Changing trends in the use of seizure prophylaxis after traumatic brain injury: a shift from phenytoin to levetiracetam.

PURPOSE: Current guidelines for traumatic brain injury (TBI) recommend antiepileptic drugs (AEDs) for 7 days after injury to decrease posttraumatic seizure risk. Phenytoin decreases seizure risk 73% vs placebo during this time. Levetiracetam (LEV) is an alternative; however, no published data validate comparable efficacy. Our objective was to evaluate seizure incidence 7 days after TBI in patients treated with phenytoin (PHT) vs LEV and to characterize practice of AED selection. METHODS: A retrospective observational study was conducted using a Trauma Registry (Collector Trauma Registry; Digital Innovation, Inc, Forrest Hill, Md) to evaluate patients with TBI. Patients with an initial Head/Neck Abbreviated Injury Scale score of 3 or higher and a Glasgow Coma Scale of 8 or less were included. RESULTS: Of 109 patients, 89 received PHT, and 20, LEV. Two patients experienced posttraumatic seizure, 1 in each group. Sixty-eight patients survived to hospital discharge; 65% received prophylactic AED greater than 7 days. Ninety-eight percent of 81 patients admitted between 2000 and 2007 received PHT, whereas 64% of 28 patients admitted between 2008 and 2010 received LEV. CONCLUSION: Only 2 patients experienced posttraumatic seizure after receiving AED, indicating low incidence. Most surviving to hospital discharge received AED prophylaxis greater than 7 days despite guideline recommendations. After approval of intravenous LEV, a trend favoring LEV was observed.

Sleep rounds: a multidisciplinary approach to optimize sleep quality and satisfaction in hospitalized patients.

BACKGROUND: Poor sleep has adverse affects on heath, yet few studies have addressed the goal of improving sleep among hospitalized patients. We evaluated the effectiveness of a sleep-promoting intervention on the quality and quantity of sleep among inpatients. METHODS: This study was conducted on a neurological ward in a large, tertiary care hospital. Sleep quality, quantity, and disruptors were assessed using questionnaires completed by patients during their hospital stay and Press Ganey surveys completed retrospectively. Room noise was also measured using noise meters. Data from each of 4 chronological phases of the study (baseline, basic intervention, "washout," and deluxe intervention) were analyzed. In the intervention phases, nurses conducted "Sleep Rounds" at bedtime, during which sleep-promoting practices were implemented, including lights out, television off, temperature adjustment, and a final restroom usage. RESULTS: Patients reported 5 (interquartile range [IQR] 3) hours of sleep per night, awoke 3 (IQR 3) times nightly, and reported a median sleep latency of 11 to 15 minutes. Pain, staff interruptions, and roommates were the most significant barriers to good sleep. Noise levels were adequately low (35-40 dB) at night but were not positively impacted by our sleep-promoting interventions. Patients perceived noise on the unit to be worse during phases of the study in which there was no intervention. CONCLUSIONS: Patient perception of sleep experience improved during the phases in which Sleep Rounds were implemented, despite the fact that there was no measurable improvement in sleep or sleep-disrupting factors.

The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists.

BACKGROUND: Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences. METHODS: An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training. RESULTS: The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care. CONCLUSION: Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.

Paroxysmal kinesigenic dyskinesias and pseudohypo-parathyroidism type Ib.

Pseudohypoparathyroidism is a rare cause of paroxysmal dyskinesias. We describe an otherwise well 10-year-old girl who was diagnosed with pseudohypoparathyroidism type Ib after presenting with involuntary movements of the hands and feet that occurred while running or walking. Magnetic resonance imaging of the brain indicated T(1) hyperintensities of the bilateral basal ganglia. A computed tomography scan of the head revealed diffuse cerebral calcifications, most prominent in the basal ganglia. Treatment with calcitriol and calcium carbonate led to a complete resolution of her signs. We recommend that hypoparathyroidism always be considered in patients with kinesigenic paroxysmal dyskinesias, especially insofar as it is a treatable disorder.