Validity of the Clinical Dementia Rating Scale Sum of Boxes in Staging and Detection of Cognitive Impairment in Mexican Americans.

OBJECTIVE: We evaluated the utility of the Clinical Dementia Rating Sum of Boxes score (CDR-SB) in staging and detecting amnestic-mild cognitive impairment (a-MCI) and Alzheimer's disease (AD) among Mexican Americans. METHODS: Receiver operator curves were generated to evaluate the validity of the CDR-SB in staging and detecting a-MCI and AD in 1,073 Mexican Americans (758 controls, 163 a-MCI, and 152 AD). RESULTS: Optimal ranges of the CDR-SB were 0, 0.5-4, 4.5-8.0, 8.5-13 and 13.5-18 for staging the global CDR score of 0, 0.5, 1, 2, and 3, respectively. The CDR-SB ≥ 0.5 differentiated the a-MCI patients from the controls (sensitivity 100% and specificity 99.5%) and ≥ 2.0 distinguished the AD from a-MCI patients (sensitivity 83.6% and specificity 87.1%). These cutoffs were also appropriate for patients with ≤6 years of education. CONCLUSION: The CDR-SB is useful to detect and stage a-MCI and AD in Mexican Americans with diverse education levels.

Antihypertensive use for stroke in United States emergency departments.

OBJECTIVE: Timely emergency department (ED) control of hypertension in the acute phase of stroke is associated with improved outcomes. It is unclear how emergency physicians use antihypertensive medications to treat severe hypertension associated with stroke. We sought to determine national patterns of antihypertensive use associated with ED visits for stroke in the United States. METHODS: We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2008-2017. We included ED visits associated with ischemic stroke (ICD9 433-434, ICD10 I630-I639) or hemorrhagic stroke (ICD9 430-432, ICD10 I600-I629). We estimated the number and proportions of stroke ED visits with triage blood pressure meeting treatment thresholds (triage systolic blood pressure [SBP] ≥180 mm Hg). We identified the frequency of antihypertensive use, as well as the most commonly used agents. RESULTS: Between 2008-2017, of a total 135,012,819 ED visits, 619,791 were associated with stroke (78.3% ischemic strokes and 21.7% hemorrhage strokes). Of all stroke visits, 21.8% received antihypertensive medications. Of the identified visits, 9.0% (95% confidence interval [CI] = 6.0%, 13.1%) ischemic stroke visits and 58.2% (95% CI = 49.0%, 66.9%) hemorrhagic stroke visits met criteria for BP reduction. A total of 47.6% (95% CI = 29.1%, 66.7%) of eligible ischemic stroke visits and 41.5% (95% CI = 30.5%, 53.3%) of eligible hemorrhagic strokes visits received antihypertensives. The most common agents used in ischemic stroke were beta-blockers, calcium-channel blockers, and ACE inhibitors. The most common agents used in hemorrhagic stroke included calcium-channel blockers, beta-blockers, and vasodilators. CONCLUSION: In this national sample, less than half of strokes presenting to the ED with hypertension received antihypertensive therapy.

Isolated left posterior insular infarction and convergent roles in verbal fluency, language, memory, and executive function.

The posterior insular cortex-a complex structure interconnecting various brain regions for different functions-is a rare location for ischemic stroke. We report a patient with isolated left posterior insular infarction who presented with multiple cognitive impairment, including impairment in semantic and phonemic verbal fluency.

Microwave oven injuries in patients with complex partial seizures.

Microwave ovens are often recommended as a safe cooking alternative for persons with epilepsy. We report four patients who suffered serious burns to their hands while handling microwave-heated liquids during a complex partial seizure (CPS). Injuries were due to the contact of the skin with a very hot container. The fact that all patients held on to the hot containers despite being burned and that they did not remember experiencing any pain at the time of the accident indicates that neither high temperatures nor pain will prevent patients who are having a CPS from suffering this type of injury. Unfortunately, there is no foolproof way to prevent the individual from opening the oven and removing its contents during a CPS. The only solution for this problem is "prevention"-individuals with poorly controlled CPS should be cautioned about these risks. The use of microwave settings that permit the heating but not boiling of liquids and the use of gloves while heating food and liquids to scalding temperatures may minimize the risk of this type of injury.

Risk of aspiration pneumonia after an epileptic seizure: a retrospective analysis of 1634 adult patients.

We reviewed the incidence of aspiration pneumonia secondary to seizures in three populations of patients with chronic epilepsy: 733 outpatients seen in an Epilepsy Foundation clinic; 806 adult patients admitted to two university video telemetry units; and 95 institutionalized, profoundly retarded adult patients with chronic epilepsy. Two of the 733 adults who had seizures in the outpatient setting and 2 of the 806 patients who had one or more epileptic seizures in the telemetry units developed aspiration pneumonia. In the 95 institutionalized patients, there were 17 instances of aspiration pneumonia after a generalized seizure and 32 instances of aspiration unrelated to seizures over a 12-month period. Our findings suggest that aspiration pneumonia is not a common complication of seizures in otherwise healthy adults. The increased incidence of aspiration in developmentally delayed individuals seems to derive from a combination of factors. Increased oral secretions, impaired swallowing mechanisms, and difficulty in attaining adequate patient positioning significantly increased the risk of aspiration.

Behaviors mimicking seizures in institutionalized individuals with multiple disabilities and epilepsy: a video-EEG study.

We reviewed 824 video-EEG telemetry requests of institutionalized patients with epilepsy, searching for evaluations of "new seizure types" identified by staff (caregivers, teachers, therapists, LPNs, RNs). Of the 63 newly identified "seizure types," epilepsy was confirmed in 4 (6.3%); 59 represented nonepileptic events. Causes for diagnostic confusion in the profoundly retarded included stereotypic repeated blinking, swallowing, buccolingual movements, spontaneous grimacing, periods of apparent psychomotor arrest and increased muscle tone, dystonic posturing, and irascible personality emerging after reduction of sedatives. Three cases of "startle seizures" were due to dystonic posturing caused by the unexpected contact of body with water during bath. Episodes of decreased daytime alertness ("somnolence") were erroneously attributed to "absence seizures" in eight cases by staff supervising tasks requiring sustained attention (i.e., school, workshop). In less impaired patients, self-stimulation, self-abuse, and ataxia with falls were the more common diagnoses. Simulation of seizures, a somewhat uncommon finding in this population, was the diagnosis in 3 cases. All were high functioning and appeared to simulate seizures to avoid work. Our findings suggest that the de novo appearance of a "new seizure type" in these patients, particularly in cases with a well-established seizure pattern, is uncommon. Four patients in whom the "new event" was confirmed to be epileptic had preexisting secondarily generalized seizures. What the staff identified was the variable clinical progression of seizures probably due to medication changes. Different fragments of the seizure appear to have occurred at different times with variable intensity and duration. A single seizure type may have appeared to be a variety of attacks because of this fragmented presentation.

The Case for Different Severity of Burns in "Contagious" versus "Possession" Seizures.

Serious seizure-related burns are reportedly common in cultures that use ground fire for cooking, heating, or ceremonial purposes. The seriousness of injuries in these cases has been ascribed to the reluctance of bystanders to assist individuals having a seizure either because of fear of contagion (Africa, New Guinea highlands) or because of fear of revenge by the occult (Haiti). We report four Haitian patients who fell into open fires during an epileptic seizure in religious gatherings. Patients were almost immediately rescued from the fire. In contrast to the African and New Guinean patients where upper body involvement was common, burns in these four patients were of moderate severity and involved primarily the lower body. The fear of contagion and belief in magic are interesting notions, but do not explain the different severity and distribution of injuries in these patients. A more likely explanation is that seizures in the African and New Guinean patients occurred while the patient and family were asleep, which probably delayed the rescue, whereas the Haitian patients were helped within moments of falling into the fire in their seizure. The position of the patient at the onset of the seizure is probably what determined the primary areas of thermal injury, and the time to rescue determined their severity and extension.