The prevalence and impact of mortality of the acute respiratory distress syndrome on admissions of patients with ischemic stroke in the United States.

PURPOSE: To determine the epidemiology of the acute respiratory distress syndrome (ARDS) and impact on in-hospital mortality in admissions of patients with acute ischemic stroke (AIS) in the United States. METHODS: Retrospective cohort study of admissions with a diagnosis of AIS and ARDS from 1994 to 2008 identified through the Nationwide Inpatient Sample. RESULTS: During the 15-year study period, we found 55 58 091 admissions of patients with AIS. The prevalence of ARDS in admissions of patients with AIS increased from 3% in 1994 to 4% in 2008 (P < .001). The ARDS was more common among younger men, nonwhites, and associated with history of congestive heart failure, hypertension, chronic obstructive pulmonary disease, renal failure, chronic liver disease, systemic tissue plasminogen activator, craniotomy, angioplasty or stent, sepsis, and multiorgan failures. Mortality due to AIS and ARDS decreased from 8% in 1994 to 6% in 2008 (P < .001) and 55% in 1994 to 45% in 2008 (P < .001), respectively. The ARDS in AIS increased in-hospital mortality (odds ratio, 14; 95% confidence interval, 13.5-14.3). A significantly higher length of stay was seen in admissions of patients with AIS having ARDS. CONCLUSION: Our analysis demonstrates that ARDS is rare after AIS. Despite an overall significant reduction in mortality after AIS, ARDS carries a higher risk of death in this patient population.

Association of morphologic and demographic features of intracranial aneurysms with their rupture: a retrospective analysis.

BACKGROUND: In spite of its common occurrence, the factors predictive of the rupture of intracranial aneurysms (IAs) remain poorly defined. METHOD: A retrospective analysis of patients admitted with a primary diagnosis of cerebral aneurysm in a single institution was done. The factors studied were age, sex, size, site, side, multiplicity, neck type, aspect ratio, positive family history, smoking and drinking habits, and hypertension. The morphological parameters were evaluated for a total of 5,138 aneurysms obtained from the 2,347 patients. Factors found significant on univariate analysis were further tested on a multivariate model. FINDINGS: We found 1,088 patients (46.36%) had at least a single aneurysmal rupture. Among the morphologic factors, size greater than 10 mm, right sidedness, aspect ratio greater than 1.6, deviated neck type, and multiplicity were found to be associated with higher incidences of rupture. Aneurysms on posterior communicating and middle cerebral arteries were found to be more prone to rupture. The demographic factors that were more linked with the ruptured aneurysms were positive family history, smoking, and hypertension. CONCLUSIONS: Relevant cases should be started on intensive lifestyle modification, and extensive screening of those with a positive family history is highly warranted. All "at-risk" patients should be evaluated for early surgical intervention.

Impact of Hunt-Hess grade on the glycemic status of aneurysmal subarachnoid hemorrhage patients.

OBJECTIVE: This study has explored the impact of Hunt-Hess (H-H) grade of aneurysmal subarachnoid hemorrhage (aSAH) on the glycemic status of such patients during their intensive care unit (ICU) stay and has also analyzed whether H-H grade predicts their outcome independent of their glycemic status. MATERIALS AND METHODS: This was a retrospective case record review of prospectively maintained database of 1090 previously non-diabetic aSAH patients admitted to Thomas Jefferson University Hospital, Philadelphia. H-H grade of SAH, serum and CSF glucose on admission, serum glucose on the day of surgery and 14 days post-surgery, as well as the extended Glasgow Outcome Score (GOS-E score) at discharge were noted. After univariate analysis, significant variables (P < 0.05) were entered into a logistic regression model to identify significant associations with admission H-H grade. RESULTS: Although admission serum glucose was significantly higher for H-H grades 4-5 than grades 1-3 (P < 0.001); after postoperative day 4, the difference between the H-H grades got blurred. Admission CSF glucose was also significantly higher for H-H grades 3-4 than for grades 1-3 and 5 (P < 0.001). H-H grades 4-5 were related with higher incidences of both hypoglycemia (serum glucose level < 80 mg/dl) and hyperglycemia (serum glucose level > 200 mg/dl) (P < 0.001) during the 14-day period of ICU stay. Also, the relationship between serum and CSF glucose levels at admission increased with HH grades 1 through 4, but became negative and more tightly bound at H-H grade 5. Admission H-H grades 4-5 contributed to poor outcome compared to lower H-H grades (P < 0.0001). CONCLUSION: Poor admission H-H grades lead to poor immediate glycemic status as well as poor short-term outcome, and it is dependent on serum glucose but independent of CSF glucose in predicting the outcome.

Comparing neuromodulation modalities involving the suprascapular nerve in chronic refractory shoulder pain: retrospective case series and literature review.

Chronic shoulder pain not relieved by either conservative or surgical management is referred to as chronic refractory shoulder pain. This is a retrospective case series where chronic refractory shoulder pain patients were treated either with peripheral nerve stimulation (PNS) or with pulsed radiofrequency (p-RF) therapy to the suprascapular nerve. Both patients receiving PNS reported 100% pain relief for the first month. At the 3- and 6-month follow-ups, one patient continued to experience 100% relief while the other reported 90% relief. One patient undergoing p-RF experienced about 90% pain relief at both 1- and 3-month intervals and 0% relief at the 6-month interval. The other patient with p-RF experienced 33% relief at 1-month and 0% relief thereafter. No patient reported any complications. The results of previous randomized controlled trials evaluating the efficacy of p-RF administered to the suprascapular nerve were mixed, and there is a lack of published studies on PNS effects. Neuromodulation of the suprascapular nerve can be effective for chronic refractory shoulder pain patients. Larger scale randomized controlled trials comparing PNS and p-RF are needed to better understand their respective therapeutic capacity.

Cervical Dystonia Refractory to Botulinum Toxin Responding to Radiofrequency Ablation: A Case Report.

A 62-year-old male diagnosed with cervical dystonia (CD) and chronic right-sided neck pain presented to the Pain Clinic after his pain and CD symptoms failed to resolve with botulinum toxin therapy. During clinical examination, right C3-C4 and C4-C5 facet arthropathy was suspected. After two sets of diagnostic right cervical, C3, C4, and C5 medial branch blocks provided >80% pain relief; cervical radiofrequency ablation (CRFA) was performed. Post CRFA, the patient was followed for 12 months. Till the last follow-up, he was not only experiencing 90% pain relief, but also had significant improvement in his CD symptoms to the point that he no longer needed botulinum toxin and other CD-related therapy. This report suggests that large-scale research is required to postulate whether CD patients, whose symptoms are refractory to botulinum toxin, should be routinely screened for cervical facet arthropathy. This is the first reported case of improvement in CD symptoms with CRFA. This effect could be explained by the fact that certain deep cervical muscles, which are affected in CD, are innervated by medial branch nerves.

Impact of acute lung injury and acute respiratory distress syndrome after traumatic brain injury in the United States.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of disability, morbidity, and mortality. The effect of the acute respiratory distress syndrome and acute lung injury (ARDS/ALI) on in-hospital mortality after TBI remains controversial. OBJECTIVE: To determine the epidemiology of ARDS/ALI, the prevalence of risk factors, and impact on in-hospital mortality after TBI in the United States. METHODS: Retrospective cohort study of admissions of adult patients>18 years with a diagnosis of TBI and ARDS/ALI from 1988 to 2008 identified through the Nationwide Inpatient Sample. RESULTS: During the 20-year study period, the prevalence of ARDS/ALI increased from 2% (95% confidence interval [CI], 2.1%-2.4%) in 1988 to 22% (95% CI, 21%-22%) in 2008 (P<.001). ARDS/ALI was more common in younger age; males; white race; later year of admission; in conjunction with comorbidities such as congestive heart failure, hypertension, chronic obstructive pulmonary disease, chronic renal and liver failure, sepsis, multiorgan dysfunction; and nonrural, medium/large hospitals, located in the Midwest, South, and West continental US location. Mortality after TBI decreased from 13% (95% CI, 12%-14%) in 1988 to 9% (95% CI, 9%-10%) in 2008 (P<.001). ARDS/ALI-related mortality after TBI decreased from 33% (95% CI, 33%-34%) in 1988 to 28% (95% CI, 28%-29%) in 2008 (P<.001). Predictors of in-hospital mortality after TBI were older age, male sex, white race, cancer, chronic kidney disease, hypertension, chronic liver disease, congestive heart failure, ARDS/ALI, and organ dysfunctions. CONCLUSION: Our analysis demonstrates that ARDS/ALI is common after TBI. Despite an overall reduction of in-hospital mortality, ARDS/ALI carries a higher risk of in-hospital death after TBI.

Analysis of nonmodifiable risk factors for intracranial aneurysm rupture in a large, retrospective cohort.

BACKGROUND: The risk factors predictive of intracranial aneurysm rupture remain incompletely defined. OBJECTIVE: To examine the association between various nonmodifiable risk factors and aneurysm rupture in a large cohort of patients evaluated at a single institution. METHODS: A retrospective analysis of patients admitted to a cerebrovascular facility between January 2006 and 2010 with a primary diagnosis of cerebral aneurysm. Aneurysms were divided into 2 groups: unruptured or ruptured. The dome diameter, aspect ratio (AR), location, sidedness, neck morphology, and multiplicity were entered into a central database. A full model was constructed, and a systematic removal of the least significant variables was performed in a sequential fashion until only those variables reaching significance remained. RESULTS: We identified 2347 patients harboring 5134 individual aneurysms, of which 34.90% were ruptured and 65.09% were unruptured. On admission, 25.89% of aneurysms with a dome diameter <10 mm and 58.33% of aneurysms with a dome >10 mm were ruptured (P < .001). Of aneurysms with an AR >1.6, 52.44% presented following a rupture (P < .001). The highest incidence of rupture (69.21%) was observed in aneurysms with an AR >1.6, dome diameter <10 mm, and a deviated neck. Deviated neck-type aneurysms had a significantly greater incidence of rupture than classical neck-type aneurysms (P < .001). CONCLUSION: An AR >1.6, dome diameter >10 mm, a deviated neck, and right-sidedness are independently associated with aneurysm rupture.