Isoflurane Use in the Treatment of Super-Refractory Status Epilepticus is Associated with Hippocampal Changes on MRI.

BACKGROUND: Refractory status epilepticus (RSE) is associated with high morbidity and mortality. Experts recommend aggressive management with continuous intravenous infusions or inhaled anesthetics such as isoflurane. However, there is concern that MRI changes in RSE reflect isoflurane neurotoxicity. We performed a case-control study to determine whether isoflurane is neurotoxic, based on MRI signal changes. METHODS: We performed a retrospective case-control study of the incidence of MRI changes in RSE treated with and without isoflurane. Charts were reviewed for demographic and treatment information. T1, T2, and FLAIR sequences of MRIs were reviewed independently by two neuroradiologists blinded to treatment group for presence or absence of signal change or atrophy in the meninges, cortex, white matter, basal ganglia, thalamus, hippocampus, brainstem, and cerebellum. RESULTS: Eight cases of RSE receiving treatment with isoflurane were identified and double-matched with 15 controls who received only intravenous anesthetics. Baseline characteristics were similar. Hippocampal signal change was observed more frequently in cases receiving isoflurane (p = 0.026). CONCLUSIONS: Hippocampal signal changes were associated with isoflurane use in patients with RSE. They were also associated with number of seizure days prior to MRI and the use of multiple anesthetic agents. Similar changes have been seen as a result of RSE itself, and one cannot rule out the possibility these changes represent seizure-related effects. If isoflurane-related, these hippocampal signal changes may be the result of a direct neurotoxic effect of prolonged isoflurane use or failure of isoflurane to protect the hippocampus from seizure-induced injury despite achieving electrographic burst-suppression.

Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach.

OBJECTIVES: The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process. METHODS: The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period. The following 5 measures were reviewed: (1) rates of reported medication administration events involving IDC medications; (2) hospital length of stay; (3) patient mortality; (4) nurses' favorability toward single checking; and (5) nursing time spent on administration of IDC medications. RESULTS: The rate of reported medication administration events involving IDC medications was not significantly different across the groups (95% confidence interval, 0.02%-0.08%; P = 0.4939). The intervention also did not significantly alter mortality ( P = 0.8784) or length of stay ( P = 0.4763) even after controlling for the patient demographic variables. Nursing favorability for single checking increased from 59% of nurses in favor during the double check phase, to 94% by the end of the single check phase. Each double check took an average of 9.7 minutes, and a single check took an average of 1.94 minutes. CONCLUSIONS: Our results suggest that performing independent double checks on high-risk medications administered in a pediatric ICU setting afforded no impact on reported medication events compared with single checking.

Evidence for a shared genetic susceptibility to migraine and epilepsy.

PURPOSE: Although epilepsy and migraine are known to co-occur within individuals, the contribution of a shared genetic susceptibility to this comorbidity remains unclear. We investigated the hypothesis of shared genetic effects on migraine and epilepsy in the Epilepsy Phenome/Genome Project (EPGP) cohort. METHODS: We studied prevalence of a history of migraine in 730 EPGP participants aged ≥ 12 years with nonacquired focal epilepsy (NAFE) or generalized epilepsy (GE) from 501 families containing two or more individuals with epilepsy of unknown cause. Information on migraine without aura (MO) and migraine with aura (MA) was collected using an instrument validated for individuals ≥ 12 years. Because many individuals have both MO and MA, we considered two nonoverlapping groups of individuals with migraine: those who met criteria for MA in any of their headaches (MA), and those who did not ("MO-only"). EPGP participants were interviewed about the history of seizure disorders in additional nonenrolled family members. We evaluated associations of migraine prevalence in enrolled subjects with a family history of seizure disorders in additional nonenrolled relatives, using generalized estimating equations to control for the nonindependence of observations within families. KEY FINDINGS: Prevalence of a history of MA (but not MO-only) was significantly increased in enrolled participants with two or more additional affected first-degree relatives. SIGNIFICANCE: These findings support the hypothesis of a shared genetic susceptibility to epilepsy and MA.

A case of complete lateral gaze paralysis and facial diplegia: the 16 syndrome.

We describe a patient with complete, bilateral horizontal gaze palsies and facial diplegia caused by a midline tegmental pontine hemorrhage. The term "16 syndrome" (7 + 7 + ½ + ½ + ½ + ½ = 16) describes this combination of clinical findings.

A photosensitive surface capable of inducing electrophysiological changes in NG108-15 neurons.

Retinal prostheses promise to be a viable therapy for many forms of blindness. Direct stimulation of neurons using an organic light-sensitive, self-assembled monolayer surface offers a simple alternative to conventional semiconductor technology. For this purpose we have derivatized an indium tin oxide (ITO) substrate with the photosensitive dye, NK5962, using 3-(aminopropyl)trimethoxysilane (APTMS) as cross-linker. The surface was characterized through contact angle goniometry, electrochemical impedance spectroscopy, grazing angle infrared and ultraviolet-visible spectrophotometry. NG108-15 neurons were grown on the ITO-APTMS-NK5962 surface and neural responses from electrical stimulation vs. photostimulation through the ITO-APTMS-NK5962 surface were measured using patch clamp electrophysiology. Under these conditions, photostimulation of depolarized cells caused an approximate 2-fold increase in voltage-gated sodium (Na(+)) current amplitude at a membrane potential of -30mV. Our results demonstrate the feasibility of stimulating neurons, grown on light-sensitive surfaces, with light impulses, which ultimately may facilitate the fabrication of a simple, passive retinal prosthetic.

Seizure localization using ictal phase-locked high gamma: A retrospective surgical outcome study.

OBJECTIVE: To determine whether resection of areas with evidence of intense, synchronized neural firing during seizures is an accurate indicator of postoperative outcome. METHODS: Channels meeting phase-locked high gamma (PLHG) criteria were identified retrospectively from intracranial EEG recordings (102 seizures, 46 implantations, 45 patients). Extent of removal of both the seizure onset zone (SOZ) and PLHG was correlated with seizure outcome, classified as good (Engel class I or II, n = 32) or poor (Engel class III or IV, n = 13). RESULTS: Patients with good outcomes had significantly greater proportions of both SOZ and the first 4 (early) PLHG sites resected. Improved outcome classification was noted with early PLHG, as measured by the area under the receiver operating characteristic curves (PLHG 0.79, SOZ 0.68) and by odds ratios for resections including at least 75% of sites identified by each measure (PLHG 9.7 [95% CI: 2.3-41.5], SOZ 5.3 [95% CI: 1.2-23.3]). Among patients with resection of at least 75% of the SOZ, 78% (n = 30) had good outcomes, increasing to 91% when the resection also included at least 75% of early PLHG sites (n = 22). CONCLUSIONS: This study demonstrates the localizing value of early PLHG, which is comparable to that provided by the SOZ. Incorporation of PLHG into the clinical evaluation may improve surgical efficacy and help to focus resections on the most critical areas.

A safety culture transformation: its effects at a children's hospital.

OBJECTIVE: To improve pediatric patient safety at a tertiary, 200-bed children's hospital by changing the safety culture and implementing processes, practices, and measures to sustain improvements. Although many core quality and safety measures exist for adult acute-care facilities, equivalent measures for pediatrics are lacking. METHODS: Helen DeVos Children's Hospital in Grand Rapids, Michigan, part of the Spectrum Health system, led a 2-year initiative beginning in late 2007 to improve pediatric patient safety. Key strategies included safety-based staff training, training in root cause analysis, failure mode classification of events and safety behavior, integration of and collaboration between risk management and clinical staff, consistent coding and classification of serious safety events and adoption of multiple safety metrics, creating a new safety leadership infrastructure, and fostering transparency of data and safety event details. RESULTS: The 2-year initiative led to an estimated 68% decrease in the number of serious safety events and adoption of a serious safety event metric reported monthly. In addition, compliance with the ventilator-associated pneumonia bundle rose from 2% to 96%; hand hygiene compliance rates rose from 56% to 95%; and the Children's Asthma Care-3 core measure, home management plan of care given to patient/caregiver, rose from 0% to 83% within 6 months. Medication errors with serious harm were reduced to only two during the initiative, and ventilator-associated pneumonias dramatically decreased, with only one occurring in 2009. CONCLUSIONS: The initiative led to key improvements in safety culture and patient safety and also had a broad impact on several clinical quality outcome measures. Using safety metrics improves transparency and enables future benchmarking with peer institutions to help improve pediatric patient safety nationwide. Because of the initiative's success in our children's hospital, the entire Spectrum Health system, including more than 16,000 staff members, is now undertaking a similar effort.

Clinical outcomes of patients with diabetes mellitus receiving medication management by pharmacists in an urban private physician practice.

PURPOSE: The clinical outcomes of patients with diabetes mellitus in an urban environment receiving pharmacist medication management in collaboration with private-practice physicians were assessed. METHODS: Patients older than 18 years with type 1 or 2 diabetes mellitus who were receiving oral and insulin therapy and who were referred to a pharmacy clinic within a private physician practice for medication management between March 1, 2002, and August 31, 2003, were eligible for study inclusion. Data were collected at three junctures: six months before the first visit with the pharmacist (preperiod measure), on the date of clinic entry (index measure), and six months after the first clinic visit (postperiod measure). Primary outcomes analyzed were glycosylated hemoglobin (HbA(1c)), weight, and blood pressure (goal, <130/80 mm Hg). Secondary outcomes analyzed were smoking cessation and initiation of aspirin, angiotensin-converting-enzyme inhibitor, or angiotensin receptor blocker therapy. RESULTS: A significant reduction in HbA(1c) from the index measure to the postperiod measure was observed (p < 0.001). No significant change was noted in weight or number of patients at goal blood pressure among the preperiod, index, and postperiod measures. No change was observed in the secondary outcomes during the study time intervals. CONCLUSION: Integrating a pharmacist into a private physician practice significantly improved patient glycemic control and maintained patients' weight and the number of patients at blood pressure goal. Clinic adherence with the American Diabetes Association recommendations was sustained.

Imperforate anus and colon atresia in a newborn.

Imperforate anus is an uncommon congenital anomaly. Colon atresia is even more infrequent. This report describes a newborn with the simultaneous occurrence of these 2 anomalies, a condition that is exceedingly rare.

Clinical efficacy of serial computed tomographic scanning in pediatric severe traumatic brain injury.

The purpose of this study is to determine whether serial computed tomography (CT) scans of the head lead to operative intervention in pediatric patients with severe traumatic brain injury (TBI). Serial CT scans are those done in addition to the initial CT scan and one follow up CT scan in the first 24-48 h. This study is a retrospective review from January 1990 to December 2003. The hospital course was reviewed for 942 pediatric patients with traumatic brain injuries. Of these, 40 patients were identified who met the following criteria: age less than 18, admission, Glasgow Coma Scale (GCS) < or = 8, intra-cranial pressure (ICP) monitoring during hospitalization, no craniotomy at admission, and at least one serial CT scan after the first 48 h. One hundred fifteen serial CT scans were ordered. Eighty-seven were ordered for routine follow up, 24 were ordered for increased ICP, and 4 were ordered for neurologic change. One craniotomy and one burr hole were performed based on serial CT scans ordered for increased ICP. Serial CT scans, beyond the initial and follow-up scans, have a limited role in children with severe TBI. In this series, only serial CT scans ordered for increased ICP (21%) and neurologic deterioration (3%) led to operative interventions. Serial scans ordered for routine follow-up (76%) resulted in no operative interventions.

Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage.

OBJECTIVE: Controversy surrounds the optimal treatment of parapneumonic effusions. This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage. DESIGN: A prospective, randomized trial was conducted at DeVos Children's Hospital (Grand Rapids, MI) between November 2003 and May 2005. All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study. After enrollment, each patient was randomly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage procedures) were similar for each group per protocol. RESULTS: Eighteen patients were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy. The groups were demographically similar. No mortalities were encountered in either group, and everyone was discharged from the hospital with acceptable outcomes. Yet, there were multiple variables that demonstrated statistical difference. Hospital length of stay, number of chest tube days, narcotic use, number of radiographic procedures, and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery. In addition, no patient in the video-assisted thoracoscopic surgery group required fibrinolytic therapy, which was also statistically different from the thoracostomy drainage group. CONCLUSIONS: The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage.

Absorption and fluorescence of 2,5-diarylidenecyclopentanones in acidic media: evidence for excited-state proton transfer.

Spectroscopic properties for a series of 2,5-diarylidenecyclopentanones in weak and strong acid environments are reported. Electronic absorption and fluorescence spectra have been measured for the all-E configurations of 2,5-dibenzylidenecyclopentanone (1), 2,5-bis(3-phenylallylidene)cyclopentanone (2), and 2,5-bis(5-phenylpenta-2,4-dienylidene)cyclopentanone (3) in acetic acid and sulfuric acid solutions. The spectroscopic evidence indicates that in 96% sulfuric acid 1, 2, and 3 are protonated both in the ground state and on the S1 potential energy surface. This assignment is supported by Zerner's intermediate neglect of differential overlap (ZINDO) and time-dependent density functional theory (TD-DFT) calculations. In glacial acetic acid, 1, 2, and 3 are unprotonated in the ground state. The absence of observable fluorescence from 1 in glacial acetic acid indicates that S1 is npi, whereas the observation of fluorescence from 2 and 3 in acetic acid is consistent with S1 being pipi. A combination of spectroscopic data, molecular orbital calculations, and fluorescence lifetime measurements indicate that 2 and 3 undergo intermolecular excited-state proton transfer in glacial acetic acid and diluted sulfuric acid solutions. Photochemical studies reveal that, unlike its behavior in organic solvents, 1 does not undergo efficient E,E --> E,Z photoisomerization in 96% sulfuric acid.

Improved outcomes in the treatment of gastroschisis using a preformed silo and delayed repair approach.

BACKGROUND/PURPOSE: The aim of this study was to critically evaluate the clinical outcomes of two different surgical treatment approaches for infants born with gastroschisis. METHODS: The medical records of 65 infants with gastroschisis treated at one institution from 1991 to 2000 were available. Infants in group I (prior to December 1998) underwent attempted early repair of the gastroschisis defect on their first day of life. Infants in group II had delayed repair after the initial placement of a preformed silo. RESULTS: Group I had 39 patients; group II had 26 patients. The two groups were equal with respect to maternal age, gestational age, and birth weight. Complete reduction and fascial closure were accomplished for 32 patients (82%) in group I and 25 patients (96%) in group II (P <.02). Median time on the ventilator was significantly less for group II (P <.0001). Infants in group II had shorter times until first postoperative feeding (P <.01) and full feedings (P <.006). Group II had fewer complications than group I (23% v 56%; P <.01). There appeared to be less necrotizing enterocolitis in group II. The average length of hospital stay was 14 days less for group II. CONCLUSIONS: The use of a preformed silo initially followed by delayed fascial closure in infants with gastroschisis is associated with improved fascial closure rates, fewer ventilator days, more rapid return of bowel function, and fewer complications compared with attempts at initial early repair.

A primary care musculoskeletal clinic for residents: success and sustainability.

Musculoskeletal complaints are common, but are often underemphasized in residency training. We evaluated the experience of residents (12) in 4 sessions of an innovative concentrated ambulatory, community-based musculoskeletal (MS) clinic precepted by general internists with additional training in teaching MS medicine. Compared with the year long longitudinal house staff (HS) clinic experience, the mean number of musculoskeletal diagnoses per resident seen in MS clinic was higher (13.9 [standard deviation 4.0] vs 5.4 [standard deviation 4.0]; P <.01). Common diagnoses in MS clinic included shoulder, hip, and knee tendonitis/bursitis, and the majority of diagnoses in HS clinic were nonspecific arthralgia (66%). Fifty-two injections were performed in MS clinic over the year, compared with one in HS clinic.

Snowmobile injuries and fatalities in children.

BACKGROUND/PURPOSE: Snowmobiling is a popular form of wintertime recreation but can be associated with significant morbidity and mortality. To better understand snowmobile trauma in children, medical records were reviewed, evaluating the relationships between demographic data, mechanisms, and resultant injuries. In addition, because prior studies of childhood snowmobile fatalities have reviewed only national databases, state and national data were combined to evaluate possible underreporting. METHODS: Medical records were reviewed of children