The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities.

BACKGROUND: Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients. METHODS: Analysis of 2017-2019 ACS-TQIP. Included severe TBI patients ≥65 years. Patients who died within 24 h were excluded. Outcomes included mortality, cerebral monitors use, complications, and discharge disposition. RESULTS: We included 208,495 patients (White = 175,941; Black = 12,194) (Hispanic = 195,769; Non-Hispanic = 12,258). On multivariable regression, White race was associated with higher mortality (aOR = 1.26; p < 0.001) and SNF/rehab discharge (aOR = 1.11; p < 0.001) and less likely to be discharged home (aOR = 0.90; p < 0.001) or to undergo cerebral monitoring (aOR = 0.77; p < 0.001) compared to Black. Non-Hispanics had higher mortality (aOR = 1.15; p = 0.013), complications (aOR = 1.26; p < 0.001), and SNF/Rehab discharge (aOR = 1.43; p < 0.001) and less likely to be discharged home (aOR = 0.69; p < 0.001) or to undergo cerebral monitoring (aOR = 0.84; p = 0.018) compared to Hispanics. Uninsured Hispanics had the lowest odds of SNF/rehab discharge (aOR = 0.18; p < 0.001). CONCLUSIONS: This study highlights the significant racial and ethnic disparities in the outcomes of geriatric TBI patients. Further studies are needed to address the reason behind these disparities and identify potentially modifiable risk factors in the geriatric trauma population.

A Survey of Neuromonitoring Practices in North American Pediatric Intensive Care Units.

BACKGROUND: Neuromonitoring is the use of continuous measures of brain physiology to detect clinically important events in real-time. Neuromonitoring devices can be invasive or non-invasive and are typically used on patients with acute brain injury or at high risk for brain injury. The goal of this study was to characterize neuromonitoring infrastructure and practices in North American pediatric intensive care units (PICUs). METHODS: An electronic, web-based survey was distributed to 70 North American institutions participating in the Pediatric Neurocritical Care Research Group. Questions related to the clinical use of neuromonitoring devices, integrative multimodality neuromonitoring capabilities, and neuromonitoring infrastructure were included. Survey results were presented using descriptive statistics. RESULTS: The survey was completed by faculty at 74% (52 of 70) of institutions. All 52 institutions measure intracranial pressure and have electroencephalography capability, whereas 87% (45 of 52) use near-infrared spectroscopy and 40% (21/52) use transcranial Doppler. Individual patient monitoring decisions were driven by institutional protocols and collaboration between critical care, neurology, and neurosurgery attendings. Reported device utilization varied by brain injury etiology. Only 15% (eight of 52) of institutions utilized a multimodality neuromonitoring platform to integrate and synchronize data from multiple devices. A database of neuromonitoring patients was maintained at 35% (18 of 52) of institutions. Funding for neuromonitoring programs was variable with contributions from hospitals (19%, 10 of 52), private donations (12%, six of 52), and research funds (12%, six of 52), although 73% (40 of 52) have no dedicated funds. CONCLUSIONS: Neuromonitoring indications, devices, and infrastructure vary by institution in North American pediatric critical care units. Noninvasive modalities were utilized more liberally, although not uniformly, than invasive monitoring. Further studies are needed to standardize the acquisition, interpretation, and reporting of clinical neuromonitoring data, and to determine whether neuromonitoring systems impact neurological outcomes.

Translumbosacral Anorectal Magnetic Stimulation Test for Fecal Incontinence.

BACKGROUND: Neuropathy may cause fecal incontinence and mixed fecal incontinence/constipation, but its prevalence is unclear, partly due to the lack of comprehensive testing of spino-anorectal innervation. OBJECTIVE: This study aimed to develop and determine the clinical usefulness of a novel test, translumbosacral anorectal magnetic stimulation for fecal incontinence. DESIGN: This observational cohort study was conducted from 2012 to 2018. SETTINGS: This study was performed at a tertiary referral center. PATIENTS: Patients with fecal incontinence, patients with mixed fecal incontinence/constipation, and healthy controls were included. INTERVENTIONS: A translumbosacral anorectal magnetic stimulation test was performed by using an anorectal probe with 4 ring electrodes and magnetic coil, and by stimulating bilateral lumbar and sacral plexuses, uses and recording 8 motor-evoked potentials at anal and rectal sites. MAIN OUTCOME MEASURES: The prevalence of lumbar and/or sacral neuropathy was examined. Secondary outcomes were correlation of neuropathy with anorectal sensorimotor function(s) and morphological changes. RESULTS: We evaluated 220 patients: 144 with fecal incontinence, 76 with mixed fecal incontinence/constipation, and 31 healthy controls. All 8 lumbar and sacral motor-evoked potential latencies were significantly prolonged (p < 0.01) in fecal incontinence and mixed fecal incontinence/constipation groups compared with controls. Neuropathy was patchy and involved 4.0 (3.0) (median (interquartile range)) sites. Lumbar neuropathy was seen in 29% to 65% of the patients in the fecal incontinence group and 22% to 61% of the patients in the mixed fecal incontinence/constipation group, and sacral neuropathy was seen in 24% to 64% and 29% to 61% of these patients. Anal neuropathy was significantly more (p < 0.001) prevalent than rectal neuropathy in both groups. There was no correlation between motor-evoked potential latencies and anal sphincter pressures, rectal sensation, or anal sphincter defects. LIMITATIONS: No comparative analysis with electromyography was performed. CONCLUSION: Lumbar or sacral plexus neuropathy was detected in 40% to 75% of patients with fecal incontinence with a 2-fold greater prevalence at the anal region than the rectum. Lumbosacral neuropathy appears to be an independent mechanism in the pathogenesis of fecal incontinence, unassociated with other sensorimotor dysfunctions. Translumbosacral anorectal magnetic stimulation has a high yield and is a safe and clinically useful neurophysiological test. See Video Abstract at http://links.lww.com/DCR/B728. PRUEBA DE ESTIMULACIN MAGNTICA TRANSLUMBOSACRAL ANORECTAL PARA LA INCONTINENCIA FECAL: ANTECEDENTES:La neuropatía puede causar incontinencia fecal y una combinación de incontinencia fe-cal/estreñimiento, pero su prevalencia no está clara, en parte debido a la falta de pruebas comple-tas de inervación espino-anorrectal.OBJETIVO:Desarrollar y determinar la utilidad clínica de una nueva prueba, estimulación magnética trans-lumbosacral anorrectal para la incontinencia fecal.DISEÑO:Estudio de cohorte observacional del 2012 al 2018.ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes con incontinencia fecal, combinación de incontinencia fecal/estreñimiento y controles sanos.INTERVENCIONES:Se realizó una prueba de estimulación magnética translumbosacral anorrectal utilizando una sonda anorrectal con 4 electrodos anulares y bobina magnética, y estimulando los plexos lumbares y sacros bilaterales y registrando ocho potenciales evocados motores las regiones anal y rectal.PRINCIPALES MEDIDAS DE RESULTADO:Se examinó la prevalencia de neuropatía lumbar y/o sacra. Los resultados secundarios fueron la correlación de la neuropatía con las funciones sensitivomotoras anorrectales y cambios morfológi-cos.RESULTADOS:Evaluamos 220 pacientes, 144 con incontinencia fecal, 76 con combinación de incontinencia fe-cal/estreñimiento y 31 sujetos sanos. Las ocho latencias de los potenciales evocadas motoras lum-bares y sacras se prolongaron significativamente (p <0,01) en la incontinencia fecal y el grupo mixto en comparación con los controles. La neuropatía fue irregular y afectaba 4,0 (3,0) (mediana (rango intercuartílico) sitios. Se observó neuropatía lumbar en 29-65% en la incontinencia fecal y 22-61% en el grupo mixto, y neuropatía sacra en 24-64% y 29-61 % de pacientes respectivamen-te. La neuropatía anal fue significativamente más prevalente (p <0,001) que la rectal en ambos grupos. No hubo correlación entre las latencias de los potenciales evocadas motoras y las presio-nes del esfínter anal, la sensación rectal o los defectos del esfínter anal.LIMITACIONES:Sin análisis comparativo con electromiografía.CONCLUSIÓNES:Se detectó neuropatía del plexo lumbar o sacro en el 40-75% de los pacientes con incontinencia fecal con una prevalencia dos veces mayor en la región anal que en el recto. La neuropatía lumbo-sacra parece ser un mecanismo independiente en la patogenia de la incontinencia fecal, no asocia-do con otras disfunciones sensitivomotoras. La estimulación magnética translumbosacral anorrec-tal tiene un alto rendimiento, es una prueba neurofisiológica segura y clínicamente útil. Consulte Video Resumen en http://links.lww.com/DCR/B728.

Using electronic health data to explore effectiveness of ICU EEG and anti-seizure treatment.

OBJECTIVES: The purpose of this study was to examine critical care continuous electroencephalography (cEEG) utilization and downstream anti-seizure treatment patterns, their association with outcomes, and generate hypotheses for larger comparative effectiveness studies of cEEG-guided interventions. METHODS: Single-center retrospective study of critically ill patients (n = 14,523, age ≥18 years). Exposure defined as ≥24 h of cEEG and subsequent anti-seizure medication (ASM) escalation, with or without concomitant anesthetic. Exposure window was the first 7 days of admission. Primary outcome was in-hospital mortality. Multivariable analysis was performed using penalized logistic regression. RESULTS: One thousand and seventy-three patients underwent ≥24 h of cEEG within 7 days of admission. After adjusting for disease severity, ≥24 h of cEEG followed by ASM escalation in patients not on anesthetics (n = 239) was associated with lower in-hospital mortality (OR 0.76 [0.53-1.07]), though the finding did not reach significance. ASM escalation with concomitant anesthetic use (n = 484) showed higher odds for mortality (OR 1.41 [1.03-1.94]). In the seizures/status epilepticus subgroup, post cEEG ASM escalation without anesthetics showed lower odds for mortality (OR 0.43 [0.23-0.74]). Within the same subgroup, ASM escalation with concomitant anesthetic use showed higher odds for mortality (OR 1.34 [0.92-1.91]) though not significant. INTERPRETATION: Based on our findings we propose the following hypotheses for larger comparative effectiveness studies investigating the direct causal effect of cEEG-guided treatment on outcomes: (1) cEEG-guided ASM escalation may improve outcomes in critically ill patients with seizures; (2) cEEG-guided treatment with combination of ASMs and anesthetics may not improve outcomes in all critically ill patients.

Seizure symptoms and ambulatory EEG findings: incidence of epileptiform discharges.

AIMS: Ambulatory video-EEG monitoring has been utilized as a cost-effective alternative to inpatient video-EEG monitoring for non-surgical diagnostic evaluation of symptoms suggestive of epileptic seizures. We aimed to assess incidence of epileptiform discharges in ambulatory video-EEG recordings according to seizure symptom history obtained during clinical evaluation. METHODS: This was a retrospective cohort study. We queried seizure symptoms from 9,221 consecutive ambulatory video-EEG studies in 35 states over one calendar year. We assessed incidence of epileptiform discharges for each symptom, including symptoms that conformed to a category heading, even if not included in the ILAE 2017 symptom list. We report incidences, odds ratios, and corresponding p values using Fisher's exact test and univariate logistic regression. We applied multivariable logistic regression to generate odds ratios for the six symptom categories that are controlled for the presence of other symptoms. RESULTS: History that included motor symptoms (OR=1.53) or automatisms (OR=1.42) was associated with increased occurrence of epileptiform discharges, whereas history of sensory symptoms (OR=0.76) predicted lack of epileptiform discharges. Patient-reported symptoms that were associated with increased occurrence of epileptiform discharges included lip-smacking, moaning, verbal automatism, aggression, eye-blinking, déjà vu, muscle pain, urinary incontinence, choking and jerking. On the other hand, auditory hallucination memory deficits, lightheadedness, syncope, giddiness, fibromyalgia and chronic pain predicted absence of epileptiform discharges. The majority of epileptiform discharges consisted only of interictal sharp waves or spikes. CONCLUSIONS: Our study shows that the use of ILAE 2017 symptom categories may help guide ambulatory video-EEG studies.

Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology.

OBJECTIVE: In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline. METHODS: We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices. RESULTS: In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment. CONCLUSION: Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.

Current status of pediatric neurocritical care in Argentina. / Estado actual del soporte neurológico crítico en pediatría en la Argentina.

INTRODUCTION: Patients with neurocritical injuries account for 10-16 % of pediatric intensive care unit (PICU) admissions and frequently require neuromonitoring. OBJECTIVE: To describe the current status of neuromonitoring in Argentina. METHODS: Survey with 37 questions about neuromonitoring without including patients' data. Period: April-June 2017. RESULTS: Thirty-eight responses were received out of 71 requests (14 districts with 11 498 annual discharges). The PICU/hospital bed ratio was 21.9 (range: 4.2-66.7). Seventy-four percent of PICUs were public; 61 %, university-affiliated; and 71 %, level I. The availability of monitoring techniques was similar between public and private (percentages): intracranial pressure (95), electroencephalography (92), transcranial Doppler (53), evoked potentials (50), jugular saturation (47), and bispectral index (11). Trauma was the main reason for monitoring. CONCLUSION: Except for intracranial pressure and electroencephalography, neuromonitoring resources are scarce and active neurosurgery availability is minimal. A PICU national registry is required.

Introducción. Los pacientes con lesiones neurocríticas representan el 10-16 % de los ingresos a unidades de cuidados intensivos pediátricas (UCIP) y, frecuentemente, requieren neuromonitoreo. Objetivo. Describir el estado actual del neuromonitoreo en la Argentina. Métodos. Encuesta con 37 preguntas sobre neuromonitoreo sin incluir datos de pacientes. Período: abril-junio, 2017. Resultados. Se recibieron 38 respuestas a 71 solicitudes (14 distritos con 11 498 egresos anuales). La relación camas de UCIP/hospitalarias fue 21,9 (rango: 4,2-66,7). El 74 % fueron públicas; el 61 %, universitarias, y el 71 %, nivel 1. La disponibilidad fue similar entre públicas y privadas (porcentajes): presión intracraneana (95), electroencefalografía (92), doppler transcraneano (53), potenciales evocados (50), saturación yugular (47) e índice bispectral (11). El principal motivo de monitoreo fue trauma. Conclusión. Excepto la presión intracraneana y la electroencefalografía, los recursos de neuromonitoreo son escasos y la disponibilidad de neurocirugía activa es mínima. Se necesita un registro nacional de UCIP.

Global Survey of Outcomes of Neurocritical Care Patients: Analysis of the PRINCE Study Part 2.

BACKGROUND: Neurocritical care is devoted to the care of critically ill patients with acute neurological or neurosurgical emergencies. There is limited information regarding epidemiological data, disease characteristics, variability of clinical care, and in-hospital mortality of neurocritically ill patients worldwide. We addressed these issues in the Point PRevalence In Neurocritical CarE (PRINCE) study, a prospective, cross-sectional, observational study. METHODS: We recruited patients from various intensive care units (ICUs) admitted on a pre-specified date, and the investigators recorded specific clinical care activities they performed on the subjects during their first 7 days of admission or discharge (whichever came first) from their ICUs and at hospital discharge. In this manuscript, we analyzed the final data set of the study that included patient admission characteristics, disease type and severity, ICU resources, ICU and hospital length of stay, and in-hospital mortality. We present descriptive statistics to summarize data from the case report form. We tested differences between geographically grouped data using parametric and nonparametric testing as appropriate. We used a multivariable logistic regression model to evaluate factors associated with in-hospital mortality. RESULTS: We analyzed data from 1545 patients admitted to 147 participating sites from 31 countries of which most were from North America (69%, N = 1063). Globally, there was variability in patient characteristics, admission diagnosis, ICU treatment team and resource allocation, and in-hospital mortality. Seventy-three percent of the participating centers were academic, and the most common admitting diagnosis was subarachnoid hemorrhage (13%). The majority of patients were male (59%), a half of whom had at least two comorbidities, and median Glasgow Coma Scale (GCS) of 13. Factors associated with in-hospital mortality included age (OR 1.03; 95% CI, 1.02 to 1.04); lower GCS (OR 1.20; 95% CI, 1.14 to 1.16 for every point reduction in GCS); pupillary reactivity (OR 1.8; 95% CI, 1.09 to 3.23 for bilateral unreactive pupils); admission source (emergency room versus direct admission [OR 2.2; 95% CI, 1.3 to 3.75]; admission from a general ward versus direct admission [OR 5.85; 95% CI, 2.75 to 12.45; and admission from another ICU versus direct admission [OR 3.34; 95% CI, 1.27 to 8.8]); and the absence of a dedicated neurocritical care unit (NCCU) (OR 1.7; 95% CI, 1.04 to 2.47). CONCLUSION: PRINCE is the first study to evaluate care patterns of neurocritical patients worldwide. The data suggest that there is a wide variability in clinical care resources and patient characteristics. Neurological severity of illness and the absence of a dedicated NCCU are independent predictors of in-patient mortality.

Patient characteristics and critical care workflow affect paging frequency in neurocritical care.

Indicator of response urgency (page tag), paging domains, distribution of pages by time of the day, and factors associated with neurocritical care paging remain elusive and were examined in this study. We examined the association between patient, neurocritical care workflow characteristics, and paging domains on frequency of paging using Student's t-test, Chi-square test, and analysis of covariance. A total of 1852 patients generated 36,472 pages. The most common page tagging was "for your information" (n = 15067, 41.3%), while 2.8% (n = 1006) pages were tagged urgent. Paging was most frequent for cardiovascular (12.2%), pain, agitation, distress (6.9%) and sodium (5.3%) concerns. Paging frequency was highest for mechanically ventilated patients (p < 0.001), those with indwelling intracranial pressure monitor (p < 0.04), arterial catheter (p < 0.001), central venous access catheter (p < 0.001), and in those with lower Glasgow Coma Score (p < 0.001). Patients admitted between 18:00-06:00 (aOR 1.47, 95% CI 1.16-1.86) and 14:30-18:00 (aOR 1.46, 95% CI 1.14-1.86), and sodium (aOR 1.52, 95% CI 1.39-1.66), and cardiovascular concerns (aOR 1.24, 95% CI 1.15-1.32) were associated with higher night time paging frequency. Incorporating paging domains in daily workflow and their impact on outcome of paging on escalation of clinical care and patient outcomes warrants further examination.

Surveillance Ultrasound in the Neuro Intensive Care Unit: Time to Deep Vein Thrombosis Diagnosis.

BACKGROUND/OBJECTIVES: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are complications of hospitalization leading to increased morbidity and mortality. Routine surveillance ultrasound has become common practice in some intensive care units (ICU) to detect DVT early and initiate anticoagulation, preventing complications. However, initiating anticoagulants for asymptomatic DVT treatment may increase risk of hemorrhage. The objective of this study was to investigate the value of routine surveillance ultrasound in early DVT diagnosis in Neuro ICU patients. METHODS: This is a retrospective review of patients diagnosed with DVT during admission to the Neuro ICU at University Hospital from January 1, 2012, through December 31, 2017. Patients were identified through International Classification of Diseases 9th and 10th Revision codes for DVT and PE, screened for inclusion criteria, and then classified as surveillance group or symptom-driven group based on intervention received. Primary outcome was time to DVT diagnosis. Secondary outcome included clinically significant hemorrhage identified by anticoagulation treatment discontinuation for suspected hemorrhage or new or expanding hemorrhage on head computerized tomography (CT). RESULTS: A total of 116 patients were identified, with 50 included: 27 were classified as surveillance and 23 as symptom-driven. Seven patients (surveillance = 3 and symptom-driven = 4) were diagnosed with only PE and were excluded from primary outcome. Median time to DVT diagnosis was similar at 148 h for surveillance versus 172 h for symptom driven (p = 0.2). There was no difference in treatment discontinuation rates (surveillance 21% vs symptom 31%; p = 0.4). Of the 27 patients with follow-up head CT, two in the surveillance group and two in the symptom-driven group showed a new or expanding hemorrhage. CONCLUSION: Routine surveillance ultrasound did not lead to significantly earlier DVT diagnosis. Hemorrhagic events were not different between groups. Utility of surveillance ultrasound in this population should be evaluated in large, prospective trials before routine use can be recommended.

A predictive epilepsy index based on probabilistic classification of interictal spike waveforms.

Quantification of interictal spikes in EEG may provide insight on epilepsy disease burden, but manual quantification of spikes is time-consuming and subject to bias. We present a probability-based, automated method for the classification and quantification of interictal events, using EEG data from kainate- and saline-injected mice (C57BL/6J background) several weeks post-treatment. We first detected high-amplitude events, then projected event waveforms into Principal Components space and identified clusters of spike morphologies using a Gaussian Mixture Model. We calculated the odds-ratio of events from kainate- versus saline-treated mice within each cluster, converted these values to probability scores, P(kainate), and calculated an Hourly Epilepsy Index for each animal by summing the probabilities for events where the cluster P(kainate) > 0.5 and dividing the resultant sum by the record duration. This Index is predictive of whether an animal received an epileptogenic treatment (i.e., kainate), even if a seizure was never observed. We applied this method to an out-of-sample dataset to assess epileptiform spike morphologies in five kainate mice monitored for ~1 month. The magnitude of the Index increased over time in a subset of animals and revealed changes in the prevalence of epileptiform (P(kainate) > 0.5) spike morphologies. Importantly, in both data sets, animals that had electrographic seizures also had a high Index. This analysis is fast, unbiased, and provides information regarding the salience of spike morphologies for disease progression. Future refinement will allow a better understanding of the definition of interictal spikes in quantitative and unambiguous terms.

Epilepsy monitoring units in Saudi Arabia: Where do we stand compared to developed countries?

OBJECTIVE: To descriptively assess Epilepsy Monitoring Units (EMUs) and the provided services in Saudi Arabia and compare them based on the geographic region. METHODS: In this cross-sectional study, an electronic questionnaire was emailed to all directors of EMUs in Saudi Arabia from July 2013 to January 2016, with constant updates being made by all respondents throughout the period of data collection. RESULTS: All EMU directors participated. There were 11 EMUs in KSA operating in 8 hospitals; 8 (54.5%) EMUs in Riyadh, 2 (18.2%) in Dammam, 2 (18.2%) in Makkah and 1 (9.1%) in Jeddah. Five (54.5%) EMUs were shared for adults and pediatrics, 3 (27.3%) were devoted to adult patients, and 3 (27.3%) to pediatric patients. The average waiting time was 11 weeks (range: 2-52 weeks). The mean percentage of patients coming from an outside region was 30.6%. The average length of stay was 7 days. Less than 100 patients were monitored annually in 54.5% of the EMUs. Seven EMUs (63.6%) admitted less than 100 patients for seizure characterization. Intracranial monitoring was available in all EMUs. Most EMUs (54.5%) admitted less than 100 patients for pre-surgical workup while 36.4% admitted 100-199, and 9.1% admitted more than 300 patients per year. Epilepsy surgeries were performed for less than 50 patients annually in 81.8% of the hospitals. CONCLUSION: There are 11 EMUs in Saudi Arabia fully equipped to serve epileptic patients. However, they are underutilized considering the number of admitted patient and the number of epilepsy surgeries per year. Also, they are unequally distributed throughout the kingdom.

Associations of Observed Performance Monitoring During Preschool With Obsessive-Compulsive Disorder and Anterior Cingulate Cortex Volume Over 12 Years.

Importance: Monitoring one's performance is necessary for learning and adaptive behavior; however, heightened performance monitoring is a purported endophenotype of obsessive-compulsive disorder (OCD). The anterior cingulate cortex (ACC), a brain region implicated in the pathogenesis of OCD, is associated with performance monitoring. Whether performance monitoring early in development is an identifiable risk factor for OCD and whether early childhood performance monitoring is associated with later alterations in ACC volume are unknown. Objective: To determine whether an observed indicator of heightened performance monitoring during the preschool age is associated with later onset of OCD and altered dorsal ACC (dACC) volume through adolescence. Design, Setting, and Participants: This longitudinal observational cohort study was performed at an academic medical center as part of the Preschool Depression Study. A sample of 292 children oversampled for depression from September 22, 2003, through May 12, 2005, completed a performance-based observational task during which they received persistent negative evaluation. Blind raters behaviorally coded child performance monitoring. During the next 12 years, children completed annual diagnostic assessments; 133 completed the final behavioral follow-up and 152 contributed 1 to 3 magnetic resonance imaging scans. Follow-up was completed on August 14, 2017. Main Outcomes and Measures: Onset of DSM-5 diagnosis of OCD from baseline to the final behavioral assessment and whole-brain-adjusted dACC volume at the 3 waves of scanning. Results: Among the 292 preschool children who completed the baseline evaluation (51.4% boys; mean [SD] age, 4.5 [0.8] years), when controlling for demographic and clinical indicators, those who exhibited observed heightened performance monitoring were 2 times more likely to develop OCD (n = 35) during the next 12 years (odds ratio, 2.00; 95% CI, 1.06-3.78; P = .03). Multilevel modeling of dACC volume across the 3 scan waves (n = 152) demonstrated that heightened performance monitoring was associated with smaller right dACC volume (intercept estimate, -0.14; SE, 0.07; t = -2.17; P = .03). Conclusions and Relevance: An ecologically valid indicator of performance monitoring in early childhood was associated with onset of OCD and smaller dACC volumes in later childhood and adolescence. Early childhood observed performance monitoring is a readily observed risk factor of OCD that can be identified in preschool-aged children.

The Use of Continuous EEG Monitoring in Intensive Care Units in The Netherlands: A National Survey.

BACKGROUND: Currently, continuous electroencephalographic monitoring (cEEG) is the only available diagnostic tool for continuous monitoring of brain function in intensive care unit (ICU) patients. Yet, the exact relevance of routinely applied ICU cEEG remains unclear, and information on the implementation of cEEG, especially in Europe, is scarce. This study explores current practices of cEEG in adult Dutch ICU departments focusing on organizational and operational factors, development over time and factors perceived relevant for abstaining its use. METHODS: A national survey on cEEG in adults among the neurology and adult intensive care departments of all Dutch hospitals (n = 82) was performed. RESULTS: The overall institutional response rate was 78%. ICU cEEG is increasingly used in the Netherlands (in 37% of all hospitals in 2016 versus in 21% in 2008). Currently in 88% of university, 55% of teaching and 14% of general hospitals use ICU cEEG. Reasons for not performing cEEG are diverse, including perceived non-feasibility and lack of data on the effect of cEEG use on patient outcome. Mostly, ICU cEEG is used for non-convulsive seizures or status epilepticus and prognostication. However, cEEG is never or rarely used for monitoring cerebral ischemia and raised intracranial pressure in traumatic brain injury. Review and reporting practices differ considerably between hospitals. Nearly all hospitals perform non-continuous review of cEEG traces. Methods for moving toward continuous review of cEEG traces are available but infrequently used in practice. CONCLUSIONS: cEEG is increasingly used in Dutch ICUs. However, cEEG practices vastly differ between hospitals. Future research should focus on uniform cEEG practices including unambiguous EEG interpretation to facilitate collaborative research on cEEG, aiming to provide improved standard patient care and robust data on the impact of cEEG use on patient outcome.

Evaluation of a wireless, portable, wearable multi-parameter vital signs monitor in hospitalized neurological and neurosurgical patients.

Unrecognized changes in patients' vital signs can result in preventable deaths in hospitalized patients. Few publications or studies instituting routine patient monitoring have described implementation and the setting of alarm parameters for vital signs. We wanted to determine if continuous multi-parameter patient monitoring can be accomplished with an alarm rate that is acceptable to hospital floor nurses and to compare the rate of patient deterioration events to those observed with routine vital sign monitoring. We conducted a prospective, observational, 5-month pilot study in a 26-bed adult, neurological/neurosurgical unit (non-ICU) in an academic medical center. A patient surveillance system employing a wireless body-worn vital signs monitor with automated nursing notification of alarms via smartphones was used to gather data. Data collected included: alarm rates, rapid response team (RRT) calls, intensive care unit (ICU) transfers, and unplanned deaths before and during the pilot study. Average alarm rate for all alarms (SpO2, HR, RR, NIBP) was 2.3 alarms/patient/day. The RRT call rate was significantly reduced (p < 0.05) from 189 to 158 per 1000 discharges. ICU transfers per 1000 discharges were insignificantly reduced from 53 to 40 compared to the previous 5-month period in the same unit. Similar measures of comparison units did not change over the same period. Although unplanned patient deaths in the study unit were also reduced during the intervention period, this was not statistically significant. Continual, multi-parameter vital signs monitoring can be customized to reduce a high alarm rates, and may reduce rapid response team calls.

Continuous Autoregulatory Indices Derived from Multi-Modal Monitoring: Each One Is Not Like the Other.

We assess the relationships between various continuous measures of autoregulatory capacity in a cohort of adults with traumatic brain injury (TBI). We assessed relationships between autoregulatory indices derived from intracranial pressure (ICP: PRx, PAx, RAC), transcranial Doppler (TCD: Mx, Sx, Dx), brain tissue-oxygenation (ORx), and spatially resolved near infrared spectroscopy (NIRS resolved: TOx, THx). Relationships between indices were assessed using Pearson correlation coefficient, Friedman test, principal component analysis (PCA), agglomerative hierarchal clustering (AHC) and k-means cluster analysis (KMCA). All analytic techniques were repeated for a range of temporal resolutions of data, including minute-by-minute averages, moving means of 30 samples, and grand mean for each patient. Thirty-seven patients were studied. The PRx displayed strong association with PAx/RAC across all the analytical techniques: Pearson correlation (r = 0.682/r = 0.677, p < 0.0001), PCA, AHC, and KMCA in the grand mean data sheet. Most TCD-based indices (Mx, Dx) were correlated and co-clustered on PCA, AHC, and KMCA. The Sx was found to be more closely associated with ICP-derived indices on Pearson correlation, PCA, AHC, and KMCA. The NIRS indices displayed variable correlation with each other and with indices derived from ICP and TCD signals. Of interest, TOx and THx co-cluster with ICP-based indices on PCA and AHC. The ORx failed to display any meaningful correlations with other indices in neither of the analytical method used. Thirty-minute moving average and minute-by-minute data set displayed similar results across all the methods. The RAC, Mx, and Sx were the strongest predictors of outcome at six months. Continuously updating autoregulatory indices are not all correlated with one another. Caution must be advised when utilizing less commonly described autoregulation indices (i.e., ORx) for the clinical assessment of autoregulatory capacity, because they appear to not be related to commonly measured/establish indices, such as PRx. Further prospective validation is required.

Secondary Insults and Adverse Events During Intrahospital Transport of Severe Traumatic Brain-Injured Patients.

BACKGROUND: Our aim was to assess the occurrence of secondary insults (SIs) or adverse events (AEs) during intrahospital transport (IHT) of severe traumatic brain injury (TBI) patients for head computed tomography (CT) scanning. METHODS: A prospective study based on severe TBI patients admitted from June 2011 through June 2013 in a level I trauma center. Patients received an IHT to perform a control CT scan in the first 3 days following trauma. The occurrence of SIs and AEs was assessed during the IHT for a control CT scan. The frequency of SIs was compared to the periods "before," "during," and "after" IHT. SI was defined by an intracranial pressure (ICP) >30 mmHg, a cerebral perfusion pressure (CPP) <50 mmHg, systolic blood pressure (SBP) <90 mmHg, or saturation pulse O2 (SpO2) <90 % for more than five consecutive minutes. An AE was defined as failures of hardware or ventilator asynchrony requiring therapeutic intervention during transport. In addition, we assessed the therapeutic benefit of a CT scan control. RESULTS: The final analysis included 31 patients and 31 IHTs. The median duration of IHT was 29 min [25;37]. SIs occurred in 16 patients (52 %) during transport, whereas it was observed in 4 patients (13 %) before (p = 0.002) and 4 patients (13 %) after IHT (p = 0.001). Twenty-four AEs occurred during transport of 19 patients (61 %). One patient benefited from hematoma evacuation after implementation of control CT. CONCLUSION: IHT carries significant SIs and AEs in severe TBI patients. To improve a risk/benefit ratio favorable for patients, a program focusing on IHT complications regarding therapeutic impact of control CT scan is needed.

EEG Monitoring and Antiepileptic Drugs in Children with Severe TBI.

BACKGROUND: Traumatic brain injury (TBI) causes substantial morbidity and mortality in US children. Post-traumatic seizures (PTS) occur in 11-42% of children with severe TBI and are associated with unfavorable outcome. Electroencephalographic (EEG) monitoring may be used to detect PTS and antiepileptic drugs (AEDs) may be used to treat PTS, but national rates of EEG and AED use are not known. The purpose of this study was to describe the frequency and timing of EEG and AED use in children hospitalized after severe TBI. METHODS: Retrospective cohort study of 2165 children at 30 hospitals in a probabilistically linked dataset from the National Trauma Data Bank (NTDB) and the Pediatric Health Information Systems (PHIS) database, 2007-2010. We included children (age <18 years old at admission) with linked NTDB and PHIS records, severe (Emergency Department [ED] Glasgow Coma Scale [GCS] <8) TBI, hospital length of stay >24 h, and non-missing disposition. The primary outcomes were EEG and AED use. RESULTS: Overall, 31.8% of the cohort had EEG monitoring. Of those, 21.8% were monitored on the first hospital day. The median duration of EEG monitoring was 2.0 (IQR 1.0, 4.0) days. AEDs were prescribed to 52.0% of the cohort, of whom 61.8% received an AED on the first hospital day. The median duration of AED use was 8.0 (IQR 4.0, 17.0) days. EEG monitoring and AED use were more frequent in children with known risk factors for PTS. EEG monitoring and AED use were not related to hospital TBI volume. CONCLUSION: EEG use is relatively uncommon in children with severe TBI, but AEDs are frequently prescribed. EEG monitoring and AED use are more common in children with known risk factors for PTS.

Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury.

OBJECTIVE: To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. DESIGN: Prospective, observational cohort study. SETTING: Twelve PICUs in North Carolina. PATIENTS: All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. CONCLUSION: Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children.

Variation in Anticonvulsant Selection and Electroencephalographic Monitoring Following Severe Traumatic Brain Injury in Children-Understanding Resource Availability in Sites Participating in a Comparative Effectiveness Study.

OBJECTIVES: Early posttraumatic seizures may contribute to worsened outcomes after traumatic brain injury. Evidence to guide the evaluation and management of early posttraumatic seizures in children is limited. We undertook a survey of current practices of continuous electroencephalographic monitoring, seizure prophylaxis, and the management of early posttraumatic seizures to provide essential information for trial design and the development of posttraumatic seizure management pathways. DESIGN: Surveys were sent to site principal investigators at all 43 sites participating in the Approaches and Decisions in Acute Pediatric TBI trial at the time of the survey. Surveys consisted of 12 questions addressing strategies to 1) implement continuous electroencephalographic monitoring, 2) posttraumatic seizure prophylaxis, 3) treat acute posttraumatic seizures, 4) treat status epilepticus and refractory status epilepticus, and 5) monitor antiseizure drug levels. SETTING: Institutions comprised a mixture of free-standing children's hospitals and university medical centers across the United States and Europe. SUBJECTS: Site principal investigators of the Approaches and Decisions in Acute Pediatric TBI trial. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Continuous electroencephalographic monitoring was available in the PICU in the overwhelming majority of clinical sites (98%); however, the plans to operationalize such monitoring for children varied considerably. A similar majority of sites report that administration of prophylactic antiseizure medications is anticipated in children (93%); yet, a minority reports that a specified protocol for treatment of posttraumatic seizures is in place (43%). Reported medication choices varied substantially between sites, but the majority of sites reported pentobarbital for refractory status epilepticus (81%). The presence of treatment protocols for seizure prophylaxis, early posttraumatic seizures, posttraumatic status epilepticus, and refractory status epilepticus was associated with decreased reported medications (all p < 0.05). CONCLUSIONS: This study reports the current management practices for early posttraumatic seizures in select academic centers after pediatric severe traumatic brain injury. The substantial variation in continuous electroencephalographic monitoring implementation, choice of seizure prophylaxis medications, and management of early posttraumatic seizures across institutions was reported, signifying the areas of clinical uncertainty that will help provide focused design of clinical trials. Although sites with treatment protocols reported a decreased number of medications for the scenarios described, completion of the Approaches and Decisions in Acute Pediatric TBI trial will be able to determine if these protocols lead to decreased variability in medication administration in children at the clinical sites.