CT.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT.,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
| | - David Y Hwang
- Yale-New Haven Hospital, New Haven, CT.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT.,Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
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Wartenberg KE, Hwang DY, Haeusler KG, Muehlschlegel S, Sakowitz OW, Madžar D, Hamer HM, Rabinstein AA, Greer DM, Hemphill JC, Meixensberger J, Varelas PN. Correction to: Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society. Neurocrit Care 2019; 31:596. [PMID: 31435836 DOI: 10.1007/s12028-019-00824-2] [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: 11/24/2022]
Abstract
This article was updated to correct the spelling of Karl Georg Haeusler.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
| | - Susanne Muehlschlegel
- Department of Neurology, Anesthesiology and Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Oliver W Sakowitz
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord St, Boston, MA, 02118, USA
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Juergen Meixensberger
- Department of Neurosurgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Panayiotis N Varelas
- Department of Neurology and Neurosurgery, Henry Ford Hospital, 2799 W. Grand Blvd Neurosurgery - K-11, Detroit, MI, 48202, USA
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Witsch J, Kuohn L, Hebert R, Cord B, Sansing L, Gilmore EJ, Hwang DY, Petersen N, Falcone GJ, Matouk C, Sheth KN. Early Prognostication of 1-Year Outcome After Subarachnoid Hemorrhage: The FRESH Score Validation. J Stroke Cerebrovasc Dis 2019; 28:104280. [PMID: 31326270 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 05/25/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIM The FRESH score is a tool to prognosticate long-term outcomes after spontaneous subarachnoid hemorrhage (SAH). Here, for the first time, we aimed to externally validate the disability part of FRESH using its original four score variables. METHODS A total of 107 patients with SAH were prospectively enrolled in the Yale Acute Brain Injury Biorepository between September 2014 and January 2018. 12-month functional outcome was recorded prospectively by trained study investigators using the modified Rankin Scale (mRS). FRESH-scores were calculated retrospectively using the original score variables. We used R2 statistics to assess goodness of fit, and the area under the receiver operating characteristic curve (AUC) to assess ability of the score to discriminate between favorable and unfavorable (defined as mRS 4-6) outcome. RESULTS We identified 86 patients with SAH with complete 1-year follow-up data. Mean age was 60 years, 60% were women. An aneurysmal bleeding source was found in 71% of patients. 80% underwent aneurysm coiling, and 5% clipping. Sixteen percent of patients were considered high grade on admission (Hunt&Hess score 4 or 5). Discrimination of the FRESH score between favorable and unfavorable outcome was high (AUC 90.8%, confidence interval 81.9%-96.5%). Nagelkerke's (.54) and Cox&Snell's R2 (.35) indicated satisfactory fit. Exclusion of patients without aneurysmal etiology of SAH did not significantly alter model performance. CONCLUSIONS FRESH, a prognostication score of long-term outcomes in patients with SAH showed excellent score performance in this external validation. FRESH may guide the efficient use of hospital resources, family discussions, and stratification of patients in future randomized controlled trials.
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Affiliation(s)
- Jens Witsch
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut.
| | - Lindsey Kuohn
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Ryan Hebert
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Branden Cord
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520, USA.
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Abstract
This chapter provides an overview of prognostication and key topics in ethics as they relate to the practice of neurocritical care. Challenges with prognostication are summarized. Outcome prognostication tools for ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury are outlined along with a discussion of their limitations. Best practices for communicating prognosis are reviewed. Shared decision-making with surrogate decision-makers in intensive care units is discussed in detail, with attention to advance care planning documentation and resolution of situations in which clinicians may have conscientious objections to potentially inappropriate treatment.
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