A comprehensive analysis of the triad of frailty, aging, and obesity in spine surgery: the risk analysis index predicted 30-day mortality with superior discrimination.

BACKGROUND CONTEXT: The United States has experienced substantial shifts in its population dynamics due to an aging population and increasing obesity rates. Nonetheless, there is limited data about the interplay between the triad of frailty, aging, and obesity. PURPOSE: To investigate discriminative thresholds and independent associations of the Risk Analysis Index (RAI), Modified Frailty Index-5 (mFI-5), and greater patient age. STUDY DESIGN: An observational retrospective cohort study. PATIENT SAMPLE: We analyzed 49,754 spine surgery patients from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. OUTCOME MEASURE: A total of 30-day postoperative mortality. METHODS: Using receiver operating characteristic (ROC) and multivariable (odds ratios [OR] and 95% confidence intervals [CI]) analyses, we compared the discriminative thresholds and independent associations of RAI, mFI-5, and greater patient age in elderly obese patients who underwent spine surgery. RESULTS: There were 49,754 spine surgery patients, with a median age of 71 years (IQR: 68-75), largely white (82.6%) and male (51.9%). The ROC analysis for 30-day postoperative mortality demonstrated superior discrimination for RAI (C-statistic 0.779, 95%CI 0.54-0.805) compared to mFI-5 (C-statistic 0.623, 95% CI 0.594-0.651) and greater patient age (C-statistic 0.627, 95% CI 0.598-0.656). Multivariable analyses revealed a dose-dependent association and a larger effect magnitude for RAI: frail patients OR: 19.52 (95% CI 18.29-20.82) and very frail patients OR: 65.81 (95% CI 62.32-69.50). A similar trend was observed in the interaction evaluating RAI-age-obesity (p<.001). CONCLUSION: Our study highlights a strong association between frailty and 30-day postoperative mortality in elderly obese spine patients, revealing a dose-dependent relationship. The RAI has superior discrimination than the mFI-5 and greater patient age in predicting 30-day postoperative mortality after spine surgery. Using the RAI in preoperative assessments may improve outcomes and help healthcare providers effectively communicate accurate surgical risks and potential benefits, set realistic recovery expectations, and enhances patient satisfaction.

Neurocritical Care Aspects of Ischemic Stroke Management.

This article reviews the care of patients with ischemic stroke in the intensive care unit, including early general critical care interventions for airway control blood pressure goals according to the type of acute stroke treatment, poststroke cerebral edema management, hemorrhagic conversion in ischemic stroke, fibrinolytic reversal, and management of carotid endarterectomy and infective endocarditis. The importance of preventing common intensive care complications is discussed, including aspiration pneumonia, deep venous thrombosis, urinary tract infections, cardiac arrhythmias, and hyperglycemia.

Spreading Depolarization as a Therapeutic Target in Severe Ischemic Stroke: Physiological and Pharmacological Strategies.

BACKGROUND: Spreading depolarization (SD) occurs nearly ubiquitously in malignant hemispheric stroke (MHS) and is strongly implicated in edema progression and lesion expansion. Due to this high burden of SD after infarct, it is of great interest whether SD in MHS patients can be mitigated by physiologic or pharmacologic means and whether this intervention improves clinical outcomes. Here we describe the association between physiological variables and risk of SD in MHS patients who had undergone decompressive craniectomy and present an initial case of using ketamine to target SD in MHS. METHODS: We recorded SD using subdural electrodes and time-linked with continuous physiological recordings in five subjects. We assessed physiologic variables in time bins preceding SD compared to those with no SD. RESULTS: Using multivariable logistic regression, we found that increased ETCO2 (OR 0.772, 95% CI 0.655-0.910) and DBP (OR 0.958, 95% CI 0.941-0.991) were protective against SD, while elevated temperature (OR 2.048, 95% CI 1.442-2.909) and WBC (OR 1.113, 95% CI 1.081-1.922) were associated with increased risk of SD. In a subject with recurrent SD, ketamine at a dose of 2 mg/kg/h was found to completely inhibit SD. CONCLUSION: Fluctuations in physiological variables can be associated with risk of SD after MHS. Ketamine was also found to completely inhibit SD in one subject. These data suggest that use of physiological optimization strategies and/or pharmacologic therapy could inhibit SD in MHS patients, and thereby limit edema and infarct progression. Clinical trials using individualized approaches to target this novel mechanism are warranted.

Neurological Emergencies During Pregnancy.

This article serves as a comprehensive review of neurologic emergencies in pregnancy. Common initial presentations of neuroemergencies are reviewed with a clinical algorithm. Neurovascular disorders in pregnancy are reviewed, including acute ischemic strokes with data on tPA and thrombectomy; cerebral venous sinus thrombosis diagnosis and management; posterior reversible encephalopathy syndrome management; reversible cerebral vasoconstriction syndrome; and intracerebral hemorrhage. Attention is paid to management of cerebral edema and safety of osmotic therapies. A review of seizures in pregnancy is provided, including new-onset causes and decreased seizure thresholds. For status epilepticus, a low teratogenicity risk medication protocol in pregnancy is provided.

Lorazepam timing for acute convulsive seizure control (LoTASC).

INTRODUCTION: Guidelines specify early administration of benzodiazepines (BZD) for the management of convulsive status epilepticus. The distinction between acute convulsive seizure and status epilepticus can be misconstrued resulting in BZD administration prior to a patient meeting criteria of status epilepticus. Early BZD administration may theoretically lead to systemic vital instability. Our study aims to assess if administering lorazepam, for convulsive seizures <5 min, causes vital instability. METHODS: This is a retrospective study analyzing patients who presented with a seizure lasting <5 min between 2011 and 2016. Continuous variables of lorazepam receivers versus non- receivers were analyzed using t-test for parametric and Mann-Whitney U test for nonparametric data. Categorical variables were analyzed using Chi-Square Test. Subsequently, subjects were analyzed through univariate and multivariate regression models to determine predictors of vital instability. RESULTS: Out of 1052 subjects initially screened, 165 were included. Of these, 91 (55 %) received lorazepam, and 74 (45 %) did not. Through univariate and multivariate analyses, there was a significantly higher incidence of vital instability (defined as receipt of a vasopressor or intubation) in patients who received lorazepam (OR = 6.76, 95 % CI = 1.48, 30.95) (p = 0.014). This was dose-dependent (p < 0.0001). It was responsible for 22.5 % of the vital instability. Lorazepam administration significantly prolonged the intensive care unit (ICU) length of stay (0 days [IQR 0 - 0] vs [IQR 0-2.3]; p = 0.038). CONCLUSION: Our study suggests that lorazepam administration for acute convulsive seizures not meeting convulsive status epilepticus criteria may lead to iatrogenic vital instability and need for ICU admission.

Clinician's Perception of Practice Changes for Stroke During the COVID-19 Pandemic.

BACKGROUND: Approach to acute cerebrovascular disease management has evolved in the past few months to accommodate the rising needs of the 2019 novel coronavirus (COVID-19) pandemic. In this study, we investigated the changes in practices and policies related to stroke care through an online survey. METHODS: A 12 question, cross-sectional survey targeting practitioners involved in acute stroke care in the US was distributed electronically through national society surveys, social media and personal communication. RESULTS: Respondants from 39 states completed 206 surveys with the majority (82.5%) from comprehensive stroke centers. Approximately half stated some change in transport practices with 14 (7%) reporting significant reduction in transfers. Common strategies to limit healthcare provider exposure included using personal protective equipment (PPE) for all patients (127; 63.5%) as well as limiting the number of practitioners in the room (129; 64.5%). Most respondents (81%) noted an overall decrease in stroke volume. Many (34%) felt that the outcome or care of acute stroke patients had been impacted by COVID-19. This was associated with a change in hospital transport guidelines (OR 1.325, P = 0.047, 95% CI: 1.004-1.748), change in eligibility criteria for IV-tPA or mechanical thrombectomy (MT) (OR 3.146, P = 0.052, 95% CI: 0.988-10.017), and modified admission practices for post IV-tPA or MT patients (OR 2.141, P = 0.023, 95% CI: 1.110-4.132). CONCLUSION: Our study highlights a change in practices and polices related to acute stroke management in response to COVID-19 which are variable among institutions. There is also a reported reduction in stroke volume across hospitals. Amongst these changes, updates in hospital transport guidelines and practices related to IV-tPA and MT may affect the perceived care and outcome of acute stroke patients.

Initial experiences of US neurologists in practice during the COVID-19 pandemic via survey.

OBJECTIVE: To test the hypothesis that US neurologists were experiencing significant challenges with lack of personal protective equipment (PPE), rapid changes in practice, and varying institutional protocols, we conducted this survey study. The current coronavirus disease of 2019 (COVID-19) pandemic has caused widespread disease and death. Rapid increases in patient volumes have exposed weaknesses in health care systems and challenged our ability to provide optimal patient care and adequate safety measures to health care workers (HCWs). METHODS: A 36-item survey was distributed to neurologists around the United States through various media platforms. RESULTS: Over a 1-week period, 567 responses were received. Of these, 56% practiced in academia. A total of 87% had access to PPE, with 45% being asked to reuse PPE due to shortages. The pandemic caused rapid changes in practice, most notably a shift toward providing care by teleneurology, although a third experienced challenges in transitioning to this model. Wide variations were noted both in testing and in the guidance provided for the exposed, sick, or vulnerable HCWs. Notably, 59% of respondents felt that their practices were doing what they could, although 56% did not feel safe taking care of patients. CONCLUSIONS: Results from our survey demonstrate significant variability in preparedness and responsiveness to the COVID-19 pandemic in neurology, affected by region, health care setting, and practice model. Practice guidelines from professional societies and other national entities are needed to improve protection for physicians and their patients, promote recommended practice changes during a pandemic, and optimize future preparedness for public health emergencies.

Critical Care of Neuromuscular Disorders.

PURPOSE OF REVIEW: Weakness is a common reason patients are seen in neurologic consultation. This article reviews the differential diagnosis of neuromuscular disorders in the intensive care unit (ICU), discusses the intensive care needs and evaluation of respiratory failure in patients with neuromuscular disorders, and provides a practical guide for management. RECENT FINDINGS: Although primary neuromuscular disorders used to be the most common cause for weakness from peripheral nervous system disease in the ICU, a shift toward ICU-acquired weakness is observed in today's clinical practice. Therefore, determining the cause of weakness is important and may have significant prognostic implications. Guillain-Barré syndrome and myasthenia gravis remain the most common primary neuromuscular disorders in the ICU. In patients with myasthenia gravis, it is important to be vigilant with the airway and institute noninvasive ventilation early in the course of the disease to attempt to avoid the need for intubation. On the other hand, patients with Guillain-Barré syndrome should be intubated without delay if the airway is at risk to avoid further complications. In patients with ICU-acquired weakness, failure to wean from the ventilator is usually the challenge. Early mobility, glucose control, minimizing sedation, and avoiding neuromuscular blocking agents remain the only therapeutic regimen available for ICU-acquired weakness. SUMMARY: Critical care management of neuromuscular disorders requires a multidisciplinary approach engaging members of the ICU and consultative teams. Developing an airway management protocol could have implications on outcome and length of stay for patients with neuromuscular disorders in the ICU. Tending to the appropriate nuances of each patient who is critically ill with a neuromuscular disorder through evidence-based medicine can also have implications on length of stay and outcome.