Eldad Hadar

Cost effectiveness of a clinical pharmacist on a neurosurgical team

OBJECTIVEIn 1999, the Society of Critical Care Medicine formally recognized that pharmacists were essential for the provision of high quality care to the critically ill population. This study is a brief quantitative analysis of the benefit provided by a clinical pharmacist in a multidisciplinary neurosurgical setting. METHODSPatients admitted to the neurosurgical service in the 2 years before and 2 years after the implementation of dedicated neurosurgical pharmacy services were retrospectively reviewed. The clinical pharmacist was responsible for monitoring and evaluating all adult patients on the service and rounding with the team 6 days a week. RESULTSA total of 2156 patients were admitted during the study period. No significant differences were noted among severity of illness scores between the 2 groups. During this time, 11 250 interventions were recorded by the pharmacist. The average pharmacy and intravenous therapy cost per patient between the pre- and postimplementation groups decreased from

Modulation of Cortical Oscillations by Low-Frequency Direct Cortical Stimulation Is State-Dependent

4833 to

Initial experience in hybrid PET-MRI for evaluation of refractory focal onset epilepsy

3239, resulting in a total savings of

Review of Epilepsy - Etiology, Diagnostic Evaluation and Treatment

1 718 260 over the duration of the study period. The average hospital stay decreased from 8.56 to 7.24 days (P = 0.003). Early hospital mortality also decreased from 3.34% to 1.95% (P = 0.06). For those patients who were discharged from the hospital, there was a significant decrease in readmission rates between the 2 groups (P < 0.05) CONCLUSIONHaving a dedicated clinical pharmacist with critical care training rounding routinely with a neurosurgical team significantly reduced hospital stay, readmission rates, and pharmacy costs. Clinical pharmacists can have a significant effect on clinical and economic measures in the intensive care unit, and their participation on a multidisciplinary critical care team should be a standard of care.

The effect of anatomic location of injury on mortality risk in a resource-poor setting

Cortical oscillations play a fundamental role in organizing large-scale functional brain networks. Noninvasive brain stimulation with temporally patterned waveforms such as repetitive transcranial magnetic stimulation (rTMS) and transcranial alternating current stimulation (tACS) have been proposed to modulate these oscillations. Thus, these stimulation modalities represent promising new approaches for the treatment of psychiatric illnesses in which these oscillations are impaired. However, the mechanism by which periodic brain stimulation alters endogenous oscillation dynamics is debated and appears to depend on brain state. Here, we demonstrate with a static model and a neural oscillator model that recurrent excitation in the thalamo-cortical circuit, together with recruitment of cortico-cortical connections, can explain the enhancement of oscillations by brain stimulation as a function of brain state. We then performed concurrent invasive recording and stimulation of the human cortical surface to elucidate the response of cortical oscillations to periodic stimulation and support the findings from the computational models. We found that (1) stimulation enhanced the targeted oscillation power, (2) this enhancement outlasted stimulation, and (3) the effect of stimulation depended on behavioral state. Together, our results show successful target engagement of oscillations by periodic brain stimulation and highlight the role of nonlinear interaction between endogenous network oscillations and stimulation. These mechanistic insights will contribute to the design of adaptive, more targeted stimulation paradigms.

Surgery for hemispheric malformations of cortical development

PURPOSE We aim to evaluate the utility/improved accuracy of hybrid PET/MR compared to current practice separate 3T MRI and PET-CT imaging for localization of seizure foci. METHOD In a pilot study, twenty-nine patients undergoing epilepsy surgery evaluation were imaged using PET/MR. This subject group had 29 previous clinical 3T MRI as well as 12 PET-CT studies. Prior clinical PET and MR images were read sequentially while the hybrid PET/MR was concurrently read. RESULTS The median interval between hybrid PET/MR and prior imaging studies was 5 months (range 1-77 months). In 24 patients, there was no change in the read between the clinical exams and hybrid PET/MR while new anatomical or functional lesions were identified by hybrid PET/MR in 5 patients without significant clinical change. Four new anatomical MR lesions were seen with concordant PET findings. The remaining patient revealed a new abnormal PET lesion without an MR abnormality. All new PET/MR lesions were clinically significant with concordant EEG and/or SPECT results as potential epileptic foci. CONCLUSION Our initial hybrid PET-MRI experience increased diagnostic yields for detection of potential epileptic lesions. This may be due to the unique advantage of improved co-registration and simultaneous review of both structural and functional data.

Psychiatric Nosology and Multidisciplinary Therapy: Structura et Mechanismus ad Curare

Epilepsy is the fourth most common neurological disorder in the US, affecting nearly 2.5 million Americans. The economic impact of epilepsy represents estimated direct and indirect costs of 12.5 billion dollars per year. Patients with this disorder experience increased morbidity and mortality with long term fatality rates of 24%. Multiple diagnostic tools are used to identify and classify the seizure type/syndrome, etiology and localization of seizures, including electroencephalogram (EEG), magnetic resonance imaging (MRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT), magneto encephalogram (MEG), and neuropsychiatric testing. Despite 29 different antiepileptic medications that are available in the US, one third of patients remain refractory to pharmacological treatment. In these intractable epilepsy patients, non-pharmacological treatments can be considered. Commonly used non-pharmacological treatment options for epilepsy include epilepsy surgery, neurostimulation therapy, and diet therapy.

Low-frequency direct cortical stimulation of left superior frontal gyrus enhances working memory performance

INTRODUCTION Injury is a significant cause of death, with approximately 4.7 million people mortalities each year. By 2030, injury is predicted to be among the top 20 causes of death worldwide. We sought to characterize and compare the mortality probability in trauma patients in a resource-poor setting based on anatomic location of injury. METHODS We performed a retrospective analysis of prospectively collected data using the trauma database at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. We included all adult trauma patients (≥16years) admitted between 2011 and 2015. We stratified patients according to anatomic location of injury, and used descriptive statistics to compare characteristics and management of each group. Bivariate analysis by mortality was done to determine covariates for our adjusted model. A Cox proportional hazard model was performed, using upper extremity injury as the baseline comparator. Descriptive statistics were used to describe the trend in incidence and mortality of head and spine injuries over five years. RESULTS Of the 76,984 trauma patients who presented to KCH from 2011 to 2015, 49,126 (63.8%) were adults, and 8569 (17.4%) were admitted. The most common injury was to the head or spine, seen in 3712 patients (43.6%). The highest unadjusted hazard ratio for mortality was in head and spine injury patients, at 3.685 (95% CI=2.50-5.44), which increased to 4.501 (95% CI=2.78-7.30) when adjusted for age, sex, injury severity, transfer status, injury mechanism, and surgical intervention. Abdominal trauma had the second highest adjusted hazard of mortality, at 3.62 (95% CI=1.92-6.84) followed by thoracic trauma (HR=1.3621, 95% CI=0.49-3.56). CONCLUSION In our setting, head or spine injury significantly increases the hazard of mortality significantly compared to all other anatomic injury locations. The prioritization of timely operative and non-operative head injury management is imperative. The development of head injury units may help attenuate trauma- related mortality in resource poor settings.

Triple pathological findings in a surgically amenable patient with mesial temporal lobe epilepsy

The treatment of patients with hemispheric malformations of cortical development presents a challenging clinical problem that often requires surgical intervention. The development of a safe and effective treatment strategy for these patients requires an extensive work-up with a great deal of attention to a variety of multidisciplinary testing methods. In this article, the authors describe the presurgical evaluation of patients with hemispheric malformations of cortical development and epilepsy and review the surgical techniques currently available. They also detail some of the controversial issues regarding surgical treatment of these patients.

Relative Adrenal Insufficiency in Patients with Acute Spinal Cord Injury

computer software. The software produces the images that appear to be “brain-like.” The problem with the end product of several types of neuroimagers, including SPECT, is that the lay person does not understand that they are not looking at an objective representation, and that it took many algorithms to produce the images they see. Roskies puts it this way: “Neuroimages are inferentially distant from brain activity, yet they appear not to be” (Roskies, 2008, 30). In sum, there is little reason to think that the use of SPECT currently has clinical validity in diagnosing or managing neuropsychiatric disorders. Indeed, medical consensus (supported by the insurance industry and the American Psychiatric Association Council on Children, Adolescents and Families) suggests that SPECT has no real clinical diagnostic efficacy for now, although it remains an important research tool. The entities offering these services appeal to vulnerable populations and rely on the allure of neuroscience explanations and the peculiarly persuasive power of pictures to, in turn, persuade people of the value of their service. In many of the same ways that 3D–4D fetal imaging centers in shopping malls and full-body computed tomography (CT) scans for otherwise healthy patients have generated controversy for unnecessarily exposing people to potentially hazardous procedures for little medical benefit, SPECT scan entrepreneurs raise serious policy questions for the oversight of medicine and business practices. REFERENCES