Psychiatric disorders of the combination of levetiracetam either with lacosamide or perampanel: a retrospective cohort study.

Background The number of patients with epilepsy receiving perampanel or lacosamide as an add-on treatment following levetiracetam treatment has increased. Although levetiracetam causes psychiatric disorders, it is unclear whether they occur with the combined use of these antiepileptic drugs. Objective To determine the frequency of psychiatric disorders in patients received lacosamide or perampanel in combination with levetiracetam. Setting A single-center retrospective cohort study. Method Patients who received levetiracetam + lacosamide or levetiracetam + perampanel were selected. Medical records from the start of combination therapy contained characteristics of patients and the incidence of psychiatric disorders. Main outcome measure The frequency of psychiatric disorders, the time to onset, dose reduction or discontinuation following psychiatric disorders, and the clinical course following disorder onset. Results Forty-four patients used levetiracetam + lacosamide and 50 used levetiracetam + perampanel. The incidence of psychiatric disorders was significantly lower (p < 0.001) with levetiracetam + lacosamide (6.8%) than with levetiracetam + perampanel (44%). The incidence of affect lability was significantly higher with levetiracetam + perampanel than with levetiracetam + lacosamide (p = 0.018). The time to the onset of psychiatric disorders was within 1 month of dose initiation or increase in one case (33.3%) with levetiracetam + lacosamide and 16 cases (72.7%) with levetiracetam + perampanel. There was no significant difference in clinical characteristics and antiepileptic drug dosages owing to the presence or absence of psychiatric disorders. Conclusion As the frequency of psychiatric disorders was higher with levetiracetam + perampanel therapy, levetiracetam + lacosamide may be preferable. These disorders tended to develop within 1 month of therapy and were not dose-dependent. Antiepileptic drugs should be cautiously prescribed to avoid psychiatric disorders.

High-grade traumatic torso visceral injury with hemodynamic instability: effectiveness of transarterial embolization using n-butyl cyanoacrylate.

Trauma patients with uncontrolled hemorrhage encountering coagulopathy are often associated with poor outcome. Recently, the concept of damage control interventional radiology, which focuses on "speedy stoppage of bleeding" by interventional radiology among trauma patients with hemodynamic instability and acute traumatic coagulopathy, was proposed as an alternative to damage control surgery. N-butyl cyanoacrylate (NBCA) has been used as a liquid embolic agent in various non-traumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy. In this case, we treated a young patient with hemodynamic instability caused by a high-grade hepatic injury, who underwent arterial embolization (AE) using NBCA assisted with resuscitative endovascular balloon occlusion of the aorta and achieved successful hemostasis. A review of published works using PUBMED was carried out, and 10 published reports involving 23 trauma patients who underwent AE using NBCA were identified. Among them, only four reports involving five trauma patients with torso visceral injuries were identified. Three of five patients who were hemodynamically unstable underwent AE using NBCA, resulting in the stabilization of hemodynamics. We concluded that AE with resuscitative endovascular balloon occlusion of the aorta as a damage control interventional radiology procedure might be acceptable for the hemodynamically unstable hepatic injury, and NBCA could be one of the effective hemostatic agents for this purpose, in cases of trauma-induced coagulopathy.

Emergency endovascular treatment of a ruptured external carotid artery pseudoaneurysm caused by a cervical stab wound: A case report and literature review.

The formation of external carotid artery (ECA) pseudoaneurysms caused by stab wounds is a rare vascular anomaly. Although the surgical exploration of the ECA segment is the standard treatment, endovascular treatment (EVT) can be considered if there is difficulty in identifying the source of bleeding in the injured regions that are difficult to operatively access. Here we treated a young patient who had hemorrhagic instability with hemorrhage-induced coagulopathy caused by a zone III cervical stab wound with a pseudoaneurysm from the main trunk of the ECA; the patient underwent EVT and successful hemostasis. A literature review based on the data available on PubMed was conducted, and 15 published reports of 82 penetrating ECA injuries treated by EVT were identified. We concluded that EVT appears to be an effective surgical alternative for patients with hemorrhage-induced coagulopathy caused by a ruptured ECA pseudoaneurysm after a cervical stab wound.

A rare case of obscure gastrointestinal bleeding: Small bowel varices flowing into the inferior epigastric vein.

Ectopic varices include all varices except esophageal or gastric varices and comprise large portosystemic venous collaterals that occur anywhere in the abdomen. Ectopic varices are relatively rare; however, approximately 5% are related to gastrointestinal bleeding. Ectopic varices usually occur in the rectum, duodenum, or colon, and portal hypertension is the most common cause. Hemodynamic profiles of ectopic varices remain unknown, and extensive bleeding from these structures occurs because diagnosis and treatment are difficult. Here we report a case of obscure gastrointestinal bleeding (GIB) due to ectopic varices in the small intestine that flowed into the inferior epigastric vein. Our observations suggest that when obscure GIB is detected in patients with either cirrhosis or post-surgical history including incisional hernia, it is essential to acquire multilanar reconstruction images and volume-rendered 3-dimensional reconstruction of computed tomography scans to investigate the complex venous supply and optimize decisions for therapy.

Procalcitonin levels predict to identify bacterial strains in blood cultures of septic patients.

BACKGROUND: We examined whether the values obtained from principal component analysis (PCA) on laboratory tests can be used to predict bacterial infections and identify bacterial strains in blood culture (BC). METHOD: This study is a single-center retrospective analysis of 315 patients suspected of having sepsis. We applied PCA on procalcitonin (PCT) and laboratory test biomarkers, namely, platelet (PLT), white blood cell, and C-reactive protein (CRP) as well as BC. RESULTS: Principal component analysis showed that PCT, CRP, and PLT contributions to component 1 were associated with bacterial infection. The number of patients who had BC-negative results, gram-positive cocci (GPC), and gram-negative rods (GNRs) were 124, 28, and 19, respectively. The mean value of component 1 in GNR-positive patients was 1.58±1.41 and was significantly higher than that in GPC-positive patients (0.28±0.87; P<.0001). Furthermore, the mean values of component 1 in both GNR- and GPC-positive patients were significantly higher than that in BC-negative patients (-0.31±0.65; P<.0001 and P<.002, respectively). One certain range showing higher value more than 2.00 for component 1 and -1.00 for component 2 only included GNR-positive patients. There were no BC-positive patients who showed less than -1.00 for component 1. CONCLUSION: The present results obtained by PCA on laboratory tests involving PCT, PLT, white blood cell, and CRP suggest the potential of PCA-obtained values to not only predict bloodstream infection but also identify bacterial strains. This provides some clinical significance in the management of sepsis in acute care.

Resuscitative endovascular balloon occlusion of the aorta for uncontrollable nonvariceal upper gastrointestinal bleeding.

BACKGROUND: Although resuscitative endovascular balloon occlusion of the aorta (REBOA) in various clinical settings was found to successfully elevate central blood pressure in hemorrhagic shock, this intervention is associated with high mortality and may represent a last-ditch option for trauma patients. We conducted a retrospective study of patients with nonvariceal upper gastrointestinal bleeding (UGIB) who underwent REBOA to identify the effectiveness of REBOA and reviewed published literatures. METHODS: REBOA were performed by trained acute care physicians in the emergency room and intensive care unit. The deployment of balloon catheters was positioned using ultrasonography guidance. Collected data included clinical characteristics, hemorrhagic severity, blood cultures, metabolic values, blood transfusions, REBOA-related complications and mortality. A literature search using PUBMED to include "aortic occlusion" and "gastrointestinal bleeding" was conducted. RESULTS: REBOA was attempted in eight patients among 140 patients with UGIB and median age was 66 years. Systolic blood pressure significantly increased after REBOA (66 ± 20 vs. 117 ± 45 mmHg, p < 0.01) and the total occlusion time of REBOA was 80 ± 48 min. Strong positive correlations were found between total occlusion time of REBOA and lactate concentration (Spearman's r=0.77), clinical Rockwall score (Spearman's r=0.80), and age (Spearman's r=0.88), respectively. CONCLUSION: REBOA can be performed with a high degree of technical success and is effective at improving hemodynamic in patients with UGIB. Correlations between total occlusion time and high lactate levels, clinical Rockall score, and age may be important for successful use of REBOA.

Middle latency auditory-evoked potential index monitoring of cerebral function to predict functional outcome after emergency craniotomy in patients with brain damage.

BACKGROUND: At present, no satisfactory reports on the monitoring of cerebral function to predict functional outcomes after brain damage such as traumatic brain injury (TBI) and stroke. The middle latency auditory-evoked potential index (MLAEPi) monitor (aepEX plus®, Audiomex, UK) is a mobile MLAEP monitor measuring the degree of consciousness that is represented by numerical values. Hence, we hypothesized that MLAEPi predicts neurological outcome after emergency craniotomy among patients with disturbance of consciousness (DOC), which was caused by brain damage. METHODS: The afore-mentioned patients who underwent emergency craniotomy within 12 h of brain damage and were subsequently monitored using MLAEPi were enrolled in this study. DOC was defined as an initial Glasgow Coma Scale score < 8. MLAEPi was measured for 14 days after craniotomy. Neurological outcome was evaluated before discharge using a cerebral performance category (CPC) score and classified into three groups: favorable outcome group for a CPC score of 1 or 2, unfavorable outcome group for a score of 3 or 4, and brain dead (BD) group for a score of 5. RESULTS: Thirty-two patients were included in this study (17 with TBIs and 15 with acute stroke). Regarding outcome, 10 patients had a favorable outcome, 15 had an unfavorable outcome, and 7 were pronounced BD. MLAEPi was observed to be significantly higher on day 5 than that observed immediately after craniotomy in cases of favorable or unfavorable outcome (63 ± 3.5 vs. 36 ± 2.5 in favorable outcome; 63 ± 3.5 vs. 34 ± 1.8 in unfavorable outcome). MLAEPi was significantly lower in BD patients than in those with a favorable or unfavorable outcome on day 3 (24 ± 4.2 in BD vs. 52 ± 5.2 and 45 ± 2.7 in favorable and unfavorable outcome, respectively) and after day 4. MLAEPi was significantly higher in patients with a favorable outcome than in those with a favorable or unfavorable outcome after day 6 (68 ± 2.3 in favorable outcome vs. 48 ± 2.3 in unfavorable outcome). CONCLUSION: We believe that MLAEPi satisfactorily denotes cerebral function and predicts outcomes after emergency craniotomy in patients with DOC, which was caused by acute brain damage.

Anti-NMDAR encephalitis: case report and diagnostic issues.

Case: A 20-year-old woman developed acute psychotic symptoms and altered level of consciousness. She presented with neck stiffness, tremulous arms, facial dyskinesia, and distension of the lower abdomen. Pelvic magnetic resonance imaging showed bilateral ovarian teratomas. Anti-N-methyl-D-aspartate receptor antibodies were detected in her cerebrospinal fluid. Outcome: Resection of the tumors and immunotherapy were carried out. She gradually recovered and was discharged with few neurological deficits on the 105th day of hospitalization. Conclusion: Our survey of 63 previous reports describing 92 cases revealed that 21.7% of the patients were sent to emergency departments and 59.8% of the patients were managed in intensive care units. Emergency physicians and intensivists should be aware of this disorder, as they may encounter undiagnosed disorders in patients with epileptic attacks, acute psychotic signs, dyskinesia, or hypoventilation in the course of the illness.

Prediction of blood culture results by measuring procalcitonin levels and other inflammatory biomarkers.

BACKGROUND: It would be helpful if we could predict positive or negative blood culture results. This study considered the usefulness of measuring procalcitonin (PCT) level and standard clinical biomarkers such as white blood cell (WBC) count, C-reactive protein (CRP) level, and platelet (PLT) count to predict blood culture results. METHOD: We retrospectively analyzed the data from 422 specimens collected at our emergency center within the preceding 36 consecutive months. Primary component analysis (PCA) was used for detecting the degree of the relational contribution of each of the 4 biomarkers to the blood culture results. RESULTS: Procalcitonin alone (cut-off value, 0.5 ng/mL) yielded a positive blood culture rate of 34.0%. Procalcitonin plus 3 biomarkers (WBC, CRP, and PLT) analyzed by PCA yielded 45.9% or 35.3% when a case was in the first or fourth quadrant, which was significantly higher than cases in the second or third quadrant. Primary component analysis also revealed that positive blood culture results were mainly affected by primary component 1, to which PCT and PLT (not WBC or CRP) predominantly contribute. CONCLUSION: Although it is difficult to predict blood culture results, even using 4 biomarkers analyzed by PCA, our new finding that blood culture results are affected not by WBC and CRP, but mainly by PCT and PLT, might help explain the mechanism of sepsis.