Long-Term Video Electroencephalographic Monitoring in <30-Week Gestational Age Infants With High-Grade Intraventricular Hemorrhage.

BACKGROUND: Despite recognizing high seizure risk, the current consensus guidelines on evaluating seizures in preterm neonates are based on limited data. We chose to investigate the seizure risk in high-risk preterm (<30 weeks gestation) asymptomatic (without a clinical concern for seizures) infants with high-grade intraventricular hemorrhage who underwent long-term video electroencephalographic monitoring. METHODS: We performed a comprehensive retrospective review on all infants of <30-week gestational age admitted to the University of Alabama at Birmingham Regional Neonatal Intensive Care Unit from June 2018 to October 2022. We selected those patients who underwent electroencephalographic monitoring without a prior clinical concern for seizures. We recorded gender, gestational age, APGAR scores (one and five minutes), intraventricular hemorrhage (grade, age at diagnosis), and electroencephalographic monitoring (timing and duration) data. RESULTS: Among 37 premature infants, six had seizures detected on electroencephalographic monitoring. All six infants had subclinical seizures. Only two of six patients had a clinical correlation (although not identified by the providers) with some of their seizures. Patients with seizures were significantly younger in chronological age (median age 6.5 days vs 9 days, P value 0.009) at the time of the electroencephalographic monitoring initiation and were more likely to have subsequent monitoring studies (P value 0.0418). CONCLUSIONS: Long-term video electroencephalographic monitoring performed after the diagnosis of high-grade intraventricular hemorrhage captured seizures in ∼16% of asymptomatic premature neonates of <30 weeks' gestation. Patients identified to have seizures were significantly younger (chronological age) at the time of the electroencephalographic monitoring initiation and were more likely to be remonitored.

Brain Magnetic Resonance Imaging (MRI) White Matter Hyperintensities in Cyclic Vomiting Syndrome With or Without Migraine.

BACKGROUND: Cyclic vomiting syndrome is classified as a possible subset of migraine. Brain magnetic resonance imaging (MRI) findings of white matter hyperintensities are well documented in migraineurs, but not in patients with cyclic vomiting syndrome. This study focuses on white matter hyperintensities in children with cyclic vomiting syndrome. METHODS: We investigated our database of outpatient medical records for the diagnosis codes associated with cyclic vomiting syndrome from January 2008 to October 2018. RESULTS: Brain MRIs were obtained in 31 of 185 patients (∼17%) with a diagnosis code related to cyclic vomiting syndrome. We excluded 13 of 31 patients because of the inaccessibility of images or a confounding diagnosis. Remaining patients were divided into 2 groups: 13 of 18 cyclic vomiting syndrome with migraine (CVS+M), and 5 of 18 cyclic vomiting syndrome without migraine (CVS-M). We found that 3 of the 13 patients in the CVS+M group had migraine-like white matter hyperintensities compared to 0 of the 5 in the CVS-M group. CONCLUSION: This small study suggests a possible relationship between white matter hyperintensities and CVS+M. A larger study is required to validate these findings.

Perioperative stroke-related mortality after non-cardiovascular, non-neurological procedures: A retrospective risk factor evaluation of common surgical comorbidities.

BACKGROUND: Perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population is an uncommon, yet devastating outcome. A combination of emboli and hypoperfusion may cause large vessel occlusions leading to perioperative strokes and mortality. Identifying independent risk factors for perioperative stroke-related mortality may enhance risk-stratification algorithms and preventative therapies. OBJECTIVES: This study utilised cause-of-death data to determine independent risk scores for common surgical comorbidities that may lead to perioperative stroke-related mortality, including atrial fibrillation and asymptomatic carotid stenosis. METHODS: This retrospective, IRB-exempt, case-control study evaluated non-cardiovascular, non-neurological surgical patients in a claims-based database. ICD-10-CM and ICD-9-CM codes identified cause of death and comorbidity incidences, respectively. A multivariate regression analysis then established adjusted independent risk scores of each comorbidity in relation to perioperative stroke-related mortality. RESULTS: Patients with atrial fibrillation were more likely (1.7 aOR, 95% CI (1.1, 2.8) p = 0.02) to die from perioperative stroke-related mortality than from other causes. No association was found with asymptomatic carotid stenosis. Further, in-hospital strokes (25.9 aOR, 95% CI (16.0, 41.8) p < 0.001) or diabetes (1.8 aOR, 95% CI (1.1, 2.9) p = 0.02) may increase perioperative stroke-related mortality risk. CONCLUSIONS: Atrial fibrillation, diabetes and in-hospital strokes may be independent risk factors for perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population.

Postoperative Neurological Complications Following Revision Spine Surgery: A State Inpatient Database Analysis.

BACKGROUND: Postoperative neurological complications after spine surgery can result in increased mortality and morbidity. Despite the introduction of new spinal implants and surgical technology, reoperation rates have remained stable over recent years. Understanding the reasons for revision (refusion) surgery and the risk of neurological complications can assist in developing more effective screening protocols for repeat surgeries and early detection of potential neurological complications. METHODS: This study was designed and conducted as a retrospective cohort study. The primary objective of this study was to evaluate whether revision spine surgery increased the risk of postoperative neurological deficits. A secondary objective of the study was to analyze whether deficits following repeat spine surgery increased morbidity and mortality. Data on revision spine procedures were extracted from the California State Inpatient Database for years 2008 to 2011. Patients who developed postoperative neurological deficits were then subdivided into causative procedure: revision anterior cervical discectomy and fusion, revision posterior cervical fusion, and revision thoracolumbar fusion. These data were then used to calculate the total incidence of postoperative neurological deficits following each type of procedure. The impact of neurological deficits on in-hospital morbidity following revision procedures was also calculated. RESULTS: Revision procedures accounted for 5.84% of all spine procedures in a total of 7645 patients. Among these patients, 67 patients (0.88%) developed a postoperative neurological deficit with an adjusted odds ratio of 1.56 (95% CI, 1.20-2.00, P < .05). When using individuals with no neurological deficit as the reference group, the odds of morbidity were 5.3 (95% CI, 3.15-9.00, P < .05) in those who sustained neurological deficit following revision procedure. CONCLUSIONS/CLINICAL RELEVANCE: This study exposes the increased risk of postoperative neurological complications in revision spine surgeries. In response, further studies are needed to evaluate the use of intraoperative neurophysiological monitoring to reduce this risk.

Perioperative Stroke and Readmissions Rates in Noncardiac Non-Neurologic Surgery.

BACKGROUND AND AIM: Perioperative stroke is a feared and potentially disastrous complication of surgery. Postdischarge care, specifically hospital readmissions, can significantly impact postsurgical recovery and provides a useful metric for quality care. Our primary aim was examining 30-day readmissions for patients who had a perioperative stroke undergoing noncardiac non-neurosurgery. METHODS: We analyzed data from the State Inpatient Database, a database of community hospital discharges, in California between 2008 and2011. Surgical patients undergoing one of the 10 highest-volume procedures were included; patients less than 18 years old, undergoing pregnancy-related procedures, or who died in-hospital were excluded. Our dataset covariates included demographic and clinical variables, comorbidities, and discharge location. After running an initial bivariate analysis using Chi-square and t-tests and testing for multicollinearity, logistical models were run to calculate adjusted odds ratios and confidence intervals for readmission predictors. RESULTS: 30-day readmissions for patients with perioperative stroke (n = 1613) occurred at a rate of 21.08% (340 patients), compared to 6.29% (63,856 patients) for patients without perioperative stroke (adjusted OR = 1.40, 95% CI 1.23-1.59, P < .0001). Demographic predictors of 30-day readmissions included male sex and African-American race. Clinical predictors of 30-day readmissions included several comorbidities (i.e. liver disease, hypertension), and discharge to a postacute care facility. Key 30-day readmission diagnoses for perioperative stroke patients included septicemia, stroke, aspiration pneumonitis, and urinary tract infections. CONCLUSIONS: Patients with perioperative stroke have high 30-day readmissions rates. A number of demographic and clinical factors increase readmission risk in this population. Further research is warranted to better support patients with perioperative stroke undergoing care transitions.

Independent Predictors of Perioperative Stroke-Related Mortality after Cardiac Surgery.

BACKGROUND AND PURPOSE: Perioperative stroke remains a devastating complication after cardiac surgery and is associated with significant morbidity and mortality. Despite the significant contribution of stroke to perioperative mortality, risk factors for perioperative stroke-related mortality have not been well characterized. Our aim was to identify independent predictors of perioperative stroke-related mortality after cardiac surgery, using the Pennsylvania Health Care Cost Containment Council (PHC4) database which provides information on cause of death. METHODS: We retrospectively examined patient medical records from 2012 to 2014 of 3345 patients (ages 18-99) who underwent a cardiac surgical procedure and suffered perioperative (30-day) mortality. Perioperative stroke-related mortality was identified by International Classification of Diseases, Tenth Revision, Clinical Modification cause of death codes. We performed Fisher's exact test and multivariate analysis to identify comorbidities that independently predict perioperative stroke-related mortality. RESULTS: After controlling for all variables with multivariate analysis, we found that patients with carotid stenosis were 4.9 (adjusted odds ratio [aOR], 95% confidence interval [CI] 1.8-12.8) times more likely to die from a stroke than from other causes, when compared to patients without carotid stenosis. Other independent predictors of perioperative stroke-related mortality included in-hospital stroke (aOR 108.8, 95%CI 48.2-245.9), history of stroke (aOR 17.1, 95%CI 3.3-88.4), and age ≥ 80 (aOR 4.9, 95%CI 2.1-11.2). CONCLUSIONS: This is the first study to establish carotid stenosis, among other comorbidities, as an independent predictor of perioperative stroke-related mortality after cardiac surgery. Understanding risk factors for mortality from stroke will help enhance the efficacy of preoperative screening, intraoperative neurophysiological monitoring, and potential treatments for stroke. Interventions to manage carotid stenosis and other identified risk factors prior to, during, or immediately after surgery may have the potential to reduce perioperative stroke-related mortality after cardiac surgery.

Diurnal, weekly and seasonal variations of chest pain in patients transported by emergency medical services.

OBJECTIVES: Chest pain is among the leading causes for emergency medical services (EMS) activation. Acute myocardial infarction (MI) is not only one of the most critical aetiologies of chest pain, but also one of few conditions encountered by EMS that has been shown to follow a circadian pattern. Understanding the diurnal relationship between the inflow of chest pain patients and the likelihood of acute MI may inform prehospital and emergency department (ED) healthcare providers regarding the prediction, and hence prevention, of dire outcomes. METHODS: This was a secondary analysis of previously collected data from an observational prospective study that enrolled consecutive chest pain patients transported by a large metropolitan EMS system in the USA. We used the time of EMS call to determine the time-of-day of the indexed encounter. Two independent reviewers examined available medical data to determine our primary outcome, the presence of MI, and our secondary outcomes, infarct size and 30-day major adverse cardiac events (MACE). We estimated infarct size using peak troponin level. RESULTS: We enrolled 2065 patients (age 56±17, 53% males, 7.5% with MI). Chest pain encounters increased from 9:00 AM to 2:00 PM, with a peak at 1:00 PM and a nadir at 6:00 AM. Acute MI had a bimodal distribution with two peaks: 10 AM in ST-elevation MI, and 10 PM in non-ST-elevation MI. ST-elevation MI with afternoon onset was an independent predictor of infarct size. Acute MI with winter and early spring presentation was an independent predictor of 30-day MACE. CONCLUSIONS: EMS-attended chest pain calls follow a diurnal pattern, with the most vulnerable patients encountered during afternoons and winter/spring seasons. These data can inform prehospital and ED healthcare providers regarding the time of presentation where patients are more likely to have an underlying MI and subsequently worse outcomes.

Perioperative stroke associated in-hospital morbidity and in-hospital mortality in common non-vascular non-neurological surgery.

Perioperative stroke in non-vascular, non-neurological surgery is a potential cause of high levels of in-hospital morbidity and mortality. Although, perioperative stroke following non-vascular and non-neurological surgery is a relatively infrequent event; high surgical volume results in thousands of patients experiencing neurological deficits. We aim to determine if perioperative stroke is an independent risk factor for 30-day in-hospital morbidity and mortality following common non-vascular non-neurological surgery. This is a retrospective analysis of 4,264,963 surgical procedures identified in the Nationwide Inpatient Sample (NIS) from the years 2000 through 2011. The exposure of interest was stroke within 30 days of total knee arthroscopy, total hip arthroscopy, lung segmentation and resection, appendectomy, hemicolectomy, cholecystectomy, and lysis of peritoneal adhesions. Study outcomes were in-hospital mortality and in-hospital morbidity. Our study found an in-hospital morbidity, in-hospital mortality, and perioperative stroke rate of 5.5%, 0.8%, and 0.2%, respectively. Multivariable analysis revealed perioperative stroke to be a significant independent predictor (p < 0.001) of length of stay exceeding 14 days (OR = 4.55, 95% CI: 4.21-4.91), cardiovascular complications (OR = 1.96, 95% CI: 1.75-2.19), pulmonary complications (OR = 2.07, 95% CI: 1.89-2.27). The impact of perioperative stroke on in-hospital mortality was (OR = 8.53, 95% CI: 7.87-9.25), whereas cardiovascular complications impact on in-hospital mortality was (OR = 8.36, 95% CI = 7.67-9.10, p < 0.001). This study identified perioperative stroke as an independent predictor of 30-day in-hospital morbidity and mortality following non-vascular, non-neurological surgery.