Pregabalin for Recurrent Seizures in Critical Illness: A Promising Adjunctive Therapy, Especially for cyclic Seizures.

BACKGROUND: Pregabalin (PGB) is an effective adjunctive treatment for focal epilepsy and acts by binding to the alpha2-delta subunit of voltage-gated calcium channels to reduce excitatory neurotransmitter release. Limited data exist on its use in the neurocritical care setting, including cyclic seizures-a pattern of recurrent seizures occurring at nearly regular intervals. Although the mechanism underpinning cyclic seizures remains elusive, spreading excitation linked to spreading depolarizations may play a role in seizure recurrence and periodicity. PGB has been shown to increase spreading depolarization threshold; hence, we hypothesized that the magnitude of antiseizure effect from PGB is more pronounced in patients with cyclic versus noncyclic seizures in a critically ill cohort with recurrent seizures. METHODS: We conducted a retrospective case series of adults admitted to two academic neurointensive care units between January 2017 and March 2019 who received PGB for treatment of seizures. Data collected included demographics, etiology of brain injury, antiseizure medications, and outcome. Continuous electroencephalogram recordings 48 hours before and after PGB administration were reviewed by electroencephalographers blinded to the administration of antiseizure medications to obtain granular data on electrographic seizure burden. Cyclic seizures were determined quantitatively (i.e., < 50% variation of interseizure intervals for at least 50% of consecutive seizures). Coprimary outcomes were decrease in hourly seizure burden in minutes and decrease in seizure frequency in the 48 hours after PGB initiation. We used nonparametric tests for comparison of seizure frequency and burden and segmented linear regression to assess PGB effect. RESULTS: We included 16 patients; the median age was 69 years, 11 (68.7%) were women, three (18.8%) had undergone a neurosurgical procedure, and five (31%) had underlying epilepsy. All seizures had focal onset; ten patients (62.5%) had cyclic seizures. The median hourly seizure burden over the 48 hours prior to PGB initiation was 1.87 min/hour (interquartile range 1.49-8.53), and the median seizure frequency was 1.96 seizures/hour (interquartile range 1.06-3.41). In the 48 hours following PGB (median daily dose 300 mg, range 75-300 mg), the median number of seizures per hour was reduced by 0.80 seizures/hour (95% confidence interval 0.19-1.40), whereas the median hourly seizure burden decreased by 1.71 min/hour (95% confidence interval 0.38-3.04). When we compared patients with cyclic versus noncyclic seizures, there was a relative decrease in hourly seizure frequency (- 86.7% versus - 2%, p = 0.04) and hourly seizure burden (- 89% versus - 7.8%, p = 0.03) at 48 hours. CONCLUSIONS: PGB was associated with a relative reduction in seizure burden in neurocritically ill patients with recurrent seizures, especially those with cyclic seizures, and may be considered in the therapeutic arsenal for refractory seizures. Whether this effect is mediated via modulation of spreading depolarization requires further study.

Inter-Rater Reliability of the Pizzi Health and Wellness Assessment (PHWA).

The objective of this study is to determine the inter-rater reliability of the Pizzi Health and Wellness Assessment (PHWA) by comparing the consistency in scores between clients and their caregivers in the following areas of participation: social, physical, family, occupational, mental/emotional, and spiritual. A retrospective inter-rater correlational design was used to analyze the agreement of scores from a convenience sample consisting of two groups: clients with disabilities (n = 19) and their healthy caregivers (n = 19). Inter-rater reliability was calculated using correlations for the PHWA as a whole, and for the current level of participation and wishing to improve participation subsections. Inter-rater reliability as calculated by an Intraclass Correlation Coefficient, and either the Pearson or Spearman rho correlation and found to be reliable between clients and caregivers (rICC = .636, p < .001; rho = .642, p < .001). More specifically, current level of participation demonstrated acceptable reliability (rICC = .513, p < .001; r = .521, p < .001) as did wishing to improve participation (rICC = .689, p < .001; r = .725, p < .001). This supports the PHWA as a clinically relevant health and wellness occupational therapy assessment.

Pterygopalatine Fossa Blockade as Novel, Narcotic-Sparing Treatment for Headache in Patients with Spontaneous Subarachnoid Hemorrhage.

BACKGROUND: Severe headache is a hallmark clinical feature of spontaneous subarachnoid hemorrhage (SAH), affecting nearly 90% of patients during index hospitalization, regardless of the SAH severity or presence of a culprit aneurysm. Up to 1 in 4 survivors of SAH experience chronic headaches, which may be severe and last for years. Data guiding the optimal management of post-SAH headache are lacking. Opioids, often in escalating doses, remain the guideline-recommended mainstay of acute therapy, but pain relief remains suboptimal. METHODS: This study is a case series of adult patients who received bilateral pterygopalatine fossa (PPF) blockade for the management of refractory headaches after spontaneous SAH (aneurysmal and non-aneurysmal) at a single tertiary care center. We examined pain scores and analgesic requirements before and after block placement. RESULTS: Seven patients (median age 54 years, 3 men, four aneurysmal and three non-aneurysmal) received a PPF-block between post-bleed day 6-11 during index hospitalization in the neurointensive care unit. The worst pain recorded in the 24-h period before the block was significantly higher than in the period 4 h after the block (9.1 vs. 3.1; p = 0.0156), and in the period 8 h after the block (9.1 vs. 2.8; p = 0.0313). The only complication was minor oozing from the needle insertion sites, which subsided completely with gauze pressure within 1 min. CONCLUSIONS: PPF blockade might constitute a promising opioid-sparing therapeutic strategy for the management of post-SAH headache that merits further prospective controlled randomized studies.

Update on Neurocritical Care of Stroke.

PURPOSE OF REVIEW: This review will highlight the recent advancements in acute ischemic stroke diagnosis and treatment, with special attention to new features and recommendations of stroke care in the neurocritical care unit. RECENT FINDINGS: New studies suggest that pre-hospital treatment of stroke with mobile stroke units and telestroke technology may lead to earlier stroke therapy with intravenous tissue plasminogen activator (tPA), and recent studies show tPA can be given in previously contraindicated situations. More rapid automated CT perfusion and angiography may demonstrate a vascular penumbra for neuroendovascular intervention. Further, the greatest advance in acute stroke treatment since 2014 is the demonstration that neuroendovascular catheter-based thrombectomy with stent retrievers recanalizing intracranial large vessel occlusion (LVO) improves both recanalization and long-term outcomes in several trials. Hemorrhagic transformation and severe large infarct cerebral edema remain serious post-stroke challenges, with new guidelines describing who and when patients should get medical or surgical intervention. The adage "time is brain" directs the most evidence-based approach for rapid stroke diagnosis for tPA eligible and LVO recanalization using an orchestrated team approach. The neurocritical care unit is the appropriate location to optimize stroke outcomes for the most severely affected stroke patients.

Promoting Health, Well-Being, and Quality of Life in Occupational Therapy: A Commitment to a Paradigm Shift for the Next 100 Years.

Since the inception of the profession of occupational therapy a century ago, a clarion call to link health with occupation and occupational engagement has been heard. For decades, leaders in the profession have emphasized the need for prevention and health promotion as well as for development of assessments and models linking health with occupation. This article addresses the need for an increased presence of occupational therapy in health and wellness, emphasizing participation over performance, to optimize the health, well-being, and quality of life of individuals, communities, and populations.

Cerebral Venous Thrombosis Associated with Intracranial Hemorrhage and Timing of Anticoagulation after Hemicraniectomy.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare cerebrovascular event that can present with headache, seizure, and focal neurological deficits. Approximately 30%-40% of patients with CVT also present with intracranial hemorrhage. Current guidelines recommend anticoagulation after CVT even in the setting of intracranial hemorrhage, but the timing of initiation is unclear. We present a case of CVT where timing of anticoagulation was unclear by current guidelines. METHODS: We conducted a literature search with search terms of "cerebral venous thrombosis," "intracranial hemorrhage," and "anticoagulation." Abstracted information included anticoagulation status and time of initiation of anticoagulation. We present a 30-year-old woman with sudden onset of right hemiplegia, global aphasia, and new-onset seizures diagnosed with left transverse and sigmoid sinus thrombosis with intraparenchymal hemorrhage. The patient was treated with endovascular thrombectomy and decompressive hemicraniectomy due to hemorrhage expansion, and anticoagulation was restarted 8 days after hemicraniectomy. RESULTS: The literature review demonstrated a wide variation of timing for anticoagulation initiation in patients with CVT and intracranial hemorrhage. Most started anticoagulation within 24 hours of admission with similar functional neurological recovery. Current guidelines on the treatment of CVT, even with intracranial hemorrhage, recommend anticoagulation. Most reports in the literature state initiation of anticoagulation within 24 hours. However, the literature does not definitively state when to initiate anticoagulation in a patient with CVT, intracranial hemorrhage, thrombectomy, and decompressive hemicraniectomy. CONCLUSION: This case illustrates the challenge of determining when to resume anticoagulation for CVT.

Promoting Health, Well-Being, and Quality of Life for Children Who Are Overweight or Obese and Their Families.

Obesity is a complex, multidimensional challenge that compromises occupational participation for children and families. Children who are overweight or obese are at serious risk for being stigmatized, bullied, or marginalized, and they often are medically compromised. They cope daily with occupational participation issues at home, in school, on playgrounds, and in their communities. Prevention and health promotion assessment and intervention in occupational therapy are imperative for the profession to make a significant and sustainable difference in the lives of these children and families. Innovative client- and occupation-centered programming promotes health, well-being, and quality of life for this population. It is incumbent upon occupational therapy practitioners to prevent occupational marginalization, deprivation, and alienation while promoting occupational justice for children who are overweight or obese.

Exploratory Study of the Clinical Utility of the Pizzi Healthy Weight Management Assessment (PHWMA) Among Burmese High School Students.

OBJECTIVE: Immigrant youth in the United States are at greater risk for weight management problems than non-Hispanic White youth. We used the Pizzi Healthy Weight Management Assessment (PHWMA) to capture data on health perceptions and weight management behaviors among adolescent Burmese refugees. METHOD: We conducted a retrospective descriptive study of 20 Burmese refugee high school students. RESULTS: The results captured an understanding of health perceptions and weight management behaviors of the program participants. The PHWMA was found to be a valid and reliable tool for use by occupational therapy practitioners. CONCLUSION: Findings from this study can inform program development and evaluation in outreach efforts to enhance minority youths' health and well-being.

Hurricane Sandy, Disaster Preparedness, and the Recovery Model.

OBJECTIVE: Hurricane Sandy was the second largest and costliest hurricane in U.S. history to affect multiple states and communities. This article describes the lived experiences of 24 occupational therapy students who lived through Hurricane Sandy using the Recovery Model to frame the research. METHOD: Occupational therapy student narratives were collected and analyzed using qualitative methods and framed by the Recovery Model. Directed content and thematic analysis was performed using the 10 components of the Recovery Model. RESULTS: The 10 components of the Recovery Model were experienced by or had an impact on the occupational therapy students as they coped and recovered in the aftermath of the natural disaster. CONCLUSION: This study provides insight into the lived experiences and recovery perspectives of occupational therapy students who experienced Hurricane Sandy. Further research is indicated in applying the Recovery Model to people who survive disasters.

The societal integration of individuals with epilepsy: perspectives for the 21st century.

Epilepsy is a common neurologic disorder seen throughout the world. Advances in therapy have made it possible for persons with epilepsy (PWEs) to have improved seizure control and a better quality of life. However, it is not entirely clear whether this has resulted in their successful integration into society. This review examines the societal integration of PWEs, identifying both the progress made and the challenges that continue to hamper further advances. In general, PWEs are more integrated in western-oriented cultures. However, there continue to be ongoing difficulties due to poor education and intellectual functioning, poor social and family support, the undertreatment of coexisting psychiatric conditions, transportation and mobility limitations, and problems obtaining employment. This review also discusses the effects of low socioeconomic status on integration and the persisting prejudices that affect certain racial groups. Most importantly, this review underscores the fact that societal stigma towards PWEs is still very much alive. At the beginning of the 21st century, PWEs still encounter difficulties in their quest for full societal integration. Along with medical advances being made to improve seizure control, much still has to be done to bring about the reforms necessary to help PWEs live more meaningful and productive lives.

Blended learning pedagogy: the time is now!

Pedagogy is rapidly changing. To develop best practice in academia, it is important that we change with the changing needs of students. This article suggests that blended learning is one of the most important pedagogical formats that can enhance student learning, optimize the use of active learning strategies, and potentially improve student learning outcomes.

Age dictates brain functional connectivity and axonal integrity following repetitive mild traumatic brain injuries.

Traumatic brain injuries (TBI) present a major public health challenge, demanding an in-depth understanding of age-specific signs and vulnerabilities. Aging not only significantly influences brain function and plasticity but also elevates the risk of hospitalizations and death following repetitive mild traumatic brain injuries (rmTBIs). In this study, we investigate the impact of age on brain network changes and white matter properties following rmTBI employing a multi-modal approach that integrates resting-state functional magnetic resonance imaging (rsfMRI), graph theory analysis, diffusion tensor imaging (DTI), and Neurite Orientation Dispersion and Density Imaging (NODDI). Utilizing the CHIMERA model, we conducted rmTBIs or sham (control) procedures on young (2.5-3 months old) and aged (22-month-old) male and female mice to model high risk groups. Functional and structural imaging unveiled age-related reductions in communication efficiency between brain regions, while injuries induced opposing effects on the small-world index across age groups, influencing network segregation. Functional connectivity analysis also identified alterations in 79 out of 148 brain regions by age, treatment (sham vs. rmTBI), or their interaction. Injuries exerted pronounced effects on sensory integration areas, including insular and motor cortices. Age-related disruptions in white matter integrity were observed, indicating alterations in various diffusion directions (mean, radial, axial diffusivity, fractional anisotropy) and density neurite properties (dispersion index, intracellular and isotropic volume fraction). Inflammation, assessed through Iba-1 and GFAP markers, correlated with higher dispersion in the optic tract, suggesting a neuroinflammatory response in aged animals. These findings provide a comprehensive understanding of the intricate interplay between age, injuries, and brain connectivity, shedding light on the long-term consequences of rmTBIs.

Obesity, health and quality of life: a conversation to further the vision in occupational therapy.

Occupational therapy is one of the most powerful professions to support the development of healthy lifestyles, promote health and well-being and empower individuals, communities and populations, especially those impacted by or at risk for obesity. Development of healthy lifestyles enhances and promotes quality of life. This article discusses the need for occupational therapy professionals to explore the many possibilities that enable lifestyle change for people at risk for or who are obese or overweight. Embracing and integrating health promotion and wellness into everyday practice, particularly for those impacted by obesity, is emphasized.

Childhood obesity: effects on children's participation, mental health, and psychosocial development.

Obesity and being overweight in a child significantly affects his or her healthy development hence there is an understandable focus in the occupational therapy literature on the physical health and difficulties in motor function related to obesity. However, this emphasis somewhat overshadows the psychosocial issues of growing-up obese or overweight. The objective of this paper is to apprise readers of the salient multiple psychosocial sequelae associated with childhood obesity including weight bias and victimization. A conceptual systems framework that supports a multifaceted approach to the occupational and developmental challenges on a population and/or individual level is discussed.

Effect of desmopressin acetate on acute spontaneous intracranial hemorrhage in patients on antiplatelet therapy.

PURPOSE: To evaluate the impact of desmopressin acetate (DDAVP) on poor outcomes, hematoma expansion, and adverse events in patients diagnosed with a non-traumatic, antiplatelet-associated intracranial hemorrhage (ICH). METHODS: This was a multicenter, retrospective, propensity-matched cohort study comparing DDAVP to control in patients diagnosed with a non-traumatic ICH previously on antiplatelet therapy. Notable exclusion criteria included admission to trauma service, subarachnoid hemorrhages, confounding coagulopathic factors, and hematoma evacuation. Poor outcome, defined as discharge to hospice or in-patient mortality, was the primary outcome. Secondary outcomes included intracranial hematoma expansion and occurrence of adverse events, which included hyponatremia and thromboembolic events. RESULTS: A total of 49 patients receiving DDAVP were compared to 107 controls in the unmatched cohort. Thirty-seven patients treated with DDAVP and 55 controls were included in the propensity-matched analysis, which was adjusted for age, ethnicity, history of diabetes, receipt of platelet transfusion, and thromboembolism prophylaxis. Poor outcome (16.2% DDAVP vs 29% control, p = 0.13), rates of hematoma expansion (11.8% DDAVP vs 11.1% control, p = 0.99), and adverse events (21.6% DDAVP vs 20% control, p = 0.99) were statistically similar between the matched groups. CONCLUSIONS: DDAVP administration in patients with spontaneous antiplatelet-associated ICH was not associated with a reduction in poor outcomes, hematoma expansion, or an increase in adverse events. Use of DDAVP in this patient population appears to be safe. Larger prospective studies are warranted to evaluate DDAVP utility in this patient population.

Acute Neurologic Manifestations of Respiratory Viruses.

PURPOSE OF REVIEW: Understanding the pathophysiology of COVID-19 and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus that causes the disease has demonstrated the complexity of acute respiratory viruses that can cause neurologic manifestations. This article describes the most common respiratory viruses that have neurologic manifestations, with a focus on SARS-CoV-2 and COVID-19. RECENT FINDINGS: In vitro and in vivo studies have better elucidated the neurotropism of various respiratory viruses. Understanding host cell receptors that mediate viral binding and entry not only demonstrates how viruses enter host cells but also provides possible mechanisms for therapeutic interventions. Elucidation of SARS-CoV-2 binding and fusion with host cells expressing the angiotensin-converting enzyme 2 (ACE2) receptor may also provide greater insights into its systemic and neurologic sequelae. Respiratory virus neurotropism and collateral injury due to concurrent inflammatory cascades result in various neurologic pathologies, including Guillain-Barré syndrome, encephalopathy, encephalitis, ischemic stroke, intracerebral hemorrhage, and seizures. SUMMARY: Numerous respiratory viruses can infect the cells of the peripheral and central nervous systems, elicit inflammatory cascades, and directly and indirectly cause various neurologic manifestations. Patients with neurologic manifestations from respiratory viruses are often critically ill and require mechanical ventilation. Neurologists and neurointensivists should be familiar with the common neurologic manifestations of respiratory viruses and the unique and still-evolving sequelae associated with COVID-19.

Ultrasound of Optic Nerve Sheath Diameter and Stroke Outcomes.

We aimed at utilizing ocular ultrasound to determine its utility in predicting outcomes among stroke patients. DESIGN: Single-center prospective observational study. SETTING: Emergency department and ICUs. PATIENTS: Patients suspected of stroke. INTERVENTIONS: None. MEASURES AND MAIN RESULTS: Bilateral optic nerve sheath diameter was measured on arrival and within the first 2 days of admission. Outcomes were inpatient survival, Cerebral Performance Category, and modified Rankin Scale at 3 and 6 months. Analysis was conducted using descriptive statistics, paired t test, chi-square test. Eighty-six patients were enrolled with ischemic or hemorrhagic stroke. Mean age was 67.2 years (± 15 yr), and 54.7% of patients were male. There was no difference between left and right eye measurements (p = 0.467 and p = 0.903, respectively) or between longitudinal and transverse measurements (transverse p = 0.163 and longitudinal p = 0.270). Mean optic nerve sheath diameter differed in patients who survived versus died prior to discharge in both ischemic (0.53 vs 0.58 cm; p = 0.009) or hemorrhagic stroke (0.57 vs 0.62 cm; p = 0.019). For every 0.1 cm increase in optic nerve sheath diameter, odds ratio for death were 4.2 among ischemic stroke (95% CI, 1.32-13.64; p = 0.015), and odds ratio 6.2 among ischemic or hemorrhagic patients (95% CI, 1.160-33.382; p = 0.033). Increased optic nerve sheath diameter correlated (r = 0.44; p < 0.0001) with poor functional outcomes measured as modified Rankin Scale scores of 3-6 at 6 months. CONCLUSIONS: Elevations in optic nerve sheath diameter were associated with increased inhospital mortality and poor functional outcome at 6 months. Optic nerve sheath diameter may serve as a noninvasive marker of inhospital mortality and functional outcome. Further multicenter prospective trials for evaluating and treating optic nerve sheath diameter in ischemic and hemorrhagic strokes are warranted.

The Modified Early Warning Score: A Useful Marker of Neurological Worsening but Unreliable Predictor of Sepsis in the Neurocritically Ill-A Retrospective Cohort Study.

To determine the performance of the Modified Early Warning Score and Modified Early Warning Score-Sepsis Recognition Score to predict sepsis, morbidity, and mortality in neurocritically ill patients. DESIGN: Retrospective cohort study. SETTING: Single tertiary-care academic medical center. PATIENTS: Consecutive adult patients admitted to the neuro-ICU from January 2013 to December 2016. INTERVENTIONS: Observational study. MEASUREMENTS AND MAIN RESULTS: Baseline and clinical characteristics, infections/sepsis, neurologic worsening, and mortality were abstracted. Primary outcomes included new infection/sepsis, escalation of care, and mortality. Patients with Modified Early Warning Score-Sepsis Recognition Score/Modified Early Warning Score greater than or equal to 5 were compared with those with scores less than 5. 5. Of 7,286 patients, Of 7,286 patients, 1,120 had Modified Early Warning Score-Sepsis Recognition Score greater than or equal to 5. Of those, mean age was 58.9 years; 50.2% were male. Inhospitality mortality was 22.1% for patients (248/1,120) with Modified Early Warning Score-Sepsis Recognition Score greater than or equal to 5, compared with 6.1% (379/6,166) with Modified Early Warning Score-Sepsis Recognition Score less than 5. Sepsis was present in 5.6% (345/6,166) when Modified Early Warning Score-Sepsis Recognition Score less than 5 versus 14.3% (160/1,120) when greater than or equal to 5, and Modified Early Warning Score elevation led to a new sepsis diagnosis in 5.5% (62/1,120). Three-hundred forty-three patients (30.6%) had neurologic worsening at the time of Modified Early Warning Score-Sepsis Recognition Score elevation. Utilizing the original Modified Early Warning Score, results were similar, with less score thresholds met (836/7,286) and slightly weaker associations. CONCLUSIONS: In neurocritical ill patients, Modified Early Warning Score-Sepsis Recognition Score and Modified Early Warning Score are associated with higher inhospital mortality and are preferentially triggered in setting of neurologic worsening. They are less reliable in identifying new infection or sepsis in this patient population. Population-specific adjustment of early warning scores may be necessary for the neurocritically ill patient population.