Gastrointestinal Bowel Obstruction in Acute Ischemic Stroke: Incidence, Risk Factors, and Outcomes in a U.S. Nationwide Analysis of 3,998,667 Hospitalizations.

OBJECTIVE: The prognosis from acute ischemic stroke (AIS) is worsened by poststroke medical complications. The incidence, risk factors, and outcomes of gastrointestinal bowel obstruction (GIBO) in AIS are not known. METHODS: We queried the Nationwide Inpatient Sample (2002-2011) to identify all patients with a primary diagnosis of AIS and subsets with and without a secondary diagnosis of GIBO without hernia. Multivariable analysis was utilized to identify risk factors for GIBO in AIS patients and the association between GIBO, in-hospital complications, and outcomes. RESULTS: We identified 16,987 patients with GIBO (.43%) among 3,988,667 AIS hospitalizations and 4.2% of these patients underwent surgery. In multivariable analysis, patients with 75+ years of age were two times as likely to suffer GIBO compared to younger patients (P < .0001). African Americans were 42% more likely to have GIBO compared to Whites (P < .0001). Stroke patients with pre-existing comorbidities (coagulopathy, cancer, blood loss anemia, and fluid/electrolyte disorder) were more likely to experience GIBO (all P < .0001). AIS patients with GIBO were 184% and 39% times more likely to face moderate-to-severe disability and in-hospital death, respectively (P < .0001). GIBO occurrence increased length of stay and total costs by an average of 9.7 days and $22,342 (P < .0001). CONCLUSION: GIBO is a rare but burdensome complication of AIS, associated with complications, disability, and mortality. The risk factors identified in this study aim to encourage the monitoring of patients at highest risk for GIBO. The predominant form of stroke-related GIBO is nonmechanical obstruction, although the causative relationship remains unknown.

Traumatic subdural hematoma: Is there a weekend effect?

OBJECTIVE: Traumatic subdural hematoma (TSDH) is a surgical emergency. The effect of weekend admission on surgery and in-hospital outcomes in TSDH is not known. METHODS: We queried the Nationwide Inpatient Sample from 2002 to 2011 and used ICD-9-CM codes to identify all non-elective admissions with a primary diagnosis of TSDH. We did a subgroup analysis of patients who underwent surgical evacuation. Predictor variables included several patient and hospital characteristics. Outcome variables included length of stay, total hospitalization cost, in-hospital complications, adverse discharge disposition, and in-hospital mortality. We used multivariable analysis to determine if weekend admission was independently associated with increased likelihood of poor outcomes. RESULTS: Out of a total of 404,212 TSDH admissions, 24.8% received surgical intervention. Patients admitted on weekends were less likely to undergo surgical intervention (odds ratio [OR]: 0.85). In the surgical cohort, weekend admissions consisted of more patients with prolonged loss of consciousness (24+h) without return to baseline (7.0% vs. 4.8%). In all TSDH patients and in sub-group of surgical cohort, weekend admission was associated with an increased likelihood of in-hospital complication (OR: 1.06 and 1.12), prolonged length of stay (OR: 1.08 and 1.17), increased total hospital costs (OR: 1.04 and 1.11), adverse discharge (OR: 1.08 and 1.18), and in-hospital mortality (OR: 1.04 and 1.11). All p-values were less than 0.01. CONCLUSION: Our study demonstrates that patients admitted on weekends had similar mortality despite higher severity with no clinically significant weekend effect for tSDH.

Recreational marijuana use and acute ischemic stroke: A population-based analysis of hospitalized patients in the United States.

BACKGROUND: Recreational marijuana use is considered to have few adverse effects. However, recent evidence has suggested that it precipitates cardiovascular and cerebrovascular events. Here, we investigated the relationship between marijuana use and hospitalization for acute ischemic stroke (AIS) using data from the largest inpatient database in the United States. METHODS: The Nationwide Inpatient Sample was queried from 2004 to 2011 for all patients (age 15-54) with a primary diagnosis of AIS. The incidence of AIS hospitalization in marijuana users and non-marijuana users was determined. We utilized multivariable logistic regression analyses to study the independent association between marijuana use and AIS. RESULTS: Overall, the incidence of AIS was significantly greater among marijuana users compared to non-users (Relative Risk [RR]: 1.13, 95% CI: 1.11-1.15, P<0.0001) and had the greatest difference in the 25-34 age group (RR: 2.26, 95% CI: 2.13-2.38, P<0.0001). Marijuana use was more prevalent among younger patients, males, African Americans, and Medicaid enrollees (P<0.0001). Marijuana users were more likely to use other illicit substances but had less overall medical comorbidity. In multivariable analysis, adjusted for potential confounders, marijuana (Odds Ratio [OR]: 1.17, 95% CI: 1.15-1.20), tobacco (OR: 1.76, 95% CI: 1.74-1.77), cocaine (OR: 1.32, 95% CI: 1.30-1.34), and amphetamine (OR: 2.21, 95% CI: 2.12-2.30) usage were found to increase the likelihood of AIS (all P<0.0001). CONCLUSION: Among younger adults, recreational marijuana use is independently associated with 17% increased likelihood of AIS hospitalization.

Autoimmune Encephalitis in the ICU: Analysis of Phenotypes, Serologic Findings, and Outcomes.

BACKGROUND: To report the clinical and laboratory characteristics, clinical courses, and outcomes of Mayo Clinic, Rochester, MN, ICU-managed autoimmune encephalitis patients (January 1st 2003-December 31st 2012). METHODS: Based on medical record review, twenty-five patients were assigned to Group 1 (had ≥1 of classic autoimmune encephalitis-specific IgGs, n = 13) or Group 2 (had ≥3 other characteristics supporting autoimmunity, n = 12). RESULTS: Median admission age was 47 years (range 22-88); 17 were women. Initial symptoms included ≥1 of subacute confusion or cognitive decline, 13; seizures, 12; craniocervical pain, 5; and personality change, 4. Thirteen Group 1 patients were seropositive for ≥1 of VGKC-complex-IgG (6; including Lgi1-IgG in 2), NMDA-R-IgG (4), AMPA-R-IgG (1), ANNA-1 (1), Ma1/Ma2 antibody (1), and PCA-1 (1). Twelve Group 2 patients had ≥3 other findings supportive of an autoimmune diagnosis (median 4; range 3-5): ≥1 other antibody type detected, 9; an inflammatory CSF, 8; ≥1 coexisting autoimmune disease, 7; an immunotherapy response, 7; limbic encephalitic MRI changes, 5; a paraneoplastic cause, 4; and diagnostic neuropathological findings, 2. Among 11 patients ICU-managed for ≥4 days, neurological improvements were attributable to corticosteroids (5/7 treated), plasmapheresis (3/7), or rituximab (1/3). At last follow-up, 10 patients had died. Of the remaining 15 patients, 6 (24%) had mild or no disability, 3 (12%) had moderate cognitive problems, and 6 (24%) had dementia (1 was bed bound). Median modified Rankin score at last follow-up was 3 (range 0-6). CONCLUSIONS: Good outcomes may occur in ICU-managed autoimmune encephalitis patients. Clinical and testing characteristics are diverse. Comprehensive diagnostics should be pursued to facilitate timely treatment.

Association of Recreational Marijuana Use with Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Our objective was to evaluate the effect of cannabis use on hospitalizations for aneurysmal subarachnoid hemorrhage (aSAH). METHODS: The Nationwide Inpatient Sample (2004-2011) was used to identify all patients (age 15-54) with a primary diagnosis of aSAH (International Classification of Diseases, Ninth Edition, Clinical Modification 430). We identified patients testing positive for cannabis use using all available diagnosis fields. The incidence and characteristics of aSAH hospitalizations among cannabis users were examined. Bivariate and multivariate analyses were performed to determine the effect of cannabis use on aSAH and in-hospital outcomes. RESULTS: Prior to adjustment, the incidence of aSAH in the cannabis cohort was slightly increased relative to the noncannabis cohort (relative risk: 1.07, 95% confidence interval [CI]: 1.02-1.11). Cannabis use in aSAH was more frequent among younger patients (40.44 ± 10.17 versus 43.74 ± 8.68, P < .0001), males (53.3% versus 40.76%, P < .0001), black patients (35.92% versus 19.10%, P < .0001), and Medicaid enrollees (31.13% versus 18.31%, P < .0001). The cannabis use cohort had greater overall illicit drug use but fewer medical risk factors for aSAH. Cannabis use (odds ratio: 1.18, 95% CI: 1.12-1.24) was found to be an independent predictor of aSAH when adjusting for demographics, substance use, and risk factors. Cannabis use was not associated with symptomatic cerebral vasospasm, inpatient mortality, or adverse discharge disposition. CONCLUSIONS: Our analysis suggests that recreational marijuana use is independently associated with an 18% increased likelihood of aSAH. Further case-control studies may analyze inpatient outcomes and other understudied mechanisms behind cannabis-associated stroke.

Do infants less than 12 months of age with an apparent life-threatening event need transport to a pediatric critical care center?

BACKGROUND: Some emergency medical services (EMS) systems transport infants with an apparent life-threatening event (ALTE) directly to hospitals capable of pediatric critical care (PCC) monitoring. OBJECTIVE: To describe factors identifiable by EMS providers that distinguish ALTE patients who may require PCC monitoring and management. METHODS: This was an observational analysis of ALTE patients who were transported by EMS and presented to four emergency departments (EDs). ED data were prospectively collected. Hospital records or reports from contacted parents were reviewed for interventions that mandated PCC management. We defined a priori the criteria by which PCC monitoring and management were required: if the subject needed 1) airway intervention with bag-valve-mask ventilation or advanced airway (e.g., endotracheal intubation) in the field, ED, or pediatric intensive care unit (PICU); 2) administration of vasopressors; 3) invasive monitoring; 4) surgery during the hospitalization; or 5) subspecialty consultation. Univariate analysis was performed to describe factors associated with requiring PCC management, and a multivariable model, accounting for within-hospital correlations, was developed. RESULTS: A total of 513 patients were enrolled. Of these, 51 (9.9%) had an intervention warranting PCC management. Univariate predictors for requiring PCC management included prematurity, past medical history, resuscitation attempt, upper respiratory infection, apnea, previous ALTE, more than one ALTE in 24 hours, and cyanosis. The multivariable model yielded the following independent predictors for requiring PCC management: resuscitation attempt before EMS arrival, cyanosis, and more than one ALTE in 24 hours. This model demonstrated a sensitivity of 96.3%, a specificity of 25.8%, a negative predictive value of 98.3%, and a positive predictive value of 13.5%. CONCLUSION: Only 9.9% of infants presenting in the field with ALTE had an intervention warranting PCC management, suggesting that many ALTE patients may be safely transported to hospitals without PCC capability. This would allow for better resource utilization of specialty care hospitals and still provide an option for secondary transports for those few patients not correctly identified in the field as requiring PCC. History of resuscitation attempt, cyanosis, and more than one ALTE in 24 hours are independent risk factors for requiring PCC management.

Spinal cord meningioma: a treatable cause of paraplegia.

Chondrocalcinosis associated with Gitelman syndrome (GS) presents in young adults with either no symptoms or joint pain, muscle weakness, muscle cramps, paresthesias, episodes of tetany, or hypokalemic paralysis. Spinal cord meningiomas present with gradual onset of lower extremities weakness, numbness, pain, or balance problem. We report a 76 year old gentleman who presented with gradually progressive leg weakness puzzling the treating physicians.

Waking up from coronary bypass surgery and one eye does not move right.

INTRODUCTION: Complications of coronary artery bypass graft surgery (CABG) include acute oculomotor nerve palsy secondary to ischemic stroke and pituitary apoplexy. These can present with impairment of extraocular muscle function as well as involvement or sparing of the pupil. CASE REPORT: We report the case of a 58-year-old male admitted for elective CABG surgery for severe coronary artery disease and found to have a pupil-sparing partial oculomotor palsy post-procedure. Neurological examination revealed left pupil-sparing isolated medial rectus and levator palpebrae superioris paresis. Magnetic resonance imaging demonstrated acute midbrain infarction. CONCLUSION: Acute pupil-sparing partial oculomotor nerve palsy should be recognized as a neurological complication of cardiac surgery. Pupillary involvement can be helpful in identifying the underlying etiology.

Severe hypercalcemia as a harbinger of acute lymphoblastic leukemia.

CASE: An 8-year-old girl presented to the emergency department with a history of nausea, vomiting, abdominal pain, tiredness, and weight loss of 18 lb over 3 weeks. The only significant examination finding was moderate dehydration. She was found to have severe hypercalcemia (serum calcium, 20 mg/dL). The complete blood count was normal. She was treated successfully for hypercalcemia with hyperhydration, furosemide, calcitonin, and pamidronate. A few days later, she developed pancytopenia when her bone marrow biopsy specimen established the diagnosis of acute lymphoblastic leukemia. CONCLUSIONS: Hypercalcemia presents with nonspecific symptoms of nausea, vomiting, pain in the abdomen, constipation, and tiredness. It can be a harbinger of acute lymphoblastic leukemia. Normal complete blood cell count at presentation does not exclude the diagnosis of leukemia.