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1.
BMC Neurol ; 20(1): 386, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33097034

RESUMO

BACKGROUND: In this study, we report a case of a young female who was hospitalized for seizures and diagnosed with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. CASE PRESENTATION: The main feature of this patient was bilateral temporal calcifications detected by routine head computed tomography (CT). The co-existence of anti-NMDAR encephalitis and cerebral calcifications has not been reported. We supposed that the patient had an incomplete form of celiac disease (CD), epilepsy and cerebral calcifications syndrome (CEC). The patient's symptoms were alleviated by a series of treatments, and she remained stable during the follow-ups. CONCLUSIONS: Our findings confirm the rarity co-existing anti-NMDAR encephalitis and cerebral calcifications. In future clinical work, we need to elucidate the relationship between anti-NMDAR encephalitis and cerebral calcifications, and the association between anti-NMDAR encephalitis and other co-existing autoimmune disorders.


Assuntos
Encefalite Antirreceptor de N-Metil-D-Aspartato/complicações , Encefalopatias/complicações , Encefalopatias/patologia , Encefalite Antirreceptor de N-Metil-D-Aspartato/diagnóstico , Calcinose/complicações , Calcinose/patologia , Feminino , Humanos , Convulsões/etiologia , Tomografia Computadorizada por Raios X , Adulto Jovem
2.
Medicine (Baltimore) ; 99(43): e22940, 2020 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-33120854

RESUMO

RATIONALE: Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) has been reported almost exclusively in the Japanese population. PATIENT CONCERNS: A 17-month-old male patient presented with fever and seizures, and subsequently fell into a coma. On the second day, he recovered consciousness. On the fourth day, he developed complex partial seizures and fell into a coma again. On day 10, the fever and seizures subsided. Head computed tomography on the first day showed no abnormalities. Brain diffusion-weighted images on the fourth day revealed reduced diffusion in the bilateral subcortical white matter. DIAGNOSIS: A diagnosis of AESD was made. INTERVENTIONS: The patient was treated with corticosteroids and intravenous immunoglobulin. OUTCOMES: At the 4-month follow-up, the patient was able to walk independently, and the epileptic seizures were well controlled. LESSONS: AESD is a rare entity, and treatment with corticosteroids and intravenous immunoglobulin can lead to a favorable prognosis. Clinicians should be aware of this condition, and clinicoradiological features can suggest the diagnosis.


Assuntos
Encefalopatias/complicações , Imagem de Difusão por Ressonância Magnética/métodos , Convulsões/etiologia , Doença Aguda , Corticosteroides/uso terapêutico , Encefalopatias/diagnóstico , Encefalopatias/tratamento farmacológico , Coma/diagnóstico , Coma/etiologia , Quimioterapia Combinada , Febre/diagnóstico , Febre/etiologia , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Lactente , Masculino , Convulsões/diagnóstico , Convulsões/fisiopatologia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Substância Branca/diagnóstico por imagem , Substância Branca/patologia
5.
J Neurovirol ; 26(5): 631-641, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32876900

RESUMO

A subset of patients with coronavirus 2 disease (COVID-19) experience neurological complications. These complications include loss of sense of taste and smell, stroke, delirium, and neuromuscular signs and symptoms. The etiological agent of COVID-19 is SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), an RNA virus with a glycoprotein-studded viral envelope that uses ACE2 (angiotensin-converting enzyme 2) as a functional receptor for infecting the host cells. Thus, the interaction of the envelope spike proteins with ACE2 on host cells determines the tropism and virulence of SARS-CoV-2. Loss of sense of taste and smell is an initial symptom of COVID-19 because the virus enters the nasal and oral cavities first and the epithelial cells are the receptors for these senses. Stroke in COVID-19 patients is likely a consequence of coagulopathy and injury to cerebral vascular endothelial cells that cause thrombo-embolism and stroke. Delirium and encephalopathy in acute and post COVID-19 patients are likely multifactorial and secondary to hypoxia, metabolic abnormalities, and immunological abnormalities. Thus far, there is no clear evidence that coronaviruses cause inflammatory neuromuscular diseases via direct invasion of peripheral nerves or muscles or via molecular mimicry. It appears that most of neurologic complications in COVID-19 patients are indirect and as a result of a bystander injury to neurons.


Assuntos
Betacoronavirus/patogenicidade , Encefalopatias/complicações , Infecções por Coronavirus/complicações , Transtornos do Olfato/complicações , Pneumonia Viral/complicações , Embolia Pulmonar/complicações , Acidente Vascular Cerebral/complicações , Encéfalo/irrigação sanguínea , Encéfalo/patologia , Encéfalo/virologia , Encefalopatias/imunologia , Encefalopatias/patologia , Encefalopatias/virologia , Efeito Espectador , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/patologia , Infecções por Coronavirus/virologia , Células Epiteliais/patologia , Células Epiteliais/virologia , Regulação da Expressão Gênica , Interações Hospedeiro-Patógeno/genética , Interações Hospedeiro-Patógeno/imunologia , Humanos , Pulmão/irrigação sanguínea , Pulmão/patologia , Pulmão/virologia , Neurônios/patologia , Neurônios/virologia , Transtornos do Olfato/imunologia , Transtornos do Olfato/patologia , Transtornos do Olfato/virologia , Pandemias , Peptidil Dipeptidase A/genética , Peptidil Dipeptidase A/imunologia , Pneumonia Viral/imunologia , Pneumonia Viral/patologia , Pneumonia Viral/virologia , Embolia Pulmonar/imunologia , Embolia Pulmonar/patologia , Embolia Pulmonar/virologia , Transdução de Sinais/genética , Transdução de Sinais/imunologia , Glicoproteína da Espícula de Coronavírus/genética , Glicoproteína da Espícula de Coronavírus/imunologia , Acidente Vascular Cerebral/imunologia , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/virologia
6.
Artigo em Chinês | MEDLINE | ID: mdl-32791773

RESUMO

Objective: To explore the possible pathogenesis of central paroxysmal positional vertigo (CPPV) by analyzing its clinical manifestations and characteristics. Methods: The clinical data of 3 patients with CPPV, including 1 male and 2 females, aged 36, 14 and 70 years old respectively, were collected from the Department of Otorhinolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences from June 2014 to June 2018. The clinical symptoms, nystagmus, other central ocular motor abnormalities, MRI, PET-CT, and laboratory findings were analyzed retrospectively. Results: All patients showed transient vertigo and nystagmus induced by head changes relative to gravity, but the characteristics of nystagmus did not conform to the typical characteristics of nystagmus in benign paroxysmal positional vertigo. None of patients response to repositioning maneuvers, and all patients presented with the signs of abnormal visual oculomotor system or other symptoms of central system. MRI, PET-CT and blood biochemical tests confirmed that the causes of CPPV in the patients were chronic hemorrhage, inflammation and paraneoplastic cerebellar degeneration. Although the etiology of the three cases is different, the lesion site is involved in the central velocity storage mechanism. Conclusion: The damage of central velocity storage mechanism may lead to the damage of feedback rotation signal correction pathway, and CPPV appears when the head position changes relative to gravity.


Assuntos
Nistagmo Patológico/diagnóstico , Nistagmo Patológico/etiologia , Vertigem/diagnóstico , Vertigem/etiologia , Adolescente , Adulto , Idoso , Encefalopatias/sangue , Encefalopatias/complicações , Encefalopatias/diagnóstico , Encefalopatias/diagnóstico por imagem , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Nistagmo Patológico/sangue , Nistagmo Patológico/diagnóstico por imagem , Posicionamento do Paciente/efeitos adversos , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons , Estudos Retrospectivos , Vertigem/sangue , Vertigem/diagnóstico por imagem
7.
Int J Mol Sci ; 21(15)2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32751841

RESUMO

Increasing evidence suggests that Severe Acute Respiratory Syndrome-coronavirus-2 (SARS-CoV-2) can also invade the central nervous system (CNS). However, findings available on its neurological manifestations and their pathogenic mechanisms have not yet been systematically addressed. A literature search on neurological complications reported in patients with COVID-19 until June 2020 produced a total of 23 studies. Overall, these papers report that patients may exhibit a wide range of neurological manifestations, including encephalopathy, encephalitis, seizures, cerebrovascular events, acute polyneuropathy, headache, hypogeusia, and hyposmia, as well as some non-specific symptoms. Whether these features can be an indirect and unspecific consequence of the pulmonary disease or a generalized inflammatory state on the CNS remains to be determined; also, they may rather reflect direct SARS-CoV-2-related neuronal damage. Hematogenous versus transsynaptic propagation, the role of the angiotensin II converting enzyme receptor-2, the spread across the blood-brain barrier, the impact of the hyperimmune response (the so-called "cytokine storm"), and the possibility of virus persistence within some CNS resident cells are still debated. The different levels and severity of neurotropism and neurovirulence in patients with COVID-19 might be explained by a combination of viral and host factors and by their interaction.


Assuntos
Betacoronavirus/fisiologia , Sistema Nervoso Central/virologia , Infecções por Coronavirus/patologia , Pneumonia Viral/patologia , Animais , Betacoronavirus/isolamento & purificação , Barreira Hematoencefálica/metabolismo , Barreira Hematoencefálica/virologia , Encefalopatias/complicações , Encefalopatias/patologia , Sistema Nervoso Central/metabolismo , Infecções por Coronavirus/virologia , Encefalite/complicações , Encefalite/patologia , Humanos , Pandemias , Peptidil Dipeptidase A/metabolismo , Pneumonia Viral/virologia
8.
J Child Neurol ; 35(13): 934-939, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32660309

RESUMO

Children are susceptible to infection with the novel coronavirus SARS-CoV-2. In this time of uncertainty, this review attempts to compile information that may be helpful to pediatric neurologists. This review consolidates current data on the disease associated with SARS-CoV-2, called COVID-19, and information from past coronavirus epidemics, to discuss diseases of pediatric neurology including Guillain-Barre syndrome (acute inflammatory demyelinating polyradiculoneuropathy); central demyelinating diseases like multiple sclerosis and acute disseminated encephalomyelitis; infantile spasms; febrile seizures; and maternal-fetal transmission of virus.


Assuntos
Betacoronavirus , Encefalopatias/complicações , Encefalopatias/terapia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Neurologia/métodos , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Criança , Infecções por Coronavirus/diagnóstico , Humanos , Neurologistas , Pandemias , Pediatras , Pediatria/métodos , Pneumonia Viral/diagnóstico
9.
J Neurovirol ; 26(5): 785-789, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32666422

RESUMO

Over the course of the pandemic due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), multiple new clinical manifestations, as the consequence of the tropism of the virus, have been recognized. That includes now the neurological manifestations and conditions, such as headache, encephalitis, as well as olfactory and taste disorders. We present a series of ten cases of RT-PCR-confirmed SARS-CoV-2-infected patients diagnosed with viral-associated olfactory and taste loss from four different countries.


Assuntos
Ageusia/complicações , Betacoronavirus/patogenicidade , Encefalopatias/complicações , Infecções por Coronavirus/complicações , Cefaleia/complicações , Transtornos do Olfato/complicações , Pneumonia Viral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Ageusia/imunologia , Ageusia/patologia , Ageusia/virologia , Encéfalo/patologia , Encéfalo/virologia , Encefalopatias/imunologia , Encefalopatias/patologia , Encefalopatias/virologia , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/patologia , Infecções por Coronavirus/virologia , Europa (Continente) , Feminino , Cefaleia/imunologia , Cefaleia/patologia , Cefaleia/virologia , Humanos , Masculino , Pessoa de Meia-Idade , América do Norte , Transtornos do Olfato/imunologia , Transtornos do Olfato/patologia , Transtornos do Olfato/virologia , Pandemias , Pneumonia Viral/imunologia , Pneumonia Viral/patologia , Pneumonia Viral/virologia , América do Sul , Fatores de Tempo
10.
BMC Infect Dis ; 20(1): 471, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32615931

RESUMO

BACKGROUND: Pertussis is a highly contagious disease of public health interest caused by the bacterium Bordetella pertussis. Although its incidence has decreased substantially after the introduction of a vaccination, the burden of the disease remains high. Although the paroxysmal phase is highly disabling, complications are uncommon and more prevalent in children than in adults. The most frequent neurological complication is encephalopathy, but seizures, paresis, paraplegia, ataxias, aphasias, and decerebration postures have also been described. The complication of decerebration postures has not been previously reported in adults. CASE PRESENTATION: We present a video case of an adult HIV patient with severe coughing paroxysms, post-tussive emesis and syncope, whose workup confirmed the diagnosis of a B. pertussis respiratory infection. During hospitalization, he had fluctuant encephalopathy and post-tussive decerebration postures following paroxysms. He was treated with antibiotic therapy and finally sent home without residual neurological deficits. CONCLUSION: This case illustrates the biological plausibility of neurologic complications of pertussis in adults, which, albeit rare, can cause important morbidities. Future research should explore whether there are differences in the clinical presentation, risk factors and pathophysiology of the disease among adults or interventions aimed at preventing or treating pertussis encephalopathy.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/complicações , Bordetella pertussis/genética , Encefalopatias/complicações , Estado de Descerebração/complicações , HIV , Coqueluche/complicações , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Infecções Oportunistas Relacionadas com a AIDS/virologia , Antibacterianos/uso terapêutico , Bordetella pertussis/isolamento & purificação , Encefalopatias/tratamento farmacológico , Encefalopatias/microbiologia , Estado de Descerebração/tratamento farmacológico , Estado de Descerebração/microbiologia , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Fatores de Risco , Resultado do Tratamento , Coqueluche/tratamento farmacológico , Coqueluche/microbiologia
11.
Arq Neuropsiquiatr ; 78(5): 290-300, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32490966

RESUMO

BACKGROUND: As the COVID-19 pandemic unfolds worldwide, different forms of reports have described its neurologic manifestations. OBJECTIVE: To review the literature on neurological complications of SARS-CoV-2 infection. METHODS: Literature search performed following systematic reviews guidelines, using specific keywords based on the COVID-19 neurological complications described up to May 10th, 2020. RESULTS: A total of 43 articles were selected, including data ranging from common, non-specific symptoms, such as hyposmia and myalgia, to more complex and life-threatening conditions, such as cerebrovascular diseases, encephalopathies, and Guillain-Barré syndrome. CONCLUSION: Recognition of neurological manifestations of SARS-CoV-2 should be emphasized despite the obvious challenges faced by clinicians caring for critical patients who are often sedated and presenting other concurrent systemic complications.


Assuntos
Infecções por Coronavirus/complicações , Doenças do Sistema Nervoso/complicações , Pneumonia Viral/complicações , Ageusia/complicações , Encefalopatias/complicações , Transtornos Cerebrovasculares/complicações , Transtornos Cerebrovasculares/fisiopatologia , Síndrome de Guillain-Barré/complicações , Humanos , Mialgia/complicações , Doenças do Sistema Nervoso/fisiopatologia , Transtornos do Olfato/complicações , Pandemias
13.
Am J Ophthalmol ; 218: 78-83, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32574776

RESUMO

PURPOSE: This study investigated the clinical manifestation and risk factors associated with remission in filamentary keratitis. DESIGN: Retrospective, interventional, comparative case series. METHODS: We retrospectively reviewed the medical records of 116 patients with filamentary keratitis diagnosed and treated between January 2012 and December 2018. We investigated the 5 causative factors including brain lesion, dry eye syndrome, autoimmune disease, ocular surgery or injury, and other conditions; treatment methods and duration; and remission status, and analyzed the risk factors associated with remission. RESULTS: The mean age of the patients was 56.9 ± 19.1 years and the mean follow-up duration was 14.9 ± 22.8 months. The most common underlying condition associated with filamentary keratitis was identified as a brain lesion (36.2%), followed by dry eye syndrome (30.2%) and autoimmune disease (24.1%). A comparison of remission rates among the causative factors revealed that cases associated with brain lesions had significantly lower remission rates (33.3%) than those associated with other causative factors (>60%) (P = .001). After adjustment for sex, age, diabetes mellitus, and hypertension, the treatment failure rate in patients affected by brain lesions was 6.602-fold higher than that associated without brain lesion (P = .001). The treatment method-dependent differences in the remission rate were observed in brain lesion and dry eye syndrome (P = .041 and P = .005, respectively). CONCLUSIONS: The most common condition leading to filamentary keratitis was a brain lesion, followed by dry eye syndrome and autoimmune disease. The treatment failure rate was statistically significantly low only in patients with filamentary keratitis associated with brain lesions.


Assuntos
Doenças Autoimunes/complicações , Encefalopatias/complicações , Síndromes do Olho Seco/complicações , Traumatismos Oculares/complicações , Ceratite/diagnóstico , Procedimentos Cirúrgicos Oftalmológicos/efeitos adversos , Acetilcisteína/administração & dosagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Fluoresceína/administração & dosagem , Seguimentos , Depuradores de Radicais Livres/administração & dosagem , Humanos , Ceratite/etiologia , Ceratite/terapia , Masculino , Pessoa de Meia-Idade , Indução de Remissão , Estudos Retrospectivos , Fatores de Risco , Soro/fisiologia , Microscopia com Lâmpada de Fenda
14.
PLoS One ; 15(5): e0232990, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32384097

RESUMO

BACKGROUND: Underlying medical causes of obesity (endocrine disorders, genetic obesity disorders, cerebral or medication-induced obesities) are thought to be rare. Even in specialized pediatric endocrinology clinics, low diagnostic yield is reported, but evidence is limited. Identifying these causes is vital for patient-tailored treatment. OBJECTIVES: To present the results of a systematic diagnostic workup in children and adolescents referred to a specialized pediatric obesity center. METHODS: This is a prospective observational study. Prevalence of underlying medical causes was determined after a multidisciplinary, systematic diagnostic workup including growth charts analysis, extensive biochemical and hormonal assessment and genetic testing in all patients. RESULTS: The diagnostic workup was completed in n = 282 patients. Median age was 10.8 years (IQR 7.7-14.1); median BMI +3.7SDS (IQR +3.3-+4.3). In 54 (19%) patients, a singular underlying medical cause was identified: in 37 patients genetic obesity, in 8 patients cerebral and in 9 patients medication-induced obesities. In total, thirteen different genetic obesity disorders were diagnosed. Obesity onset <5 years (p = 0.04) and hyperphagia (p = 0.001) were indicators of underlying genetic causes, but only in patients without intellectual disability (ID). Patients with genetic obesity with ID more often had a history of neonatal feeding problems (p = 0.003) and short stature (p = 0.005). BMI-SDS was not higher in patients with genetic obesity disorders (p = 0.52). Patients with cerebral and medication-induced obesities had lower height-SDS than the rest of the cohort. CONCLUSIONS: To our knowledge, this is the first study to report the results of a systematic diagnostic workup aimed at identifying endocrine, genetic, cerebral or medication-induced causes of pediatric obesity. We found that a variety of singular underlying causes were identified in 19% of the patients with severe childhood obesity. Because of this heterogeneity, an extensive diagnostic approach is needed to establish the underlying medical causes and to facilitate disease-specific, patient-tailored treatment.


Assuntos
Obesidade Pediátrica/etiologia , Adolescente , Instituições de Assistência Ambulatorial , Encefalopatias/complicações , Criança , Pré-Escolar , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Doenças do Sistema Endócrino/complicações , Feminino , Testes Genéticos , Humanos , Lactente , Recém-Nascido , Deficiência Intelectual/complicações , Masculino , Países Baixos , Obesidade Pediátrica/diagnóstico , Obesidade Pediátrica/genética , Fenótipo , Estudos Prospectivos
15.
World Neurosurg ; 139: 223-225, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32305611

RESUMO

BACKGROUND: Osteosarcoma is a common malignant bone tumor that occurs in children or adolescents but rarely in the skull. Epidermoid cysts, also known as cholesteatomas, represent approximately 0.2%-1.8% of all intracranial tumors. The occurrence of osteosarcoma with an epidermoid cyst is extremely rare. CASE DESCRIPTION: A 41-year-old woman had both osteosarcoma and cholesteatoma in the left cerebellopontine angle. We resected the 2 tumors using the suboccipital retrosigmoid approach, and she received radiotherapy and chemotherapy after the surgery. One year after surgery, the patient is healthy and has recovered well. CONCLUSIONS: Osteosarcomas and epidermoid cysts should be completely resected to prevent tumor recurrence and aseptic meningitis. Postoperative osteosarcoma treatment should include radiotherapy and chemotherapy to improve the survival rate of patients. It is hoped that this report will help clinicians in diagnosis and treatment of patients with similar conditions.


Assuntos
Encefalopatias/patologia , Neoplasias Cerebelares/patologia , Ângulo Cerebelopontino/patologia , Colesteatoma/patologia , Osteossarcoma/patologia , Adulto , Encefalopatias/complicações , Neoplasias Cerebelares/complicações , Colesteatoma/complicações , Cisto Epidérmico/complicações , Cisto Epidérmico/patologia , Feminino , Humanos , Osteossarcoma/complicações
16.
Mult Scler Relat Disord ; 37: 101436, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32173001

RESUMO

Susac's syndrome (SuS) is a rare disorder with a clinical triad of encephalopathy, sensorineural hearing loss, and branch retinal artery occlusions. We report a 7-year-old girl who presented with chronic, progressive sensorineural hearing loss, who, years later, presented with encephalopathy and vision loss. Such prolonged period between symptoms is unusual and to our knowledge, this is the longest interval between onset of hearing loss and completion of the full triad in SuS. In addition, she had a protracted disease course, requiring multiple immune therapies for disease control.


Assuntos
Perda Auditiva Neurossensorial/fisiopatologia , Oclusão da Artéria Retiniana/fisiopatologia , Síndrome de Susac/fisiopatologia , Transtornos da Visão/complicações , Encefalopatias/complicações , Criança , Feminino , Angiofluoresceinografia/métodos , Perda Auditiva Neurossensorial/complicações , Perda Auditiva Neurossensorial/diagnóstico , Humanos , Oclusão da Artéria Retiniana/diagnóstico , Síndrome de Susac/complicações , Síndrome de Susac/diagnóstico
17.
Epilepsia ; 61(3): 498-508, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32077099

RESUMO

OBJECTIVE: Electroencephalographic seizures (ESs) are common in encephalopathic critically ill children, but ES identification with continuous electroencephalography (EEG) monitoring (CEEG) is resource-intense. We aimed to develop an ES prediction model that would enable clinicians to stratify patients by ES risk and optimally target limited CEEG resources. We aimed to determine whether incorporating data from a screening EEG yielded better performance characteristics than models using clinical variables alone. METHODS: We performed a prospective observational study of 719 consecutive critically ill children with acute encephalopathy undergoing CEEG in the pediatric intensive care unit of a quaternary care institution between April 2017 and February 2019. We identified clinical and EEG risk factors for ES. We evaluated model performance with area under the receiver-operating characteristic (ROC) curve (AUC), validated the optimal model with the highest AUC using a fivefold cross-validation, and calculated test characteristics emphasizing high sensitivity. We applied the optimal operating slope strategy to identify the optimal cutoff to define whether a patient should undergo CEEG. RESULTS: The incidence of ES was 26%. Variables associated with increased ES risk included age, acute encephalopathy category, clinical seizures prior to CEEG initiation, EEG background, and epileptiform discharges. Combining clinical and EEG variables yielded better model performance (AUC 0.80) than clinical variables alone (AUC 0.69; P < .01). At a 0.10 cutoff selected to emphasize sensitivity, the optimal model had a sensitivity of 92%, specificity of 37%, positive predictive value of 34%, and negative predictive value of 93%. If applied, the model would limit 29% of patients from undergoing CEEG while failing to identify 8% of patients with ES. SIGNIFICANCE: A model employing readily available clinical and EEG variables could target limited CEEG resources to critically ill children at highest risk for ES, making CEEG-guided management a more viable neuroprotective strategy.


Assuntos
Encefalopatias/fisiopatologia , Epilepsia/fisiopatologia , Convulsões/diagnóstico , Estado Epiléptico/diagnóstico , Encefalopatias/complicações , Pré-Escolar , Estado Terminal , Eletroencefalografia , Feminino , Humanos , Lactente , Modelos Logísticos , Masculino , Estudos Prospectivos , Medição de Risco , Convulsões/etiologia , Estado Epiléptico/etiologia
18.
EBioMedicine ; 52: 102663, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32062359

RESUMO

BACKGROUND: Although thalamic magnetic resonance (MR) spectroscopy (MRS) accurately predicts adverse outcomes after neonatal encephalopathy, its utility in infants without MR visible deep brain nuclei injury is not known. We examined thalamic MRS metabolite perturbations in encephalopathic infants with white matter (WM) injury with or without cortical injury and its associations with adverse outcomes. METHODS: We performed a subgroup analysis of all infants recruited to the MARBLE study with isolated WM or mixed WM/cortical injury, but no visible injury to the basal ganglia/thalamus (BGT) or posterior limb of the internal capsule (PLIC). We used binary logistic regression to examine the association of MRS biomarkers with three outcomes (i) WM injury score (1 vs. 2/3); (ii) cortical injury scores (0/1 vs. 2/3); and (iii) adverse outcomes (defined as death, moderate/severe disability) at two years (yes/no). We also assessed the accuracy of MRS for predicting adverse outcome. FINDINGS: Of the 107 infants included in the analysis, five had adverse outcome. Reduced thalamic N-acetylaspartate concentration [NAA] (odds ratio 0.4 (95% CI 0.18-0.93)) and elevated thalamic Lactate/NAA peak area ratio (odds ratio 3.37 (95% CI 1.45-7.82)) were significantly associated with higher WM injury scores, but not with cortical injury. Thalamic [NAA] (≤5.6 mmol/kg/wet weight) had the best accuracy for predicting adverse outcomes (sensitivity 1.00 (95% CI 0.16-1.00); specificity 0.95 (95% CI 0.84-0.99)). INTERPRETATION: Thalamic NAA is reduced in encephalopathic infants without MR visible deep brain nuclei injury and may be a useful predictor of adverse outcomes. FUNDING: The National Institute for Health Research (NIHR).


Assuntos
Encefalopatias/complicações , Encefalopatias/metabolismo , Lesões Encefálicas/etiologia , Lesões Encefálicas/patologia , Metabolismo Energético , Tálamo/metabolismo , Substância Branca/patologia , Biomarcadores , Encefalopatias/diagnóstico , Lesões Encefálicas/diagnóstico por imagem , Feminino , Humanos , Lactente , Recém-Nascido , Doenças do Recém-Nascido , Imagem por Ressonância Magnética , Espectroscopia de Ressonância Magnética , Masculino , Sensibilidade e Especificidade , Substância Branca/diagnóstico por imagem
19.
BMC Infect Dis ; 20(1): 182, 2020 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-32106821

RESUMO

BACKGROUND: Death from bacterial meningitis is rarely attributed to the actual event causing death. The present study therefore categorized and characterized the cause and time of death due to bacterial meningitis. METHODS: In a cohort of patients > 15 years of age with community acquired bacterial meningitis the medical records were reviewed, and a clinical cause of death categorized into six main categories: 1) CNS complications, 2) Systemic complications, 3) Combination of systemic and CNS complications, 4) Sudden death, 5) Withdrawal of care, or 6) Unknown. RESULTS: We identified 358 patients of which 84 (23%) died in-hospital. Causes of death were ascribed to CNS complications in 43%, Systemic complications in 39%, Combined CNS and systemic complications in 4%, Sudden death in 7% and withdrawal of care in 5%. Brain herniation, circulatory failure, intractable seizures and other brain injury were the most common specific causes of death within 14 days from admission (55%). CONCLUSION: Fatal complications due to the primary infection - meningitis - is most common within 14 days of admission. The diversity of complications causing death in meningitis suggest that determining the clinical cause of death is essential to the evaluation of novel treatment strategies.


Assuntos
Meningites Bacterianas/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Encefalopatias/complicações , Causas de Morte , Doenças do Sistema Nervoso Central/complicações , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Meningites Bacterianas/complicações , Meningites Bacterianas/diagnóstico , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque/complicações , Adulto Jovem
20.
JAMA Netw Open ; 3(2): e1921363, 2020 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-32074288

RESUMO

Importance: Despite improvements in antenatal care and increasing cesarean delivery rates, birth asphyxia leading to neonatal encephalopathy (NE) continues to contribute to neonatal death and long-term neurodevelopmental disability. Cardiotocography (CTG) has been used in labor for several decades to detect a stressed fetus so that delivery can be expedited and NE avoided. Objective: To investigate whether experienced clinicians can detect and respond to abnormal readings from CTGs during the penultimate hour before birth in infants with moderate to severe NE but no acute peripartum event. Design, Setting, and Participants: This case-control study included 10 practicing obstetricians and midwives at maternity hospitals in New Zealand. Participants, who were masked to the perinatal outcome, were asked to assess CTG tracings from 35 neonates with NE and evidence of birth hypoxia (ie, cases) and 105 neonates without NE or birth hypoxia (ie, controls), all of whom were born in 2010 to 2011. Data analysis was conducted from May to December 2017. Exposures: Brief clinical details and 1 hour of CTG tracings from the penultimate hour before birth were provided for each baby. Clinicians assessed the CTG tracings and recommended a plan. Main Outcomes and Measures: Intra-assessor and interassessor agreement on CTG findings and action plans as well as sensitivity (ie, detection of NE) and specificity (ie, ruling out those without NE) for the assessment of abnormal CTG readings leading to immediate action (ie, fetal blood sample or immediate delivery) were reported. Results: A total of 35 infants (mean [SD] gestational age, 40 [1.4] weeks; 16 [45.7%] cesarean deliveries) were designated cases, and 105 infants (mean [SD] gestational age, 39.4 [1.2] weeks; 22 [21.0%] cesarean deliveries) were designated controls. No infants had congenital anomalies. The mean (range) sensitivity for detection of abnormal CTG results and for recommending immediate action for all assessors was 75% (63%-91%) and 41% (23%-57%), respectively, with a mean (range) specificity of 67% (53%-77%) and 87% (65%-99%), respectively. A sensitivity analysis including only assessors with 80% or more interassessor agreement only differed from the main analysis by 6% or less (mean [range] sensitivity for detection, 76% [63%-91%]; sensitivity for action plan, 36% [25%-49%]; specificity for detection, 71% [53%-77%]; and specificity for action plan, 93% [88%-99%]). Conclusions and Relevance: Experienced clinicians detected 3 of 4 infants who were subsequently diagnosed with NE. Action to expedite delivery was recommended for more than 40% of infants with NE. These results indicate that CTG does not identify all infants at risk of NE, and that there is a need for further investment in new approaches to fetal surveillance in labor.


Assuntos
Asfixia Neonatal/complicações , Asfixia Neonatal/diagnóstico , Encefalopatias/complicações , Cardiotocografia , Competência Clínica/estatística & dados numéricos , Estudos de Casos e Controles , Feminino , Humanos , Recém-Nascido , Tocologia/estatística & dados numéricos , Nova Zelândia , Médicos/estatística & dados numéricos , Gravidez
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