Axel Rosengart

Mold Infections of the Central Nervous System

Molds are ubiquitous in soil, water, and decaying vegetation and can cause devastating infections that are difficult to treat. This review summarizes the epidemiologic profiles, clinical characteristics, and treatment of mold infections of the central nervous system.

Factors Contributing to Ventriculostomy Infection

OBJECTIVE Catheter-related infection remains a cause of morbidity in the use of external ventricular drains (EVDs). The aim of this retrospective single-center study was to assess the rate and factors related to ventriculostomy infections in the setting of the published literature. METHODS Patients that underwent EVD placement in a single-center were retrospectively reviewed. Diagnosis, treatment, hospital course, and infection-related data were collected and analyzed in reference to ventriculitis rates. The protocols for EVD placement and maintenance were reviewed. RESULTS Of 343 patients, 12 acquired an EVD infection. No significant differences existed between those with and without ventriculitis for age, sex, underlying diagnosis, or concomitant systemic infection. Although not significant, concomitant systemic infection existed in 4.7% of patients with ventriculitis versus 1.5% without. There was a significant difference in length of EVD placement in patients with ventriculitis (20.9 ± 15.3 days) versus those without (12.1 ± 18.2; P = 0.005). Coagulase-negative Staphylococcus and Staphylococcus aureus represented the most commonly associated pathogens. With an overall cumulative incidence of 3.5%, our rate compared favorably to the published literature (cumulative incidence 9.5%; range, 3.9%-23.2%). CONCLUSIONS Catheter-related infection remains an important complication of EVD placement. Of factors evaluated, length of time of catheter placement has the most notable relationship to infection incidence, suggesting that early drain removal should be a goal whenever medically appropriate.

Efficacy spectrum of antishivering medications: Meta-analysis of randomized controlled trials.

Objectives:Shivering after anesthesia or in the critical care setting is frequent, can be prolonged, and has the potential for serious adverse events and worsening outcomes. Furthermore, there are conflicting published data and clinical protocols on how to best treat shivering. In this study, we aimed to critically analyze the published evidence of antishivering medications. Data Sources:We systematically reviewed, categorized, and analyzed all literature on antishivering medications published in English. Target key words and study types were determined and major scientific databases (PubMed, EMBASE, the Cochrane Controlled Trials Register, Ovid-Medline, and JAMA Evidence) and individual target journals were systematically searched up to August 1, 2011. Study Selection:Publications were categorized by the pharmacological intervention used, regardless of whether the subjects were ventilated, underwent surgery, received anesthesia, or received additional medications. Randomized, double-blinded, placebo-controlled trials investigating antishivering treatment were extracted and evaluated for clinical and statistical homogeneity and, if suitable, included in a subsequent meta-analysis using linear comparisons calculating shivering risk-reduction ratios. Data Extraction:A total of 41 individual and eight combination antishivering medications were tested in 124 publications containing 208 substudies and recruiting a total of 9,668 subjects. Among those, 80 publications containing 119 substudies were identified as randomized, double-blinded, placebo-controlled of which 94 substudies were subjected to linear comparison analysis. Data Synthesis:Study drug frequencies, calculated pooled risk benefits, and pooled numbers needed to treat of the five most frequently studied and efficacious medications were clonidine (22 studies; risk ratio: 1.6, numbers needed to treat: 4), meperidine (16; 2.2, 2), tramadol (8; 2.2, 2), nefopam (7; 2.1, 2), and ketamine (7; 1.8, 3). Conclusions:There is significant heterogeneity in the literature with respect to study methods and efficacy testing of antishivering treatments. Clonidine, meperidine, tramadol, nefopam, and ketamine were the most frequently reported pharmacological interventions and showed a variable degree of efficacy in randomized, double-blinded, placebo-controlled trials.

Depressed mood and quality of life after subarachnoid hemorrhage

BACKGROUND Cognitive impairment is widely considered the main cause of disability and handicap after subarachnoid hemorrhage (SAH). The impact of depression on recovery after SAH remains poorly defined. We sought to determine the frequency of post-SAH depression, identify risk factors for its development, and evaluate the impact of depression on quality of life (QOL) during the first year of recovery. METHODS We prospectively studied 216 of 534 SAH patients treated between July 1996 and December 2001 with complete one-year follow-up data. Depression was evaluated with the Center for Epidemiological Studies Depression (CES-D) scale, cognitive status with the Telephone Interview for Cognitive Status (TICS), and QOL with the Sickness Impact Profile (SIP) 3 and 12 months after SAH. RESULTS Depressed mood occurred in 47% of patients during the first year of recovery; 26% were depressed at both 3 and 12 months. Non-white ethnicity predicted early (3 month) and late (12 month) depressions; early depression was also predicted by previously-diagnosed depression, cigarette smoking, and cerebral infarction, whereas late depression was predicted by prior social isolation and lack of medical insurance. Depression was associated with inferior QOL in all domains of the SIP, and changes in depression status were associated with striking parallel changes in QOL, disability, and cognitive function during the first year of recovery. CES-D scores accounted for over 60% of the explained variance in SIP total scores, whereas TICS performance accounted for no more than 6%. CONCLUSION Depression affects nearly half of SAH patients during the first year of recovery, and is associated with poor QOL. Systematic screening and early treatment for depression are promising strategies for improving outcome after SAH.

Endovascular management of distal anterior inferior cerebellar artery aneurysms: Report of two cases and review of the literature

Background: Aneurysms of the anterior inferior cerebellar artery (AICA), especially those located in the distal portion of the AICA, are rare. There are few reported cases treated with surgery or endovascular embolization. Case Description: We report two cases of fusiform distal AICA aneurysms presenting with subarachnoid hemorrhage. Parent artery occlusion with coils and n-butyl cyanoacrilate (n-BCA) resulted in complete aneurysm occlusion and prevented rebleeding. Both patients presented postprocedure neurological deficits, but have made a good recovery at 4 and 10 months, respectively. Conclusion: Occlusion of the parent artery for the treatment of ruptured fusiform distal AICA aneurysms is effective but has significant neurological risks.

Efficacy of Nonpharmacological Antishivering Interventions: A Systematic Analysis.

Objective:We performed a systematic review of the published evidence regarding nonpharmacologic antishivering interventions in various clinical settings. Data Sources:Studies through November 2014 were identified using predefined search terms in electronic databases, including PubMed, the Cochrane Library, EMBASE: Excerpta Medica (Ovid), and Web of Science. Study Selection:All identified articles were critically analyzed by applying prespecified criteria. We included experimental trials with comparable baseline data investigating the antishivering efficacy of nonpharmacological interventions in subjects without underlying thermoregulatory dysfunction. Data Extraction:Sixty-five publications (3,361 subjects) were analyzed by the type of clinical setting, intervention, comparison, and study design. In addition, each study underwent a standardized study quality assessment. Data Synthesis:Nonpharmacological interventions consisted of active cutaneous warming (forced-air warming, electric heating pad/blanket, radiant heating, and water-circulating mattress), body core warming (fluid or gas warming system), passive cutaneous warming (space blankets or towels), and electroacupuncture. Identified clinical settings included perioperative settings without induced hypothermia (60 of 77 comparisons), perioperative settings with induced hypothermia (8 of 77), and induced hypothermia without anesthesia (9 of 77). Active cutaneous warming was the most commonly studied intervention, and it was associated with the highest prevalence of positive results when compared with controls in all three clinical settings. In contrast, passive cutaneous warming and body core warming showed conflicting efficacy. Comparison evaluations among different antishivering interventions were limited due to the paucity and heterogeneity of studies directly comparing different interventions against one another. Conclusion:This systematic review of the effectiveness of nonpharmacological antishivering methods delineates active cutaneous warming as the most effective nonpharmacologic antishivering intervention in the perioperative and induced hypothermia settings.

Effect of early mobilization on sedation practices in the neurosciences intensive care unit: A preimplementation and postimplementation evaluation

INTRODUCTION The use of sedation and analgesia protocols, daily interruption of sedation, and early mobilization (EM) have been shown to decrease duration of mechanical ventilation and hospital length of stay (LOS). METHODS A retrospective chart review was conducted during a 6-month premobilization (pre-EM) and 6-month postmobilization (post-EM) period. Patients older than 18 years who were admitted to the neurosciences intensive care unit (ICU) and mechanically ventilated for at least 24 hours without documentation of withdrawal of life support or brain death were included. RESULTS Thirty-one pre-EM and 37 post-EM patients were included. Baseline demographics were similar with the exception of more ischemic stroke patients in the pre-EM group (P < .05). In the pre-EM and post-EM groups, patients received similar cumulative doses of propofol, dexmedetomidine, and benzodiazepines but higher median (interquartile range) doses of opioids (50.0 [13.8-165.0] vs 173.3 [41.2-463.2] μg of fentanyl equivalents [P < .05]) in the post-EM group. Neurosciences ICU LOS was 10 (6-19) and 13 (8-18) days, respectively (P = .188). CONCLUSIONS After implementation of an EM program, an increase in opioid use and no significant change in other sedatives were observed. Despite an increase in the amount of physical therapy and occupational therapy provided to patients, there was no change in hospital and ICU LOS or duration of mechanical ventilation.

498: CNS PHARMACOKINETICS OF ANTITUBERCULOUS AGENTS IN TUBERCULOUS MENINGITIS

pulmonary (17 vs. 7, p=0.0007) and cardiac (16 vs. 8, p=0.005) disease. On hospital presentation, the two groups had similar rates of hypotension requiring vasopressor therapy, respiratory failure requiring positive pressure ventilation, and acute kidney injury. SOFA scores were similar. Mechanical ventilation (MV) was initiated in most patients in both groups (27 vs. 21, p=1.00). The PaO2/FiO2 ratio was significantly higher in Group A on days 1 (216 vs. 81, p=0.0009), 3 (202 ± 99 vs. 100 ± 46, p=0.002) and 7 (199 ± 103 vs. 113 ± 44, p=0.019) but by day 14 no difference was seen. Tidal volumes were similar throughout, but patients in group B were kept on higher positive end expiratory pressures after day 7 (17 ± 8 vs. 12 ± 6, p=0.035). Rescue therapies were used more often in patients in Group B (48% vs. 20%, p=0.028), including prone ventilation (10 vs. 3, p=0.015), inhaled vasodilator therapy (11 vs. 4, p=0.015) and extracorporeal membrane oxygenation (ECMO) (4 vs. 2, p=NS). Duration of MV, ICU and hospital length of stay and mortality (9 [33%] and 12 [34%]) for both groups were similar. Conclusions: Group B was older, had more underlying diseases, worse oxygenation and utililized rescue modalities more often. The emergence of data supporting treatment modalities (such as ECMO and proning) may have improved outcomes for the patients in Group B.