Early identification of NORSE and transfer to care setting with appropriate supports: A proposed algorithm.

New-onset refractory status epilepticus (NORSE) is a clinical presentation where an individual develops refractory status epilepticus without active epilepsy, or related neurological conditions. A subset of these individuals has a preceding fever and would be diagnosed with febrile infection-related epilepsy syndrome (FIRES). The underlying etiology of this condition varies and includes autoimmune and viral encephalitides. These conditions require multiple specialized health care teams working collaboratively and specific resources for investigation of the underlying etiology and management to provide optimal patient care. In this paper, we provide: (1) recommendations upon early recognition of NORSE and FIRES, (2) guidance on the resources needed to optimally provide care, and (3) guidance on considerations to initiate transfer of patients to a more specialized medical center. Additional recommendations for resource-austere centers without the ability to transfer such patients are also discussed. These recommendations are only for adult patients with NORSE as pediatric patients may require additional special considerations.

The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'?

RATIONALE: Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis. METHODS: The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential. RESULTS: The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables. LIMITATIONS: The analysis suggests associations not causality. CONCLUSION: The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.

Discharge Destination from a Rehabilitation Unit After Acute Ischemic Stroke.

BACKGROUND: We reviewed numerous variables for ischemic stroke patients admitted to a rehabilitation unit to determine those that were statistically associated with discharge destination. METHODS: A retrospective chart review of patients with ischemic stroke discharged from the rehabilitation unit between January 1, 2005 and December 31, 2015. Variables were examined for their association with discharge destination (home versus long-term care (LTC)). Univariable relationships with discharge destination were assessed, and a multivariable logistic regression model was built. RESULTS: Univariate predictors of discharge to LTC: advanced age, decreasing admission and discharge functional independence measure (FIM) scores, increasing change in FIM score from admission to discharge, dependency, residence outside of home before the stroke, absence of a caregiver, urinary and bowel incontinence, low Berg balance score at admission and discharge, low Montreal Cognitive Assessment scores, smoking, chronic heart failure, and an inability to transfer. Multivariable logistic regression: five factors remained significant predictors with LTC disposition: advanced age, bowel incontinence, residence outside of the home prior to stroke, right hemisphere site of the stroke, and absence of a caregiver. CONCLUSIONS: Several easily measured variables were significantly associated with discharge to LTC versus home following stroke rehabilitation.

Algorithm for Quantifying Frontal EMG Responsiveness for Sedation Monitoring.

INTRODUCTION: To study stimulation-related facial electromyographic (FEMG) activity in intensive care unit (ICU) patients, develop an algorithm for quantifying the FEMG activity, and to optimize the algorithm for monitoring the sedation state of ICU patients. METHODS: First, the characteristics of FEMG response patterns related to vocal stimulation of 17 ICU patients were studied. Second, we collected continuous FEMG data from 30 ICU patients. Based on these data, we developed the Responsiveness Index (RI) algorithm that quantifies FEMG responses. Third, we compared the RI values with clinical sedation level assessments and adjusted algorithm parameters for best performance. RESULTS: In patients who produced a clinically observed response to the vocal stimulus, the poststimulus FEMG power was 0.33 µV higher than the prestimulus power. In nonresponding patients, there was no difference. The sensitivity and specificity of the developed RI for detecting deep sedation in the subgroup with low probability of encephalopathy were 0.90 and 0.79, respectively. CONCLUSION: Consistent FEMG patterns were found related to standard stimulation of ICU patients. A simple and robust algorithm was developed and good correlation with clinical sedation scores achieved in the development data.

Application of subhairline EEG montage in intensive care unit: comparison with full montage.

PURPOSE: Problems with the availability of standard EEG monitoring in the intensive care unit have led to the use of recordings that have limited spatial coverage. We studied the performance of limited coverage EEG compared with more traditional full-montage EEG. METHODS: Continuous EEG recordings were performed on 170 patients using the full-montage 10-20 placement of electrodes as a reference recording and an abbreviated montage of electrodes applied below the hairline (subhairline). Recordings were reviewed independently, with the identity of the patients concealed. RESULTS: Seizures were found in 8% of patients. Sensitivity for detecting patients with seizures using the subhairline system was 0.54 [95% confidence interval (95% CI), 0.29-0.77] with specificity of 1.00 (95% CI, 0.97-1.00) and positive predictive value of 1.00 (95% CI, 0.65-1.00). For detecting interictal epileptiform activity, we found sensitivity to be 0.60 (95% CI, 0.46-0.74), specificity to be 0.94 (95% CI, 0.88-0.97), and positive predictive value to be 0.81 (95% CI, 0.65-0.91). Performance was poor for triphasic waves, alpha/theta/spindle coma, and suppression. CONCLUSIONS: The subhairline montage shows excellent specificity for detecting patients with seizure activity but has limited sensitivity. It has relatively poor performance for other EEG phenomena, but further applications in trending and assessing reactivity should be assessed in further studies.

Traumatic encephalopathy.

Traumatic brain injury is the leading cause of death and disability among young adults. Clinical evaluation is of limited value in the assessment of patients with traumatic brain injury and is often inaccurate in determining the extent of brain damage. Neurophysiological techniques and neuroimaging can provide valuable prognostic information and are useful in monitoring for seizures and other causes of secondary brain damage and in tracking the effects of therapy. More recently, cognitive electrophysiology and functional magnetic resonance imaging have shown that many patients clinically deemed to be in vegetative or in minimally conscious states are, in fact, aware. This opens new frontiers for further research into establishing communication with otherwise unresponsive patients.