Haemiballism/haemichorea: an atypical presentation of ischaemic stroke.

A 76-year-old man was admitted to the hospital with acute onset of involuntary movements of the left side of his body. His neurological examination revealed he was oriented only to himself, and aforementioned movements of his left arm and leg. CT head demonstrated old infarcts in his right aspect of his pons and basal ganglia. Cerebrospinal fluid analysis was unremarkable. He initially had a normal blood glucose with an elevated anion gap and elevated creatine kinase. Brain MRI showed a small lacunar-type ischaemic infarct within the anteromedial aspect of the right cerebral peduncle, which localised to his haemiballism. To prevent worsening rhabdomyolysis associated with his haemiballism, the primary team initiated both tetrabenazine and diazepam. His movements improved after 1 week of medication therapy. This report discusses a thorough workup for this movement disorder and when to intervene for this distressing condition.

Chiral lanthanide complexes: coordination chemistry, spectroscopy, and catalysis.

The coordination chemistry and catalytic applications of organometallic and related lanthanide complexes bearing chiral oxazoline ligands is an area that has been largely underdeveloped, in comparison to complexes based upon lanthanide triflates for use in Lewis acid catalysis. In this article we report on the coordination chemistry of the bis(oxazolinylphenyl)amide (BOPA) ligand with lanthanide alkyl and amide co-ligands (Ln = Y, La, Pr, Nd, Sm). Their structural and spectroscopic characterisation are reported, including an assessment of their photophysical properties using luminescence spectroscopy, and are supported by density functional calculations. The application of these complexes in the hydroamination/cyclisation of aminoalkenes, and in the ring-opening polymerisation of rac-lactide is reported.

Near-IR luminescent neodymium complexes: spectroscopic probes for hydroamination catalysis.

Neodymium complexes bearing the sensitising bis(oxazolinylphenyl)amine (BOPA) ligands have been prepared, and analysed spectroscopically under both catalytic and pseudo-catalytic conditions with respect to the intramolecular hydroamination of an aminoalkene, providing a direct means of monitoring binding events and relative space around the metal centre.

Interrater reliability of the bedside shivering assessment scale.

BACKGROUND: Since its early development, the Bedside Shivering Assessment Scale (BSAS) has had only initial psychometric testing. Before this instrument is incorporated into routine practice, its interrater reliability should be explored in a diverse group of practitioners. METHODS: This prospective nonrandomized study used a panel of 5 observers who completed 100 paired assessments. Observers independently scored patients for shivering by using the BSAS. Kappa statistics were determined by using SAS version 9.4 with BSAS scores treated as ordinal data. RESULTS: A weighted kappa value of 0.48 from 100 paired observations of 22 patients indicates moderate agreement of the BSAS scores. Most of the BSAS scores were 0 or 1; dichotomizing shivering as little or no shivering versus significant shivering resulted in a kappa of 0.66 (substantial agreement). No relationship was found between timing of assessment or the role of the practitioner and the likelihood of both observers assigning the same BSAS score. CONCLUSION: The BSAS has adequate interrater reliability to be considered for use among a diverse group of practitioners.

Apnea testing during brain death assessment: a review of clinical practice and published literature.

The diagnosis of brain death is a complex process. Strong knowledge of neurophysiology and an understanding of brain death etiology must be used to confidently determine brain death. The key findings in brain death are unresponsiveness, and absence of brainstem reflexes in the setting of a devastating neurological injury. These findings are coupled with a series of confirmatory tests, and the diagnosis of brain death is established based on consensus recommendations. The drive to breathe in the setting of an intense ventilatory stimulus (ie, respiratory acidosis) is a critical marker of brainstem function. As a consequence, apnea testing is an important component of brain death assessment. This procedure requires close monitoring of a patient as all ventilator support is temporarily removed and Paco2 levels are allowed to rise. A "positive" test is defined by a total absence of respiratory efforts under these conditions. While apnea testing is not new, it still lacks consensus standardization regarding the actual procedure, monitored parameters, and evidence-based safety measures that may be used to prevent complications. The purpose of this report is to provide an overview of apnea testing and discuss issues related to the administration and safety of the procedure.

Effect of mechanical chest percussion on intracranial pressure: a pilot study.

BACKGROUND: Treatment of brain injury is often focused on minimizing intracranial pressure, which, when elevated, can lead to secondary brain injury. Chest percussion is a common practice used to treat and prevent pneumonia. Conflicting and limited anecdotal evidence indicates that physical stimulation increases intracranial pressure and should be avoided in patients at risk of intracranial hypertension. OBJECTIVES: To explore the safety of performing chest percussion for patients at high risk for intracranial hypertension. METHODS: A total of 28 patients with at least 1 documented episode of intracranial hypertension who were having intracranial pressure monitored were studied in a prospective randomized control trial. Patients were randomly assigned to either the control group (no chest percussion) or the intervention group (10 minutes of chest percussion at noon). Intracranial pressure was recorded once a minute before, during, and after the intervention. RESULTS: Mean intracranial pressures for the control group before, during, and after the study period (14.4, 15.0, and 15.9 mm Hg, respectively) did not differ significantly from pressures in the intervention group (13.6, 13.7, and 14.2 mm Hg, respectively). CONCLUSIONS: Mechanical chest percussion may be a safe intervention for nurses to use on neurologically injured patients who are at risk for intracranial hypertension.

Use of high frequency oscillatory ventilation (HFOV) in neurocritical care patients.

INTRODUCTION: Adult respiratory distress syndrome (ARDS) can be a common problem associated with the treatment of acute brain injury. High frequency oscillatory ventilation (HFOV) is a developing therapy for the treatment of ARDS in adult patients that can be life saving. However, often patients with acute, severe brain injury demonstrate intracranial hypertension (hICP) due to a variety of injuries (e.g., traumatic brain injury, mass lesion, acute hydrocephalus). There is concern over the use of HFOV due to its effects on intracranial pressure in patients with hICP. METHODS: Retrospective case series study. RESULTS: We describe the effects of HFOV on hemodynamics, respiratory function, and intracranial pressure in five patients with acute brain injury being treated for ARDS. CONCLUSIONS: HFOV did not cause unmanageable or sustained increases in ICP in our series of patients. It appears HFOV may be a relatively safe and effective means of oxygenating patients with severe ARDS and concomitant hICP secondary to acute brain injury.

Changes in intracranial pressure associated with chest physiotherapy.

INTRODUCTION: Management of intracranial hypertension is pivotal in the care of brain-injured patients. SUMMARY OF CASE: We report the case of a patient with both a closed head injury and anoxic encephalopathy, who subsequently experienced episodes of refractory intracranial hypertension. The patient's care was complicated by the development of a pneumonia, which required frequent turning of the patient and chest physiotherapy. Conventional wisdom suggests that these interventions may stimulate the patient and worsen intracranial pressure, and therefore should be avoided. RESULTS: Our observations on this patient, however, contradict this belief. This single-subject study presents data to support the use of chest physiotherapy in patients at risk for intracranial hypertension. CONCLUSIONS: Further, the evidence is compelling that a randomized-controlled trial is indicated to test the hypothesis that chest physiotherapy may actually result in short-term resolution of high intracranial pressure, and thus provide one more clinical tool in the management of elevated intracranial pressure.