Outcome of neurological early rehabilitation patients carrying multi-drug resistant bacteria: results from a German multi-center study.

BACKGROUND: Colonization or infection with multi-drug resistant (MDR) bacteria is considered detrimental to the outcome of neurological and neurosurgical early rehabilitation patients. METHODS: In a German multi-center study, 754 neurological early rehabilitation patients were enrolled and and reviewed in respect to MDR status, length of stay (LOS) and the following outcome variables: Barthel Index (BI), Early Rehabilitation Index (ERI), Glasgow Outcome Score Extended (GOSE), Coma Remission Scale (CRS), Functional Ambulation Categories (FAC). RESULTS: The mean age of the study population was 68.0 ± 14.8 years. Upon admission, the following prevalence for MDRs was observed: MRSA (methicillin resistant staphylococcus aureus) 7.0% (53/754), ESBL- (extended spectrum beta-lactamase) producing bacteria strains 12.6% (95/754), VRE (vancomycin resistant enterococci) 2.8% (21/754). Patients colonized or infected with MDR bacteria (MDR+) were significantly more frequently diagnosed with a critical illness polyneuropathy - CIP - than non-colonized (MDR-) patients: 29.0% vs. 14.8%. In addition, they were more frequently mechanically ventilated (MDR+: 55/138, 39.9%; MDR- 137/616, 22.2%). MDR+ patients were referred to rehabilitation earlier, had a longer LOS in early rehabilitation, lower BI on admission and at discharge, lower ERI on admission and lower CRS at discharge than MDR- patients. There was a highly significant correlation of the BI upon admission with the BI at discharge (rs = 0.492, p < 0.001). GOSE at discharge differed significantly between both groups (χ 2-test, p < 0.01). Perhaps of greatest importance, mortality among MDR+ was higher in comparison to MDR- (18.1% vs. 7.6%). CONCLUSIONS: The outcome of neurological early rehabilitation patients colonized or infected with MDR bacteria including MRSA or ESBL producing strains is significantly poorer than by non-colonized patients. There is some evidence that the poor outcome could be related to the higher morbidity and lower functional status upon admission.

Criterion validity and sensitivity to change of the Early Rehabilitation Index (ERI): results from a German multi-center study.

BACKGROUND: Evaluation of functional status is difficult in neurological and neurosurgical early rehabilitation patients. The Early Rehabilitation Index (ERI) was introduced in Germany over 20 years ago, but since then validation studies are lacking. The ERI (range -325 to 0 points) includes highly relevant items including the necessity of intermittent mechanical ventilation or tracheostomy. METHODS: The present paper analyzed data from a German multi-center study, enrolling 754 neurological early rehabilitation patients. Together with ERI, Barthel Index (BI), Glasgow Coma Scale (GCS), Glasgow Outcome Score Extended, Coma Remission Scale (CRS), Functional Ambulation Categories and length of stay were obtained. RESULTS: ERI showed significant improvements from admission to discharge (p < 0.001). In addition, there were significant correlations of the ERI upon admission and at discharge with BI, CRS and GCS. CONCLUSIONS: Evaluation of our study data suggest that the ERI may be used as a valid assessment instrument for neurological and neurosurgical early rehabilitation patients.

[Course of rehabilitation in early neurological/neurosurgical rehabilitation. Results of a 2014 multi-center evaluation in Germany]. / Rehabilitationsverlauf von Patienten in der neurologisch-neurochirurgischen Frührehabilitation.

BACKGROUND: In Germany, neurological-neurosurgical early rehabilitation is well established in the treatment of severe neurological diseases. To develop quality standards, knowledge of the current rehabilitation course is required. PATIENTS AND METHODS: A retrospective analysis was performed on the course of rehabilitation from patients in an early neurological/neurosurgical rehabilitation program in 16 centers from 10 German states. The odds for a good or poor outcome were investigated using a multivariate logistic regression model. RESULTS: Seven hundred and fifty-four patients were included in the study. The average age of the patients was 68 ± 15 years. Of the patients studied, 26 % were on mechanical ventilation commencing their neurological rehabilitation. The average duration of stay was 56 ± 51 days. Weaning rate from mechanical ventilation was 65 % and the rate of weaning from tracheal cannula was 54 %. Mean improvement in the Barthel Index of 17 points, significant reduction of dysphagia (from 62 to 30 %) and depended walking (from 99 to 82 %), and the achievement of phase C (the next stage of rehabilitation) in 38 % can still be counted as signs of successful rehabilitation. During their course of stay, near 10 % of the patients died. Of these, 67 % received solely palliative care. In the multivariate logistic models, the absence of the factor "necessity for mechanical ventilation on admission" (odds ratio 0.61; 95 % confidence interval (CI): 0.42 … 0.89) increased the chance for good outcome and the presence of this factor the risk of dying with an odds ratio of 8.07 (95 % CI: 4.54-14.34). DISCUSSION: In spite of the severity of neurological deficits, significant functional progress has been made. These results could be interpret as positive proof of the efficacy of neurological/neurosurgical early rehabilitation programs.

Differences in the insulin tolerance test in patients with brain damage depending on posture.

OBJECTIVE: The insulin tolerance test (ITT) is the gold standard for the diagnosis of GH deficiency (GHD) and hypocortisolism. As hypopituitarism is a common disorder after traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH), the test is increasingly used in patients with pre-existing brain damage. DESIGN: A cross-sectional, observational study. METHODS: Fifty-six patients (41 TBI and 15 SAH) were tested with the ITT (0.15 IE/kg body weight, mean glucose 33 mg/dl). In 38 patients, the test was performed in a supine position; the other 18 patients were in a sitting position during the ITT. RESULTS: Hypocortisolism and GHD were more often diagnosed in a supine than in a sitting position (hypocortisolism: 55.3% supine versus 0% sitting, P<0.0001; GHD: 42.1% supine versus 11.1% sitting, P=0.03). Patients in a sitting position suffered more often from symptoms such as tachycardia (61.1% sitting versus 15.8% supine, P=0.001), trembling (22.2 vs 7.9%, NS), and sweating (66.7 vs 28.9%, P=0.007). There were no significant differences between the groups in drowsiness (72.2% sitting versus 65.8% supine, NS), dizziness (44.4 vs 44.7%, NS), and fatigue (33.3 vs 15.8%, NS). Because of somnolence, the hypoglycemic state could only be stopped with i.v. administration of glucose in 25 supine patients (66%). In contrast, none of the 18 patients (0%) tested in a sitting position got somnolent or was in need of i.v. application of glucose (P<0.001). CONCLUSIONS: In patients with brain injury, posture might affect rates of diagnosing GHD and hypocortisolism and sympathetic symptoms in the ITT. These findings are exploratory and need replication in a standardized setting.

Predictors of anterior pituitary insufficiency after traumatic brain injury.

BACKGROUND: Several studies have reported a high prevalence of hypopituitarism after traumatic brain injury (TBI). Risk stratification is a prerequisite for cost-effective hormonal screening of these patients. However, it is still unclear which risk factors predispose patients to develop anterior hypopituitarism after TBI. OBJECTIVE: To assess clinical and radiological risk factors for post-traumatic hypopituitarism. PATIENTS AND METHODS: Seventy-eight consecutive patients (52 men, 26 women; mean age 36.0 years, range 18-65 years) with mild, moderate or severe TBI were studied. Endocrine and clinical parameters were assessed 3 and 12 months after TBI. RESULTS: We found diffuse axonal injury, basal skull fracture and older age to be major risk factors of post-traumatic hypopituitarism. CONCLUSIONS: We have defined specific risk factors for the development of post-traumatic hypopituitarism that are consistent with pathophysiological considerations. These findings might help to identify at-risk patients.

Prevalence of anterior pituitary insufficiency 3 and 12 months after traumatic brain injury.

OBJECTIVE: Cross-sectional studies report a high prevalence of hypopituitarism after traumatic brain injury (TBI); however, no longitudinal studies on time of manifestation and reversibility exist. This study was conducted to assess hypopituitarism 3 and 12 months after TBI. DESIGN: This was a prospective, longitudinal, diagnostic study. METHODS: Seventy-eight patients (52 men, 26 women, mean age 36.0 years) with TBI grades I-III and 38 healthy subjects (25 men, 13 women, mean age 36.4 years) as a control group for the GHRH + arginine test were studied. The prevalence of hypopituitarism was assessed 3 and 12 months after TBI by GHRH + arginine test, short adrenocorticotropic hormone (ACTH) test, and basal hormone measurements in patients. RESULTS: After 3 months, 56% of all patients had impairments of at least one pituitary axis with axes being affected as follows: gonadotropic 32%, corticotropic 19%, somatotropic 9% and thyrotropic 8%. After 12 months, fewer patients were affected, but in some cases new impairments occurred; 36% still had impairments. The axes were affected as follows after 12 months: gonadotropic 21%, somatotropic 10%, corticotropic 9% and thyrotropic 3%. CONCLUSIONS: Hypopituitarism occurs often in the post-acute phase after TBI and may normalize later, but may also develop after the post-acute phase of TBI.

Visuospatial neglect in near and far space: dissociation between line bisection and letter cancellation.

The differential performance on a line bisection and a cancellation task in near and far space was studied. A group of 10 patients with severe left-sided visuospatial neglect and a group of 10 right-brain damaged patients without neglect were examined. The stimuli were presented at a distance of 60 cm (near space) and 160 cm (far space), respectively, and corrected for visual angle. In the line bisection task, patients were asked to point to the estimated line centre with a pencil (near space) or a stick (far space). In the cancellation task, patients pointed to all target stimuli they could detect using either a pencil (near space) or a stick (far space). Most patients with left hemineglect showed a more prominent neglect in far space as compared to near space for the line bisection task, whereas no difference of performance between near and far space was found in the control patients. In contrast, no group showed a distance effect in the cancellation task. The observation that only line bisection is influenced by the distance of the stimulus suggests that line bisection and cancellation are processed differentially. It is proposed that line bisection requires an allocentric reference system focusing attention on objects, whereas cancellation tasks are based on an egocentric reference system responsible for visuospatial attention. Our results indicate that distance changes perception within the allocentric but not within the egocentric system.

[Typical anticipation in type 7 spinocerebellar ataxia]. / Typische Antizipation bei spinozerebellärer Ataxie Typ 7.

Spinocerebellar ataxia type 7 (SCA7) belongs to the category of autosomal dominant cerebellar ataxias (ADCA). The clinical picture is characterised by progressive ataxia and macular degeneration. Other common signs are slow saccades, external ophthalmoplegia, and pyramidal tract signs. The disease is caused by the expansion of an unstable CAG trinucleotide repeat in the gene for ataxin 7 on chromosome 3. SCA7 is a rare disorder. The first case in Germany was described only recently. We report two additional patients, father and son, with the molecular genetic diagnosis of SCA7. The father carries a trinucleotide expansion of 42 CAG repeats, the son 51. Normal alleles range from 7 to 35 CAG repeats. Both patients show the typical picture with progressive ataxia and macular degeneration. We found a pronounced anticipation (earlier disease onset in subsequent generations), which is highly characteristic of CAG repeat disorders.

MRI detection of epidural spinal abscesses at noncontiguous sites.

We report the cases of two patients with the very uncommon clinical finding of two noncontiguous spinal epidural abscesses, which were located in the cervical and lumbar spine. In each case the diagnosis of the second spinal abscess was made by MRI only after the appearance of a new neurological deficit. Decompressive spinal surgery and intravenous antibiotic therapy led to complete recovery in one patient; the other patient was moderately disabled. As epidural spinal abscesses can occur at noncontiguous sites, MRI of the entire spine may be necessary in selected cases.

Cerebrospinal fluid penetration after single or multiple dosage with ticarcillin/clavulanate.

Penetration of ticarcillin and clavulanate into the cerebrospinal fluid was studied in ten patients with varying degrees of impairment of the blood-brain barrier. In general, penetration of both drugs was relatively low and variable (5.4 +/- 5.8% for clavulanate and 2.0 +/- 4.0% for ticarcillin) but markedly better in those patients with impaired blood/brain barrier.

Molecular mechanisms of glial swelling in vitro.

The pathophysiological chain of events occurring during cerebral ischemia is still poorly understood on a molecular level. Therefore, an in vitro model to study glial swelling mechanisms, using C6 glial cells under controlled extracellular conditions, has been established. Flow cytometry serves to determine even small cell volume changes. In this report, the effects of anoxia and acidosis on glial swelling are summarized. Anoxia alone, or in combination with iodoacetate to inhibit anaerobic glycolysis, did not cause an increase of glial volume for up to 2 h. Acidification of the incubation medium below pH 6.8, on the other hand, was immediately followed by cell swelling to 115% of normal. Amiloride or the absence of bicarbonate and Na+ in the medium significantly reduced glial swelling. The data support the contention that swelling results from an activation of the Na+/H+-antiporter to control intracellular pH. It is suggested that swelling in an ischemic penumbra is promoted by this mechanism. Therapeutic approaches to control cerebral pH might be useful to protect brain tissue in cerebral ischemia.

Control of glial cell volume in anoxia. In vitro studies on ischemic cell swelling.

Volume regulation of C6 glial cells was studied in anoxia in vitro to improve the understanding of ischemic cell swelling in the brain. Contrary to in vivo conditions, anoxia or anoxia plus iodoacetate for additional inhibition of anaerobic energy metabolism did not induce glial swelling. However, intracellular K+ was markedly decreased while intracellular Na+ increased. Induction of energy failure by anoxia plus iodoacetate was found to prevent the regulatory volume decrease on hyposmotic exposure of the cells, which is regularly observed in normoxic control conditions. Hyposmotic exposure in anoxia plus iodoacetate led only to an initial tendency of cell volume normalization followed by secondary cell swelling. This was associated with a net increase of intracellular Na+ that may explain the failure of volume regulation under these circumstances. Maintenance of a normal glial cell size during complete energy deprivation by anoxia plus iodoacetate in isotonic medium strongly indicates that energy failure per se does not suffice to induce cell swelling. Cell swelling in cerebral ischemia in vivo thus is likely to require additional mechanisms, most likely an increase of membrane permeability to Na+, which may be caused by release and accumulation of excitotoxins such as glutamate or by an extracellular release of K+. Such a mechanism would hardly influence the extracellular homeostasis in vitro due to the large medium-to-cell volume ratio. The findings demonstrate, nonetheless, the significance of a competent energy metabolism to support cell volume regulation. This is concluded from the failure of regulatory volume decrease of hypotonically suspended glial cells in anoxia plus iodoacetate.(ABSTRACT TRUNCATED AT 250 WORDS)