Rehabilitation Outcomes in Multiple Sclerosis Patients on Ocrelizumab Diagnosed With West Nile Virus Encephalitis.

Multiple sclerosis (MS) has a global prevalence exceeding two million people and is a leading cause of non-traumatic physical disability. MS can be treated with ocrelizumab, an anti-CD20 monoclonal antibody. West Nile virus (WNV) is the most common cause of mosquito-borne viral encephalitis in North America. It can lead to neuroinvasive WNV disease (WNND) affecting the brain and peripheral nervous system, especially in immunocompromised patients, such as those being treated with ocrelizumab for MS. WNND is exceedingly rare and reported in less than 1% of cases of WNV. It has been established that inpatient rehabilitation improves functional outcomes in patients with MS and those with WNND. However, the inpatient rehabilitation outcomes in patients diagnosed with both WNND and MS have not been reported. In this study, we aimed to examine the rehabilitation outcomes of MS patients on ocrelizumab diagnosed with WNND. We performed a retrospective chart review of patients with MS treated with ocrelizumab, who were diagnosed with WNND and admitted to a single facility. Rehabilitation outcomes were assessed using functional independence measure (FIM) scores on admission and discharge. Three patients met the inclusion criteria; two in acute rehab, and one in the long-term acute care hospital (LTACH). Both patients admitted to acute inpatient rehabilitation showed an improvement in FIM scores from admission to discharge, one patient from 9 to 16 and the other from 14 to 54. However, the patient admitted to the LTACH had no improvement in FIM score from admission to discharge. Patients admitted to acute rehab were ultimately discharged home, while the patient admitted to the LTACH required discharge to a subacute rehabilitation facility. Based on our findings, intense and prolonged comprehensive inpatient rehabilitation is associated with improved functional outcomes and increased likelihood of discharge to home in this population suffering from both central and peripheral nervous system involvement due to MS and WNND.

Concurrent Pansinusitis and Orbital Cellulitis Complicated by Extensive Head and Neck Venous Thrombosis in an Unvaccinated Adolescent Patient with COVID-19: A Case Report.

BACKGROUND: Orbital cellulitis is an infrequent but serious infectious complication of rhinosinusitis, most commonly seen in the pediatric population. Extension into the cavernous sinus, leading to further infection and thrombosis, is a rare but life-threatening complication. Although COVID-19 has been linked to an increased risk of venous thromboembolism, most cases involve extremity deep venous thrombosis or pulmonary embolism; reports of intracranial or jugular system thrombosis are rare. CASE REPORT: We describe a case of a 17-year-old female patient with no significant medical history or thrombotic risk factors found to have orbital cellulitis and severe pansinusitis, complicated by multiple venous thromboses in the head and neck requiring emergent surgical intervention and pediatric intensive care admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Extensive head and neck venous thrombosis and intracranial abscesses are rare complications of pansinusitis and orbital cellulitis, and the thrombotic complications of COVID-19 are well documented. A delay in diagnosis and treatment can lead to potentially devastating consequences.

Analysis of Preoperative CT Scan Can Help Predict Technical Failure of Endovascular Treatment of TASC C-D Aortoiliac Chronic Total Occlusions.

BACKGROUND AND AIMS: To evaluate if features of occlusion analyzable on preoperative computed tomography scan could predict risks of technical failure or iliac rupture of endovascular treatment of TransAtlantic InterSociety Consensus C-D aortoiliac chronic total occlusion. METHODS AND RESULTS: All patients treated by endovascular techniques for a TransAtlantic InterSociety Consensus C-D aortoiliac chronic total occlusion between 2009 and 2016 were included (107 patients, 148 iliac arteries). We evaluated the location of the occlusion and the importance of the arterial calcifications. For this factor, patients were divided into 3 groups: the Black occlusion group with mild or no calcifications, the white occlusion group with moderate no protrusive calcifications, and the white protrusive occlusion group with heavy endoluminal calcifications. Technical failure occurred in 11 iliac arteries and peroperative iliac rupture in 6. The location in the external iliac artery is the most significate risk factor of technical failure in univariate (OR = 9.93; P = 0.0012) and multivariate analysis (OR = 15.26; P = 0.0006). The presence of heavy endoluminal calcifications is a further significate risk factor (OR = 13.88; P = 0.0365). Rupture rate was comparable between the 3 groups. CONCLUSIONS: Preoperative computed tomography scan can predict risk of technical failure but not of iliac rupture.

The telephone effect: Overcoming initiation deficits in two settings.

PURPOSE: Disorders of motivation substantially impair an individual's ability to communicate with their families, therapists, and doctors. One method of overcoming initiation deficits is by utilizing the telephone effect, which is the ability for individuals with severe motivation deficits to communicate more readily when speaking on a telephone. However, little is available in the extant literature on how this effect works or how best to integrate this into patient care. This article aims to provide the first report of a proposed mechanism underlying the telephone effect and the first published procedures for eliciting this effect. DESIGN: This is largely a review article that also contains descriptions of clinical procedures for eliciting the telephone effect with 2 patient populations: acute inpatients following brain injury and dementia residents. A case vignette is also provided. RESULTS: We propose that the telephone effect is the result of an interaction between the patient and environment, and occurs because of Gibson's (1979) law of affordances. The use of this theory provides an explanation of the behaviors often observed when attempting to elicit this effect (i.e., disruption of the effect when using a cellular phone). Moreover, we argue that this can, and does, apply to social interactions as well. CONCLUSIONS/IMPLICATIONS: The telephone effect is an understudied phenomenon that provides a means of improving care for individuals with disorders of motivation. Future directions include systematic research into the telephone effect and further investigation of the mechanism underlying this effect. (PsycINFO Database Record

Fluoroscopy procedure and equipment changes to reduce staff radiation exposure in the interventional spine suite.

BACKGROUND: Fluoroscopic guided percutaneous interventional spine procedures are increasingly performed in recent years as they have been shown to be target specific and enhance patient safety. However, ionizing radiation has been associated with stochastic effects such as cancer and genetic defects as well as deterministic effects such as cataracts, erythema, epilation, and even death. These are dose related, and hence, measures should be taken to minimize radiation exposure to patients and health care personnel to reduce these adverse effects. OBJECTIVE: A risk reduction project was completed with the goal of reducing effective doses to the staff and patients in a university-based spinal interventional practice. Effective dose reduction to the staff and patients was hypothesized to occur with technique and equipment changes in the procedure suite. The goal of this study was to quantify effective dose rates to staff before and after interventions. STUDY DESIGN: Retrospective study comparing descriptive data of effective dose to the health care staff before and after implementation of a combination of technique and equipment changes. METHODS: Technique changes from pre to post intervention period included continuous needle advancement under continuous fluoroscopic controlled by the interventional physician to intermittent needle advancement under pulsed fluoroscopic controlled by the radiology technician. Equipment changes included circumferential lead drape skirt around the procedure table and use of mobile transparent lead barriers on both sides of the procedure table.Effective dose exposure measured in Millirem (mrem) from the radiation dosimetry badges for pre-intervention (February 2009 through June 2009) and post-intervention (November 2009 through March 2010) periods were examined through monthly radiation dosimetry reports for the fluoroscopy suite staff. RESULTS: A total of 685 interventional procedures were performed in the pre-intervention period and 385 in the post-intervention period. The median cumulative mrem (interquartile range) for all staff combined in the pre-intervention period was 71 (28,75) and post-intervention period was 1 (0,3). The median mrem per procedure was significantly higher in the pre-intervention group 0.46 (0.36, 0.54) compared to post-intervention 0.01 (0.0.03); P < 0.01. The percentage reduction in overall effective dose per procedure to all staff was 97.3%. LIMITATIONS: Observational study, multiple radiation reduction interventions confound the individual effects of each intervention's effective dose CONCLUSIONS: Spinal injection technique and equipment changes in the procedure suite significantly reduced the rate of effective dose to the clinical staff.

Propofol limits microglial activation after experimental brain trauma through inhibition of nicotinamide adenine dinucleotide phosphate oxidase.

BACKGROUND: Microglial activation is implicated in delayed tissue damage after traumatic brain injury (TBI). Activation of microglia causes up-regulation of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, with the release of reactive oxygen species and cytotoxicity. Propofol appears to have antiinflammatory actions. The authors evaluated the neuroprotective effects of propofol after TBI and examined in vivo and in vitro whether such actions reflected modulation of NADPH oxidase. METHODS: Adult male rats were subjected to moderate lateral fluid percussion TBI. Effect of propofol on brain microglial activation and functional recovery was assessed up to 28 days postinjury. By using primary microglial and BV2 cell cultures, the authors examined propofol modulation of lipopolysaccharide and interferon-γ-induced microglial reactivity and neurotoxicity. RESULTS: Propofol improved cognitive recovery after TBI in novel object recognition test (48 ± 6% for propofol [n = 15] vs. 30 ± 4% for isoflurane [n = 14]; P = 0.005). The functional improvement with propofol was associated with limited microglial activation and decreased cortical lesion volume and neuronal loss. Propofol also attenuated lipopolysaccharide- and interferon-γ-induced microglial activation in vitro, with reduced expression of inducible nitric oxide synthase, nitric oxide, tumor necrosis factor-α, interlukin-1ß, reactive oxygen species, and NADPH oxidase. Microglial-induced neurotoxicity in vitro was also markedly reduced by propofol. The protective effect of propofol was attenuated when the NADPH oxidase subunit p22 was knocked down by small interfering RNA. Moreover, propofol reduced the expression of p22 and gp91, two key components of NADPH oxidase, after TBI. CONCLUSION: The neuroprotective effects of propofol after TBI appear to be mediated, in part, through the inhibition of NADPH oxidase.

Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program.

PURPOSE OF THE STUDY: To assess the recruitment, adherence, and retention of urban elderly, predominantly African Americans to a falls reduction exercise program. DESIGN AND METHODS: The randomized controlled trial was designed as an intervention development pilot study. The goal was to develop a culturally sensitive intervention for elderly persons who suffered a fall and visited an emergency department (ED). Participants were taught exercises during 4 on-site group classes and encouraged to continue exercising at home for 12 weeks and attend additional on-site monthly classes. The protocol included a specifically designed intervention for increasing retention through trained community interventionists drawn from the participants' neighborhoods. RESULTS: The screening of 1,521 ED records after falling yielded the recruitment of 204 patients aged 65 years and older. Half were randomized into the falls prevention program. Of the 102 people in the intervention group, 92 completed the final 6-month assessment, 68 attended all on-site sessions, but only 1 reported exercising at home all 12 weeks. Those who lived alone were more likely (p = .03) and those with symptoms of depression were less likely (p = .05) to attend all on-site exercise classes. The final recruitment rate was estimated as 31.8%. The final retention rates were 90.2% and 87.3% for the intervention and control groups, respectively. IMPLICATIONS: Recruitment of frail elderly African American patients is resource intensive. Adherence to the on-site exercise classes was better than to the home-based component of the program. These findings have implications for the design of future community-based exercise programs and trials.

Grading: an annotated "pen and paper" approach to multidimensional case-mix-adjusted continuous quality improvement.

In this article, we present a simple multidimensional approach to case-mix adjustment that can be used without sophisticated statistical or computer programs. The objectives are to synthesize and offer examples of practical applications of the principles provided in the other articles in this issue of Topics in Stroke Rehabilitation. Combining case-mix adjustment concepts presented by Berlowitz and coworkers with the educate, execute, and evaluate process presented by Needham and coworkers, the approach applies functional grading to show how to evaluate the impact on patient outcomes after major changes in the structural characteristics of an integrated rehabilitation program within a large hospital-based health system. The example is based on the vignette, Maintaining Functional Outcomes in Times of Change, which appears in the article, "Unraveling the Conundrum of Quality" in this issue.