Neha Kramer

Seizures Following Ischemic Stroke: Frequency of Occurrence and Impact on Outcome in a Long-Term Population-Based Study

BACKGROUND AND PURPOSE Seizures are a known complication of ischemic stroke (IS). This study assesses the long-term incidence and characteristics of poststroke seizures in a well-defined population. METHODS Using the Rochester Epidemiology Project medical records-linkage system, we identified all incident cases of IS among Rochester, Minnesota, residents from 1990 to 1994 and followed the patients in the comprehensive medical record through March 2014. All patients with poststroke seizures were identified, and data regarding incident IS, seizures, and status at last follow-up were analyzed. RESULTS We identified 489 patients with first IS. Mean follow-up was 6.5 (standard deviation 6.3) years. New onset seizures occurred in 35 patients (7.2%). Patients with poststroke seizure did not differ from those without in terms of IS etiologic subtype (P = .44) or IS risk factors (P > .05). Early seizures (within 14 days of index stroke) developed in 14 patients (40%), the majority within the first 24 hours (n = 9, 64.3%). The median time of seizure onset for the remaining 21 patients was 13.8 months. Functional outcome, as measured by modified Rankin Scale (mRS), was worse following development of poststroke seizures (mean mRS score 2.9 after IS, 3.3 following index seizure; P = .005), and mortality was higher as well, even after adjusting for IS etiologic subtype (HR 1.52, 95% confidence interval 1.07-2.16, P = .02). CONCLUSION Development of poststroke seizures is an infrequent but significant complication of IS, portending a worse short-term functional outcome and a higher long-term mortality rate. Seizure occurrence did not differ based on IS etiologic subtype or stroke risk factors.

Structured handoff checklists improve clinical measures in patients discharged from the neurointensive care unit

SummaryWhile up to 80% of medical errors may result from poor communication at clinical transitions of care, there has been relatively little study of the effect of standardized communication tools on clinical quality measures. We prospectively examined the effect of a standardized handoff checklist on clinical outcomes for patients dismissed from the neurointensive care unit. We found that the checklist resulted in significant reductions in patients transferred with inaccurate medication reconciliation and unnecessary urinary catheters. Participating physicians were surveyed and generally viewed the handoff checklist favorably. Standardized communication tools such as checklists may play a useful role in reducing medical errors related to communication between patient care teams.

Palliative Sedation and What Constitutes Active Dying A Case of Severe Progressive Dystonia and Intractable Pain

We present the case of a 34-year-old woman with Klippel-Feil syndrome who developed progressive generalized dystonia of unclear etiology, resulting in intractable pain despite aggressive medical and surgical interventions. Ultimately, palliative sedation was required to relieve suffering. Herein, we describe ethical considerations including defining sedation, determining prognosis in the setting of an undefined neurodegenerative condition, and use of treatments that concurrently might prolong or alter end-of-life trajectory. We highlight pertinent literature and how it may be applied in challenging and unique clinical situations. Finally, we discuss the need for expert multidisciplinary involvement when implementing palliative sedation and illustrate that procedures and rules need to be interpreted to deliver optimal patient-centered plan of care.

Challenges to safe and effective pain management in patients with super obesity: case report and literature review

The prevalence of obesity continues to rise in the United States and impacts on morbidity, mortality and overall costs in health care considerably. In 2013–2014, more than one-third (37.9%) of U.S. adults were classified as obese, and the prevalence of those with a body mass index (BMI) ≥40kg/m2, was 7.7%. (1) The heaviest groups (BMI ≥50kg/m2) increases in prevalence at the fastest rates. (2) Pertinent to healthcare providers—the larger the patient, the more health care resources utilized and the worse the survival. (3) Having a BMI >40kg/m2 predicts use of more than double the healthcare dollars of a normal weight individual. (4) Providing care to individuals with severe obesity is complex, as the physiologic changes associated with morbid and super obesity alter the pharmacokinetic properties of most drugs. (5) Derangements in cardiovascular and respiratory physiology make the patients with morbid obesity more vulnerable to drug-induced respiratory depression and upper airway obstruction, thus increasing the risk of treating them with opioids. In reviewing the literature, it appears that much of what is understood regarding the care of patients with super obesity must be extrapolated from what is known regarding the morbidly obese, a group that has been studied more frequently. The term “super obesity” has been used variably, but defined often as weighing 150 pounds or more than ideal body weight or having a BMI ≥50kg/m. (6) Herein we present a case of a patient with a BMI of 100kg/m2 admitted with uncontrolled pain due to large necrotic skin ulcers from nonuremic calciphylaxis. Through this case, we review the limitations of data regarding pharmacologic properties for those with super obesity, and provide palliative medicine providers with a framework for such management.