Images: Benign myoclonus of sleep associated with K-complexes on electroencephalography.

In this brief case report on paroxysmal sleep-related movements, we describe an adolescent patient's presentation of brief jerking movements during sleep and the accompanying differential diagnosis. In examining the patient's overnight electroencephalogram we use hallmark sleep architecture to provide reassurance to the patient and her family. CITATION: Silverman A, Miglis MG, Gallentine W. Images: Benign myoclonus of sleep associated with K-complexes on electroencephalography. J Clin Sleep Med. 2024;20(1):183-184.

Impact of an Interactive, Animation-Based Electroencephalography Curriculum on Learner Confidence and Knowledge.

BACKGROUND: There is a national need for innovative electroencephalography (EEG) education with efficacy evaluated by rigorous statistical analysis. We created a dynamic, online resource that includes a series of animated videos at a single academic medical center. METHODS: For the animations and interactive module, we used VideoScribe and Articulate, respectively. The module comprised three chapters: (1) Origin & Technical Aspects of EEG, (2) Normal Adult EEG in Wakefulness & Sleep, and (3) Abnormal EEG, with appendices on artifacts, variants, activation procedures, seizure/epilepsy classification, and neonatal/pediatric EEG. The curriculum and knowledge assessments were reviewed independently by two fellowship-trained physicians before distribution. Linear mixed-effects models with bootstrapping were used to compare paired pre- and post-tests as well as Likert scale questionnaires. RESULTS: Forty-nine learners participated in the pretest survey; 38 matched participants completed post-tests (78%). Learners across fields perceived benefit (100% would recommend to colleagues), indicated improved self-efficacy (P < 0.0001), and performed better on post-test knowledge assessments (54.1 vs 88.2%, P < 0.0001). In the neurology providers subgroup (n = 20), pretest scores correlated with years in training (Spearman r = 0.52, P = 0.039), neurology rotations (r = 0.70, P = 0.003), epilepsy/EEG rotations (r = 0.6, P = 0.014), and EEG teaching hours (r = 0.62, P = 0.01); content knowledge and self-efficacy improvement for neurology providers remained significant in a multivariate model adjusting for these covariates. CONCLUSIONS: This animation-based, interactive EEG module proved effective in elevating learner confidence and knowledge across several medical specialties and training levels. Further study across institutions and subspecialties is needed to substantiate broad applicability, but our data appear promising for early EEG learners.

Clinical Problem Solving: A 38-year-Old Woman With Systemic Lupus Erythematosus Presenting With Headache, Nausea, and Vomiting.

A 38-year-old woman with migraine headaches and systemic lupus erythematosus with recent cessation of her immunosuppressive therapy presents with prolonged headache and hypertensive emergency. Her examination is notable for a peripheral right facial palsy and stable malar rash. There are no signs of systemic infection nor systemic symptoms of a lupus flare. Initial CT head reveals bilateral hypodensities in the basal ganglia. Within 8 hours of presentation, she develops right hemiplegia and becomes encephalopathic. MRI shows multifocal acute infarcts (most notably in the left basal ganglia), enhancement of the right facial nerve, and multifocal vessel wall enhancement in the anterior and posterior circulation. We discuss the differential diagnosis, comprehensive workup, and subsequent treatment decisions in the management of this immunocompromised patient with encephalopathy, headache, and rapidly progressing focal neurologic deficits.

Youth Suicidality in the Context of Disasters.

PURPOSE OF REVIEW: The purpose of this review is to summarize the current literature regarding youth suicidality (suicidal ideation, suicidal behavior, and completed suicide) in the context of disasters. RECENT FINDINGS: There are fewer studies that examine the effect of disasters on suicidality specifically in children and youth than studies that focus on adults or general population. Numerous studies have reported on the effect of disasters on youth mental health in general without zeroing in on suicide risk. Some variables that have shown to increase suicide risk in children and youth after disasters include female gender, age at the time of disaster exposure, dependence on adults, attachments to places and caregivers, family functioning, and vulnerability to mistreatment. Several studies have demonstrated that youth suicidality fluctuates in response to disasters, at times increasing immediately post-disaster and at other times decreasing immediately post-disaster followed by an increase later. Exposure to natural disasters (e.g., earthquakes, typhoons, hurricanes, wildfires, and extremes of temperature and humidity), man-made disasters (e.g., armed conflict, global warming, and pollution), and unique disasters (e.g., the COVID-19 pandemic) have had significant impact on suicidality in children and adolescents. Although there are several promising interventions to mitigate the post-disaster suicide risk among youth, there is no consensus on a single intervention that is superior to others. More research is needed to study youth suicide risk in the context of disasters and develop culturally appropriate and evidence-based interventions.

Resuscitate but not Intubate? Partial Codes in Pediatrics.

The use of partial code status in pediatric medicine presents clinicians with unique ethical challenges. The clinical vignette describes the presentation of a pulseless infant with a limited life expectancy. The infant's parents instruct the emergency medicine providers to resuscitate but not to intubate. In an emergency, without a clear understanding of parents' goals, complying with their request risks an ineffective resuscitation. The first commentary focuses on parental grief and how, in certain circumstances, a partial code best serves their needs. Its authors argue that providers are sometimes obligated to endure moral distress. The second commentary focuses on the healthcare team's moral distress and highlights the implications of a relational ethics framework for the case. The commentators emphasize the importance of honest communication and pain management. The final commentary explores the systems-level and how the design of hospital code status orders may contribute to requests for partial codes. They argue systems should discourage partial codes and prohibit resuscitation without intubation.

Child Neurology: Horner Syndrome in an Otherwise Well-Appearing Infant.

We report an exemplary case of acquired Horner syndrome secondary to neuroblastoma in infancy. The patient presented with ptosis, miosis, and heterochromia. In reviewing the patient's laboratory and imaging workup, we highlight key etiologic differences between the pediatric and adult populations. Other important teaching points included in the discussion are a review of sympathetic neuroanatomy and oculosympathetic paresis, the appropriate and evidence-based diagnostic workup in infants and children, and a review of pharmacologic testing using cocaine and apraclonidine drops.

Blood Pressure Trajectory Groups and Outcome After Endovascular Thrombectomy: A Multicenter Study.

BACKGROUND: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. METHODS: This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. RESULTS: Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation. CONCLUSIONS: Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.

Outcomes of hepatitis C virus nucleic acid testing positive donors in aviremic recipients with delayed direct-acting antiviral initiation.

The use of allografts from hepatitis C virus (HCV) Nucleic Acid Testing (NAT)+ donors into HCV NAT- recipients has been reported to be efficacious in a handful of studies. However, these studies have not reflected real-world practice where the initiation of direct-acting antivirals (DAA) is dependent on insurance coverage. A single-center, retrospective chart review of HCV NAT- recipients who underwent solid organ transplantation (SOT) from a HCV NAT+ donor between April 1, 2019 and May 27, 2020 was conducted. Sixty-one HCV NAT- patients underwent SOT with a HCV NAT+ organ, with 59 transplant recipients included for evaluation: 22 kidney (KT), 18 liver (LiT), 10 heart (HT), nine lung (LuT). HCV transmission occurred in 100% of recipients. Average time to DAA initiation was POD 46.3 ± 25 days. SVR12 was achieved in 98% (56/57; two patients ineligible for analysis). Treatment failure occurred in one LuT on glecaprevir/pibrentasvir with P32del and Q80K mutations. No patients developed fibrosing cholestatic hepatitis. Two patients died, secondary to anastomotic complication (LuT) and pulmonary embolism (HT). Clinically significant rejection was diagnosed and treated in two HT (one patient with ACR2 and one with ACR2/pAMR2) and one LiT (RAI 5/9). Six patients (10.2%) had documented adverse effects attributed to DAA therapy, primarily gastrointestinal.

30-day readmission prevention program in heart failure patients (RAP-HF) in a community hospital: creating a task force to improve performance in achieving CMS target goals.

In 2012, Centers for Medicare and Medicaid Services (CMS) announced it would penalize any hospitals that had 30-day readmission rates for heart failure (HF) patients above 20%. Mather Hospital Northwell Health, a community teaching hospital, organized a proactive task force to meet these goals. We describe our hospital-wide Readmission Prevention in Heart Failure (RAP-HF) project. We focused on the following interventions: early identification of patients at risk for readmission, discipline-specific mitigation planning by the interdisciplinary rounding team, enhanced medication education for heart failure patients, education of family/caregivers on medication and heart failure symptoms, facilitation in scheduling of post-discharge follow up visits and hard-wired communication between hospital and post-discharge care providers. We saw a 25.53% decrease in 30-day readmission rates.

Progressive Tetraparesis in a 57-Year-Old Man With Congenital Absence of an Anterior Spinal Artery: A Case of Anterior Spinal Cord Infarction.

A 57-year-old man presented with sudden neck pain radiating down his arms. This pain progressed to bilateral upper and subsequently lower extremity weakness and numbness. His vitals were notable for systolic blood pressures lower than his baseline (down to 90 mm Hg). The patient's neurological examination as well as magnetic resonance imaging of the cervical and thoracic spine localized to a lesion in the anterior spinal cord. The differential diagnosis for such an acute presentation included stroke, demyelination, intramedullary neoplasm, infection, metabolic myelopathy, and a dural arteriovenous fistula. Further imaging with angiography demonstrated that our patient lacked an anterior spinal artery. In its place, collateral flow from cervical artery branches provided sustenance to the anterior spinal cord. In the setting of hemodynamic instability, this variant anatomy likely predisposed the patient to ischemia, leading to the classic presentation of anterior cord syndrome.

Effects of Collateral Status on Infarct Distribution Following Endovascular Therapy in Large Vessel Occlusion Stroke.

BACKGROUND AND PURPOSE: We aim to examine effects of collateral status and post-thrombectomy reperfusion on final infarct distribution and early functional outcome in patients with anterior circulation large vessel occlusion ischemic stroke. METHODS: Patients with large vessel occlusion who underwent endovascular intervention were included in this study. All patients had baseline computed tomography angiography and follow-up magnetic resonance imaging. Collateral status was graded according to the criteria proposed by Miteff et al and reperfusion was assessed using the modified Thrombolysis in Cerebral Infarction (mTICI) system. We applied a multivariate voxel-wise general linear model to correlate the distribution of final infarction with collateral status and degree of reperfusion. Early favorable outcome was defined as a discharge modified Rankin Scale score ≤2. RESULTS: Of the 283 patients included, 129 (46%) had good, 97 (34%) had moderate, and 57 (20%) had poor collateral status. Successful reperfusion (mTICI 2b/3) was achieved in 206 (73%) patients. Poor collateral status was associated with infarction of middle cerebral artery border zones, whereas worse reperfusion (mTICI scores 0-2a) was associated with infarction of middle cerebral artery territory deep white matter tracts and the posterior limb of the internal capsule. In multivariate regression models, both mTICI (P<0.001) and collateral status (P<0.001) were among independent predictors of final infarct volumes. However, mTICI (P<0.001), but not collateral status (P=0.058), predicted favorable outcome at discharge. CONCLUSIONS: In this cohort of patients with large vessel occlusion stroke, both the collateral status and endovascular reperfusion were strongly associated with middle cerebral artery territory final infarct volumes. Our findings suggesting that baseline collateral status predominantly affected middle cerebral artery border zones infarction, whereas higher mTICI preserved deep white matter and internal capsule from infarction; may explain why reperfusion success-but not collateral status-was among the independent predictors of favorable outcome at discharge. Infarction of the lentiform nuclei was observed regardless of collateral status or reperfusion success.

Hemodynamics and Hemorrhagic Transformation After Endovascular Therapy for Ischemic Stroke.

Hemorrhagic transformation remains a potentially catastrophic complication of reperfusion therapies for the treatment of large-vessel occlusion ischemic stroke. Observational studies have found an increased risk of hemorrhagic transformation in patients with elevated blood pressure as well as a high degree of blood pressure variability, suggesting a link between hemodynamics and hemorrhagic transformation. Current society-endorsed guidelines recommend maintaining blood pressure below a fixed threshold of 180/105 mmHg regardless of thrombolytic or endovascular intervention. However, given the high recanalization rates with mechanical thrombectomy, it is unclear if the same hemodynamic goals from the pre-thrombectomy era apply. Also, individual patient factors such as the degree of reperfusion, infarct size, and collateral status likely need to be considered. In this review, we will discuss current evidence linking hemodynamics to hemorrhagic transformation after mechanical thrombectomy. In addition, we will review the clinical relevance of cerebral autoregulation in stroke, highlighting recent studies that have harnessed autoregulatory physiology to define and trend individualized limits of autoregulation. This review will go on to emphasize the translatability of this approach to stroke management. Finally, we will discuss novel statistical approaches like trajectory analysis to post-thrombectomy hemodynamics.

Direct carotid puncture for mechanical thrombectomy in acute ischemic stroke patients with prohibitive vascular access.

OBJECTIVE: While the benefit of mechanical thrombectomy (MT) for patients with anterior circulation acute ischemic stroke with large-vessel occlusion (AIS-LVO) has been clearly established, difficult vascular access may make the intervention impossible or unduly prolonged. In this study, the authors evaluated safety as well as radiographic and functional outcomes in stroke patients treated with MT via direct carotid puncture (DCP) for prohibitive vascular access. METHODS: The authors retrospectively studied patients from their prospective AIS-LVO database who underwent attempted MT between 2015 and 2018. Patients with prohibitive vascular access were divided into two groups: 1) aborted MT (abMT) after failed transfemoral access and 2) attempted MT via DCP. Functional outcome was assessed using the modified Rankin Scale at 3 months. Associations with outcome were analyzed using ordinal logistic regression. RESULTS: Of 352 consecutive patients with anterior circulation AIS-LVO who underwent attempted MT, 37 patients (10.5%) were deemed to have prohibitive vascular access (mean age [± SD] 82 ± 11 years, mean National Institutes of Health Stroke Scale [NIHSS] score 17 ± 5, with females accounting for 75% of the patients). There were 20 patients in the DCP group and 17 in the abMT group. The two groups were well matched for the known predictors of clinical outcome: age, sex, and admission NIHSS score. Direct carotid access was successfully obtained in 19 of 20 patients. Successful reperfusion (thrombolysis in cerebral infarction score 2b or 3) was achieved in 16 (84%) of 19 patients in the DCP group. Carotid access complications included an inability to catheterize the carotid artery in 1 patient, neck hematomas in 4 patients, non-flow-limiting common carotid artery (CCA) dissections in 2 patients, and a delayed, fatal carotid blowout in 1 patient. The neck hematomas and non-flow-limiting CCA dissections did not require any subsequent interventions and remained clinically silent. Compared with the abMT group, patients in the DCP group had smaller infarct volumes (11 vs 48 ml, p = 0.04), a greater reduction in NIHSS score (-4 vs +2.9, p = 0.03), and better functional outcome (shift analysis for 3-month modified Rankin Scale score: adjusted OR 5.2, 95% CI 1.02-24.5; p = 0.048). CONCLUSIONS: DCP for emergency MT in patients with anterior circulation AIS-LVO and prohibitive vascular access is safe and effective and is associated with higher recanalization rates, smaller infarct volumes, and improved functional outcome compared with patients with abMT after failed transfemoral access. DCP should be considered in this patient population.

Distinguishing melanophages from tumor in melanoma patients treated with talimogene laherparepvec.

Response to talimogene laherparepvec (T-Vec) is difficult to assess as pigmented macrophages that have ingested melanoma cells ('melanophages') persist after injection, mimicking melanoma. We used quantitative immunofluorescence (qIF) to (1) distinguish melanophages from melanoma in biopsies from two patients treated with T-Vec and (2) evaluate the tumor microenvironment pretreatment and posttreatment. Tissues were stained with 4',6-diamidino-2-phenylindole, cluster of differentiation (CD) 3, CD8, CD68, human leukocyte antigen-DR isotype (HLA-DR), and SRY-Box Transcription Factor 10 (SOX10), and multispectral images were analyzed. Post-T-Vec samples showed melanophages with cytoplasmic costaining of CD68, SOX10, and HLA-DR, without nuclear SOX10 expression. qIF revealed a dense immune infiltrate of CD3, CD8, and CD68 cells in post-T-Vec samples. Melanophages from tumors post-T-Vec stain the nuclear melanoma marker SOX10 in their cytoplasms as compared to melanoma cells that stain nuclear SOX10. This novel finding highlights the phagocytosis of melanoma cell components by macrophages after treatment with T-Vec. qIF may assist pathologists in determining whether lesions treated with immunotherapy contain residual viable melanoma.

Vaping induced pneumonitis: a small community hospital's case series and analysis.

BACKGROUND: Electronic cigarettes/e-cigarettes (ECs), or vaping, is currently the most popular form of smoking amongst youth in the United States. ECs are battery-powered devices that vaporize a liquid that comes in small cartridges, or pods, that contain various chemicals, nicotine, and an array of flavors that can be modified to include cannabinoids (THC). With increasing popularity, however, there is an epidemic of pulmonary and gastrointestinal illnesses associated with vaping in the continental U.S.A. METHODS: We analyzed medical charts of three patients who were active users of ECs and presented with pneumonitis to our community medical center between January and August 2019. RESULTS: We report three cases of vaping pneumonitis in young adults, ages 18 to 21, who presented with similar symptoms, profiles, imaging studies, and disease progression. The average length of stay was approximately one week, and all patients had an extensive work-up in addition to a relapsing and remitting course of their condition. CONCLUSIONS: Early recognition and diagnosis of vaping pneumonitis are essential in the treatment of the ongoing epidemic. Extensive unnecessary work up may lead to increased healthcare costs. Our case series echoes the concerns of the CDC such that ECs should be avoided, and those with any pulmonary or gastrointestinal symptoms should seek medical attention promptly.