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Introduction. Central hyperthermia is common in patients with brain injury. It typically has a rapid onset with high temperatures and marked fluctuations and responds poorly to antibiotics and antipyretics. It is also associated with worse outcomes in the brain injured patient. Recognizing this, it is important to aggressively manage it. Case Report. We report a 34-year-old male with a right thalamic hemorrhage extending to the midbrain and into the ventricles. During his admission, he developed intractable fevers with core temperatures as high as 39.3°C. Infectious workup was unremarkable. The fever persisted despite empiric antibiotics, antipyretics, and cooling wraps. Bromocriptine was started resulting in control of the central hyperthermia. The fever spikes were reduced to minor fluctuations that significantly worsened with any attempt to wean off the bromocriptine. Conclusion. Diagnosing and managing central hyperthermia can be challenging. The use of bromocriptine can be beneficial as we have reported.
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BACKGROUND: Status epilepticus (SE) often does not respond to initial treatment. A second-line agent with a less established safety and efficacy profile is then required. This study examined the safety of intravenous (IV) lacosamide (LCM) in a critically ill population and obtained an estimate of effectiveness in patients with refractory SE on continuous video EEG monitoring (cEEG). METHODS: Retrospective review of critically ill patients in SE on cEEG treated with IV LCM from June 2009 to April 2011. RESULTS: Eighty-four patients in SE (43 F/41 M), mean age 59.6 years, were identified; and 59.5 % had nonconvulsive SE. The most common etiologies were ischemic and hemorrhagic strokes. There were no significant changes in serial blood pressure monitoring, PR prolongation, aspartate aminotransferase (AST), or creatinine pre- and post-LCM. There was a significant increase in alanine aminotransferase (ALT) from days 1-7 (p = 0.031). Fifty-one patients were LCM-naïve. In these patients, cessation of SE on cEEG after LCM occurred in 15.7, 25.5, 58.8, and 82.4 % by 4, 12, 24, and 48 h, respectively. CONCLUSION: IV LCM appears safe short term in critically ill patients with SE. The retrospective estimate of effectiveness for LCM appears promising for management in SE. Prospective, randomized controlled studies are needed to better determine the role of LCM in treating SE.
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Acetamidas/farmacología , Anticonvulsivantes/farmacología , Enfermedad Crítica/terapia , Epilepsia Refractaria/tratamiento farmacológico , Evaluación de Resultado en la Atención de Salud , Estado Epiléptico/tratamiento farmacológico , Acetamidas/administración & dosificación , Acetamidas/efectos adversos , Administración Intravenosa , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anticonvulsivantes/administración & dosificación , Anticonvulsivantes/efectos adversos , Femenino , Humanos , Lacosamida , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
Introduction. Autoimmune encephalitis (AE) is a clinically challenging diagnosis with nonspecific neurological symptoms. Prompt diagnosis is important and often relies on neuroimaging. We present a case series of AE highlighting the importance of an early [(18)F]-fluoro-deoxy-glucose positron emission tomography (FDG-PET) scan. Methods. Retrospective review of seven consecutive cases of autoimmune encephalitis. Results. All patients had both magnetic resonance imaging (MRI) and FDG-PET scans. Initial clinical presentations included altered mental status and/or new onset seizures. Six cases had serum voltage-gated potassium channel (VGKC) antibody and one had serum N-methyl-D-aspartate (NMDA) antibody. MRI of brain showed mesial temporal lobe hyperintensity in five cases of VGKC. The other two patients with VGKC or NMDA AE had restiform body hyperintensity on MRI brain or a normal MRI, respectively. Mesial temporal lobe hypermetabolism was noted in three cases on FDG-PET, despite initial unremarkable MRI. Malignancy workup was negative in all patients. Conclusion. A high index of suspicion for AE should be maintained in patients presenting with cognitive symptoms, seizures, and limbic changes on neuroimaging. In cases with normal initial brain MRI, FDG-PET can be positive. Additionally, extralimbic hyperintensity on MRI may also be observed.
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In a rat model, the baroreceptor reflex can be assessed by graded infusions of either phenylephrine or sodium nitroprusside with continuous hemodynamic monitoring. Microinjection of the cholinergic agonist carbachol (CCh) into the posterior hypothalamic nucleus (PHN) evokes an increase in mean arterial pressure and a change in heart rate. Lower doses of CCh evoke only tachycardia, whereas middle and higher doses evoke a biphasic change in heart rate of tachycardia followed by bradycardia. The bradycardia following the microinjection of CCh into the PHN can be attenuated by the previous administration of the vasopressin V1 receptor antagonist [d(CH2 )5 Tyr(Me)] arginine vasopressin (AVPX). Circulating arginine vasopressin (AVP) has been shown to increase the sensitivity of the baroreceptor reflex by stimulating vasopressin V1 receptors in the area postrema. The attenuation by AVPX of the bradycardia that results following the high doses of CCh suggests that AVP is released into the circulation following stimulation of cholinergic systems within the PHN. Thus, microinjection of a high dose of CCh (11 nmol) into the PHN alters the sensitivity of the baroreceptor reflex by increasing peripheral levels of AVP.
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Barorreflejo/fisiología , Carbacol/administración & dosificación , Agonistas Colinérgicos/administración & dosificación , Hipotálamo Posterior/fisiología , Microinyecciones , Animales , Barorreflejo/efectos de los fármacos , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Frecuencia Cardíaca/efectos de los fármacos , Frecuencia Cardíaca/fisiología , Hipotálamo Posterior/efectos de los fármacos , Masculino , Microinyecciones/métodos , Ratas , Ratas Sprague-DawleyRESUMEN
Introduction. Strokes and stroke-mimics have been extensively studied in the emergency department setting. Although in-hospital strokes are less studied in comparison to strokes in the emergency department, they are a source of significant direct and indirect costs. Differentiating in-hospital strokes from stroke-mimics is important. Thus, our study aimed to identify variables that can differentiate in-hospital strokes from stroke-mimics. Methods. We present here a retrospective analysis of 93 patients over a one-year period (2009 to 2010), who were evaluated for a concern of in-hospital strokes. Results. About two-thirds (57) of these patients were determined to have a stroke, and the remaining (36) were stroke-mimics. Patients with in-hospital strokes were more likely to be obese (p = 0.03), have been admitted to the cardiology service (p = 0.01), have atrial fibrillation (p = 0.03), have a weak hand or hemiparesis (p = 0.03), and have a prior history of stroke (p = 0.05), whereas, when the consults were called for "altered mental status" but no other deficits (p < 0.0001), it is likely a stroke-mimic. Conclusion. This study demonstrates that in-hospital strokes are a common occurrence, and knowing the variables can aid in their timely diagnosis and treatment.
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INTRODUCTION: Creutzfeldt-Jakob disease (CJD) is a rapidly progressive dementia with a median survival of 2-14 months. The diagnosis can only be made accurately by biopsy/autopsy. However, this is not always feasible or desirable. Thus, diagnostic criteria have been proposed by UCSF, European MRI-CJD Consortium, and WHO. We will compare these criteria. PATIENTS AND METHODS: Retrospective study of 31 patients (average age of 69.2 years) between 2003 to 2010 by ICD9 codes 046.1, 046.11, and 046.19. RESULTS: All patients presented with rapidly progressive dementia (mean duration of 4.25 months). Pyramidal and extrapyramidal findings, myoclonus, cerebellar changes, akinetic mutism, and visual disturbances were observed in 6.5-48.4%. Five had periodic pattern on EEG. CSF biomarker 14-3-3 was positive in 11. Tau was positive in 6. Neuron specific enolase was positive in 9. By consensus (kappa = 0.62), MRI was "typical" of CJD in 23 with cortical ribboning (n = 16), basal ganglia hyperintensity (n = 15), or combination (n = 8). By WHO criteria, which does not include neuroimaging, CJD was diagnosed in 10, but 14 if any CSF biomarker was used (p = NS). The UCSF criteria, which does not include CSF biomarkers, diagnosed 18 cases, and the European MRI-CJD Consortium, which includes neuroimaging and CSF biomarkers but with less neurological signs, diagnosed 23 cases (p < 0.05 and p < 0.001, respectively). CJD-mimics included urosepsis, neurosarcoidosis, idiopathic left temporal lobe epilepsy, alcohol intoxication, central nervous system vasculitis, viral encephalitis, and non-Hodgkin's lymphoma. CONCLUSION: This study illustrates the variability in diagnosing CJD and emphasizes the diagnostic utility of neuroimaging. It also highlights false-positives that occur with neuroimaging.
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Encéfalo/patología , Síndrome de Creutzfeldt-Jakob/diagnóstico , Imagen por Resonancia Magnética/normas , Neuroimagen/normas , Guías de Práctica Clínica como Asunto , Anciano , Biomarcadores/líquido cefalorraquídeo , Reacciones Falso Positivas , Femenino , Humanos , Masculino , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Continuous electroencephalogram (cEEG) is tightly linked to cerebral metabolism and is sensitive to cerebral ischemia and hypoxia. The severity of cerebral ischemia can be seen on cEEG as changes in morphology, amplitude, or frequency, and cEEG may detect neuronal dysfunction at a reversible stage. METHODS: Case report and imaging. RESULTS: We present a case of focal cerebral edema with changes seen on cEEG 24 h before clinical signs of increased intracranial pressure. cEEG showed developing asymmetry in the left hemisphere followed by burst suppression. The right hemisphere showed similar progression to burst suppression. Complete suppression of both hemispheres was noted 6 h before clinical signs of herniation. Computed tomography (CT) head confirmed a large left parietal intracerebral hematoma with mass effect. CONCLUSIONS: cEEG has applications in monitoring cerebral dysfunction in addition to detecting seizure activity in the intensive care unit. It may serve a vital role in multi-modality monitoring for early recognition of neurological complications from brain injuries that may not be noticed clinically, which is paramount to early intervention.
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Edema Encefálico/fisiopatología , Encéfalo/fisiopatología , Progresión de la Enfermedad , Electroencefalografía/métodos , Hemorragias Intracraneales/fisiopatología , Anciano , Anticonvulsivantes/uso terapéutico , Encéfalo/patología , Edema Encefálico/complicaciones , Edema Encefálico/patología , Encefalocele/complicaciones , Encefalocele/patología , Encefalocele/fisiopatología , Resultado Fatal , Hematoma/complicaciones , Hematoma/patología , Humanos , Hemorragias Intracraneales/complicaciones , Hemorragias Intracraneales/patología , Masculino , Lóbulo Parietal/patología , Lóbulo Parietal/fisiopatología , Pronóstico , Estado Epiléptico/tratamiento farmacológico , Estado Epiléptico/etiología , Factores de Tiempo , Tomografía Computarizada por Rayos XRESUMEN
We audited the effect of introducing HIV opt-out in a genitourinary medicine clinic in central London, UK. We found that opt-out increased the rate at which HIV testing was offered to low-risk patients and that more tests were done.
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Serodiagnóstico del SIDA , Instituciones de Atención Ambulatoria , Infecciones por VIH/diagnóstico , Aceptación de la Atención de Salud , Negativa del Paciente al Tratamiento , Serodiagnóstico del SIDA/estadística & datos numéricos , Adulto , Diagnóstico Precoz , Femenino , Anticuerpos Anti-VIH/sangre , Infecciones por VIH/virología , VIH-1/inmunología , Humanos , Londres , MasculinoRESUMEN
A 30-year-old HIV-infected intravenous drug user presented with sepsis, acute renal failure, oedema, proteinuria and iron deficiency anaemia. After extensive investigation, a diagnosis of reactive systemic AA (amyloid, serum amyloid A protein) amyloidosis was made on the basis of renal, gastric and duodenal biopsies.
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Amiloidosis/complicaciones , Enfermedades Duodenales/virología , Infecciones por VIH/complicaciones , Insuficiencia Renal/etiología , Gastropatías/virología , Abuso de Sustancias por Vía Intravenosa/complicaciones , Adulto , Enfermedades Duodenales/patología , Mucosa Gástrica/patología , Humanos , Masculino , Proteinuria/virología , Insuficiencia Renal/patología , Sepsis/complicaciones , Gastropatías/patologíaAsunto(s)
Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/prevención & control , Inhibidores de la Transcriptasa Inversa/uso terapéutico , Conducta Sexual , Serodiagnóstico del SIDA/métodos , Adulto , Quimioterapia Combinada , Infecciones por VIH/diagnóstico , Infecciones por VIH/transmisión , Humanos , MasculinoRESUMEN
First aid training for the trained soldier has been modified to incorporate the best available current clinical evidence and clinical experience. This annual training requirement will be achieved in one day and is introduced as Individual Training Directive (Army) 3 (ITD(A) 3) on 1 April 1999. With the exception of a short introductory video, the course is entirely taught and assessed on practical models. ITD(A) 3 teaches a systematic approach to every incident and to each injured soldier. This is presented in a robust, waterproof pocket aide memoire of Battlefield First Aid Drills, which is an individual issue item. The soldier must start with the MASTER DRILL to control the incident, and will then follow the INJURED SOLDIER DRILL to identify and treat life-threatening injuries. The best available clinical experience has resulted in the replacement of the three-sided dressing with the Asherman Chest Seal for open pneumothorax, and the introduction of a simple physiology based triage system. The best available clinical evidence has led to the removal of basic life support in the context of a soldier with no vital signs on the battlefield. It is retained as an 'add on' package for peace and peace-keeping environments.
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Primeros Auxilios/métodos , Medicina Militar/educación , Personal Militar/educación , Reanimación Cardiopulmonar , Humanos , Masculino , Guerra , Heridas y Lesiones/terapiaRESUMEN
We have used Townsend scores from postcode data to compare levels of material deprivation and Epstein-Barr virus (EBV)-positivity for 223 patients diagnosed with Hodgkin's disease (HD) in the period 1981-1997. The presence of EBV in HD tumours was determined using in situ hybridization to target the abundantly expressed EBV early RNAs. EBV was detected in the malignant Hodgkin and Reed-Sternberg cells in 47/223 HD cases (21%). There was found to be a tendency for higher Townsend scores (indicative of higher levels of material deprivation) in EBV-positive HD patients, but this association was not statistically significant. When various subgroups of patients from the study were examined separately the indication of higher Townsend scores in EBV-positive patients was found to be more marked for patients with mixed cellularity disease (P = 0.09) and for females (P = 0.03). The results of this study suggest that differences in the level of material deprivation are important in determining the likelihood of EBV-positive HD in the UK, particularly for certain subgroups of patients. It is not known what specific socioeconomic factors are responsible for these differences, although alterations in the timing or rate of primary EBV infection, or decline in the level of EBV-specific immunity, may be important.
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Infecciones por Herpesviridae/epidemiología , Herpesvirus Humano 4 , Enfermedad de Hodgkin/virología , Clase Social , Infecciones Tumorales por Virus/epidemiología , Adolescente , Adulto , Factores de Edad , Anciano , Niño , Preescolar , Inglaterra/epidemiología , Femenino , Infecciones por Herpesviridae/complicaciones , Infecciones por Herpesviridae/virología , Enfermedad de Hodgkin/epidemiología , Humanos , Hibridación in Situ , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Pobreza , Factores Sexuales , Infecciones Tumorales por Virus/complicaciones , Infecciones Tumorales por Virus/virologíaRESUMEN
From 1972 to 1983 the Duke University Department of Anesthesiology designed, built, and maintained most of its own operating room patient monitoring equipment. Construction of a new hospital facility in 1980 provided the opportunity to design and test a new computer-based system, the Duke Automatic Monitoring Equipment (DAME) System. The system consist of microcomputer-based instrumentation on monitoring carts, which communicate with a central minicomputer that allows selection of different software monitoring packages based on the needs of the patient. Multiple problems, including frequent total monitoring failures during surgery, plagued the DAME System in its first year of operation. Despite resolution of many of these problems, user acceptance was poor because of the large size and weight of the monitoring carts, the inadequate quality of displayed physiological waveforms, and inability to overcome the difficulties of the man-machine interface. Because the remaining problems could not be rectified with the existing monitoring carts, a new generation of monitors was designed. The smaller, multiprocessor microDAME was designed to be as automatic and user tolerant as possible. It would omit much of the flexibility that had proved undesirable in the DAME system. When the microDAME was nearly completed, however, departmental research in that area ceased. It remains for others to apply our experiences to further improve operating room patient monitors.
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Anestesiología/instrumentación , Computadores , Monitoreo Fisiológico/instrumentación , Presentación de Datos , HumanosRESUMEN
A new double-tipped strip for home glucose monitoring without a meter is described. Comparison between values obtained with the new method by trained nursing staff and those obtained with a glucose-oxidase analyzer demonstrates close correlation between the two methods (r = +0.95, a = +22.2 mg/dl, b = +1.14). The mean concentration in 117 strip tests over an analyzer range of 5-775 mg/dl (0.3-43.0 mmol/L) was 52 mg/dl (2.9 mmol/L) greater than the analyzer estimate. Forty-seven percent of samples were read as the color block closest to the analyzer estimate. Samples in the lower glucose range tended to read one block high. The technique is faster to perform than most other visual blood glucose strip methods, and is a useful addition to the equipment available for home glucose monitoring. Modifications to the strip by the manufacturers appear to have overcome the low value over-reading error.