Publications by authors named "Ali Seifi"

77 Publications

Stent retriever versus direct aspiration thrombectomy for acute large vessel occlusion: A meta-analysis including 17,556 patients, from MR CLEAN to present.

Clin Neurol Neurosurg 2022 Jan 10;213:107122. Epub 2022 Jan 10.

Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, TX, United States. Electronic address:

Objective: Stent retriever (SR) and direct aspiration (DA) mechanical thrombectomy (MT) improve clinical outcomes for stroke secondary to large vessel occlusion. The purpose is to perform an updated meta-analysis comparing the two techniques.

Methods: PubMed database was searched for studies between January 1, 2015, and July 5th, 2021 with mechanical thrombectomy to treat acute ischemic stroke.

Results: We identified 136 studies including 17,556 patients, with 11,258 (64.1%) patients treated by SR or a combined approach and 6298 (35.9%) patients with DA. The DA group had less posterior cerebral artery strokes, was significantly older, and had lower National Institutes of Health Stroke Scale scores (p = .05,.02,.04) There was no difference between groups in percentage of middle cerebral artery or internal carotid artery occlusions or intravenous tissue plasminogen activator administered (p = .62,.19,.06). A regression model showed no difference between SR and DA in mortality, symptomatic intracranial hemorrhage, and disability (mRS > 2) at 90 days (p = .13,.75,.84). Successful reperfusion (mTICI 2b/3 rates) were higher in the DA group (DA 87.6% vs SR 82.3%, p < .01), but after accounting for covariates was not significant (p = .17).

Conclusion: Our updated meta-analysis shows that DA has similar safety, reperfusion and 90-day clinical outcomes compared to SR. These results should serve to increase confidence in DA thrombectomy for acute ischemic stroke secondary to LVO.
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http://dx.doi.org/10.1016/j.clineuro.2022.107122DOI Listing
January 2022

Clinical outcomes of pharmacological thromboprophylaxis among patients with intracerebral hemorrhage: Systematic review and meta-analysis.

Clin Neurol Neurosurg 2022 Jan 2;212:107066. Epub 2021 Dec 2.

Division of Neuro Critical Care, Department of Neurosurgery, UT Health, San Antonio, TX, USA. Electronic address:

Objective: Efficacy and safety of pharmacologic thromboprophylaxis after an episode of intracerebral hemorrhage remains unclear. This meta-analysis aimed at comparing the clinical outcomes of intracerebral hemorrhage patients with or without pharmacologic thromboprophylaxis.

Methods: We performed a comprehensive literature review of PubMed to identified relevant studies. The primary and secondary endpoints included venous thromboembolism, deep venous thrombosis, pulmonary emboli, rebleeding, hematoma enlargement (defined as increase in hematoma volume of ≥33%), major disability (defined as modified Rankin score of 3-5), and death. Pooled outcomes were estimated by fitting random effects model with restricted maximum likelihood method. A total of 8 original studies including 3893 patients were analyzed.

Result: Compared to the control group, pharmacologic thromboprophylaxis was associated with a lower risk of pulmonary embolism (odds ratio [OR]: 0.34, 95% CI: 0.15-0.80, P = 0.01). There was no significant difference in the risk of DVT (OR: 0.75; [95% CI: 0.37-1.53], P = 0.44) and VTE (OR: 0.65; [95% CI: 0.34-1.25], P = 0.20). Finally, anticoagulation was not associated with an increase rate of major disability (OR:1.36; [95% CI: 0.57 - 3.23], P = 0.48), rebleeding (OR: 0.35; [95% CI: 0.10-1.19], P = 0.09), hematoma enlargement (OR:1.34; [95% CI: 0.58-3.12], P = 0.49), or death (OR:0.90; [95% CI: 0.68-1.19], P = 0.46).

Conclusion: Among patients with intracerebral hemorrhage, pharmacologic thromboprophylaxis was associated with a significant reduction in pulmonary embolism, without an increase in rebleeding or hematoma enlargement. The results of this meta-analysis need to be further validated in large scale clinical trials.
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http://dx.doi.org/10.1016/j.clineuro.2021.107066DOI Listing
January 2022

The pathophysiologic, diagnostic, and therapeutic aspects of posterior reversible encephalopathy syndrome during pregnancy.

J Matern Fetal Neonatal Med 2021 Dec 8:1-9. Epub 2021 Dec 8.

Division of Neuro Critical Care, Department of Neurosurgery, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA.

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition with a wide range of symptoms, including visual disturbances, headache, vomiting, seizures, and altered consciousness. This review describes the pathophysiology of PRES, as well as the clinical, diagnostic, and therapeutic intervention during pregnancy. The gold standard for diagnosis of PRES is Magnetic Resonance Imaging (MRI), helping to differentiate it from other similar conditions. The aim of this paper is to review the principal aspects of PRES, general care, blood pressure control, and seizures prevention while avoiding potential injuries to the mother and fetus in the event of pregnancy. We concluded that PRES can be effectively treated and reversed if prompt diagnostic action is made, and adequate care is initiated.
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http://dx.doi.org/10.1080/14767058.2021.2001454DOI Listing
December 2021

Paroxysmal sympathetic hyperactivity during traumatic brain injury.

Clin Neurol Neurosurg 2022 Jan 27;212:107081. Epub 2021 Nov 27.

Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA. Electronic address:

Traumatic brain injury (TBI) is one of the leading causes of disability, morbidity, and mortality worldwide. Some of the more common etiologies of TBI include closed head injury, penetrating head injury, or an explosive blast head injury. Neuronal damage in TBI is related to both primary injury (caused by mechanical forces), and secondary injury (caused by the subsequent tissue and cellular damages). Recently, it has been well established that Paroxysmal Sympathetic Hyperactivity (PSH), also known as "Sympathetic Storm", is one of the main causes of secondary neuronal injury in TBI patients. The clinical manifestations of PSH include recurrent episodes of sympathetic hyperactivity characterized by tachycardia, systolic hypertension, hyperthermia, tachypnea with hyperpnea, and frank diaphoresis. Given the diverse manifestations of PSH and its notable impact on the outcome of TBI patients, we have comprehensively reviewed the current evidence and discussed the pathophysiology, clinical manifestations, time of onset and duration of PSH during TBI. This article reviews the different types of head injuries that most commonly lead to PSH, possible approaches to manage and minimize PSH complications in TBI and the current prognosis and outcomes of PSH in TBI patients.
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http://dx.doi.org/10.1016/j.clineuro.2021.107081DOI Listing
January 2022

Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit.

World Neurosurg 2021 Nov 9. Epub 2021 Nov 9.

Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA. Electronic address:

Background And Objective: Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207).

Methods: Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge.

Results: Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes.

Conclusions: Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.
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http://dx.doi.org/10.1016/j.wneu.2021.11.004DOI Listing
November 2021

Evaluation of Cardiac Troponin and Adverse Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

Neurocrit Care 2021 Oct 22. Epub 2021 Oct 22.

Department of Neurosurgery and Neurology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.

Several studies have demonstrated the usefulness of cardiac troponin I (cTn) levels in predicting adverse clinical outcomes of patients with anerusmal subarachnoid hemorrhage (aSAH). However, it remains unclear whether cTn levels can be a useful factor in predicting adverse neurologic and cardiovascular outcomes regarding follow-up duration. The study aimed to evaluate the clinical value of cTn elevation among patients with aSAH. A systematic literature search was performed in PubMed and Cochrane to collect original studies that compared the adverse outcomes in patients with aSAH who had elevated cTn levels and those who did not have elevated cTn levels. Data on patient demographics and outcome measurements (mortality, major disability, delayed cerebral ischemia, cardiac dysfunction, and pulmonary edema) were extracted. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were computed by fitting a random effects model. A total of 4,117 patients with aSAH were included in the meta-analysis. Elevated cTn levels was associated with a higher all-cause mortality (OR 3.64; 95% CI 2.68-4.94; I = 22.05%), poor major disability (OR 2.27; 95% CI 1.5-3.37; I = 52.07%), delayed cerebral ischemia (OR 2.10; 95% CI 1.46-3.03; I = 13.80%), cardiac dysfunction (OR 9.20; 95% CI 4.31-19.60; I = 39.89), and pulmonary edema (OR 10.32; 95% CI 5.64-18.90; I = 0.00%). Additionally, elevated cTn levels was associated with higher mortality in prospective studies (OR 3.66; 95% CI 2.61-5.14) as well as when compared with studies with short-term and long-term follow-up periods. Patients with aSAH who had elevated cTn levels also tended to experience poor short-term major disability (OR 2.36; 95% CI 1.48-3.76). Among patients with aSAH, elevated cTn levels was associated with higher mortality and adverse neurologic and cardiovascular outcomes. Given its clinical value, cardiac troponin levels may be included in the assessment of patients withs aSAH.
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http://dx.doi.org/10.1007/s12028-021-01368-0DOI Listing
October 2021

Physicians-in-Training: From Digital Devices to Digital Amnesia.

South Med J 2021 09;114(9):577-578

From the Departments of Neurosurgery and Family and Community Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA and McMaster University, Hamilton, Ontario, Canada.

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http://dx.doi.org/10.14423/SMJ.0000000000001296DOI Listing
September 2021

The Rothman Index Does Not Predict a Successful Extubation in the Neurosurgical Critical Care Unit.

Cureus 2021 Jul 12;13(7):e16339. Epub 2021 Jul 12.

Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

Background Identification of risk factors associated with successful extubation in neurosurgical critical care units (NSICUs) has been elusive due to the complex nature of neurocritical care injuries and patient factors. Traditional risk factors for extubation were shown to have poor predictive value in neurocritical care patients as compared to mixed ICU patients. The aim of this study was to determine if any risk factors, including the Rothman Index, could reliably predict successful extubation in a large sample size of neurocritical care patients. Methods We retrospectively analyzed 610 consecutively intubated patients in an NSICU while collecting variables of interest in airway management. Furthermore, Rothman Indices were collected immediately after intubations and extubations. A paired t-test of the immediate changes in Rothman Indices after airway manipulation was compared in patients who needed reintubation. In a smaller cohort of 88 patients, in whom complete data points existed for airway management, we performed a principal component analysis (PCA) to determine which risk factors were associated with extubation success when indexed with the magnitude of the Rothman Index. Results In 610 consecutively intubated patients, the mean pre-intubation Rothman Index average was 41.0 compared to the mean post-extubation Rothman Index was 35.4 (p<0.0001). Compared to those who were re-intubated, the Rothman Index did not correlate well with the prediction of extubation (p=0.355). Furthermore, an analysis of the PCA plot showed that a higher respiratory rate, longer length of stay, shorter length of intubation, and smaller cuff leak percentage were identified as risk factors associated with reintubation. Age and change in rapid shallow breathing index (RSBI) did not correlate with reintubation. Conclusion The Rothman Index does not predict extubation success in patients in an NSICU. Risk factors associated with reintubation were respiratory rate, length of stay, length of intubation, and cuff leak percentage. Reintubation rates in our single-center NSICU are on par with general critical care populations.
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http://dx.doi.org/10.7759/cureus.16339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357080PMC
July 2021

Thrombolysis for stroke in elderly in the late window period.

Acta Neurol Scand 2021 Dec 27;144(6):663-668. Epub 2021 Jul 27.

Departments of Neurology and Neurosurgery, University of Cincinnati Medical Center, Cincinnati, OH, USA.

Objectives: Safety of intravenous thrombolysis (IVT) within 3-4.5 hours of stroke onset in patients ≥80 years is still disputable. We evaluated the association of symptom onset-to-treatment time (SOTT) with the symptomatic intracranial hemorrhage (sICH), poor outcome, and mortality in patients≥80 years.

Materials And Methods: In a retrospective study, patients treated with IVT following stroke were registered. Outcomes were poor outcome (mRS>2), sICH/ECASS-2, and in-hospital mortality. We compared the patients≥80 years who received IVT within 3 hours with those receiving IVT within 3-4.5 hours. We further compared the patients who were <80 years with those ≥80 years and SOTT of 3-4.5 hours.

Results: Of 834 patients, 265 aged over 80. In those above 80 and in multivariable analysis, the associations of SOTT with poor outcome (aOR: 1.401, CI: 0.503-3.903, p=0.519), sICH (aOR=2.50, CI=0.76-8.26, p= 0.132) and mortality (aOR=1.12, CI=0.39-3.25, p= 0.833) were not significant. 106 patients received IVT within 3-4.5 hours. In multivariable analysis, the associations of age (≥80 versus <80) with poor outcome (aOR=1.87, CI=0.65-5.37, p=0.246), sICH (aOR=0.65, CI=0.14-3.11, p=0.590), and mortality (aOR=0.87, 95% CI=0.16-4.57, p=0.867) were not significant in patients with SOTT of 3-4.5 hours.

Conclusion: IVT within 3-4.5 hours in patients ≥80 years is not associated with increased sICH, poor outcome, and mortality compared to the early time window, and also compared to the younger patients in 3-4.5 hours window period. The decision of IVT administration in this age group should not be made solely on the basis of stroke onset timing.
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http://dx.doi.org/10.1111/ane.13512DOI Listing
December 2021

Evaluation of the Forced Inspiratory Suction and Swallow Tool to Stop Hiccups.

JAMA Netw Open 2021 06 1;4(6):e2113933. Epub 2021 Jun 1.

Department of Neurosurgery, Division of Neurocritical Care, University of Texas Health Science Center at San Antonio.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.13933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214157PMC
June 2021

Hispanic ethnicity and in-hospital morbidity and mortality outcomes in Alzheimer's Disease: A U.S. National Study 2005-2015.

Clin Neurol Neurosurg 2021 08 8;207:106753. Epub 2021 Jun 8.

Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address:

Background: Hispanics are one of the largest and fastest-growing population in the United States. Having been reported as one of the high-risk ethnicities to develop Alzheimer's Disease (AD) makes elder Hispanics one of the significant groups of AD in the country, indicating a need to study the disparities in Hispanics vs. non-Hispanics patients. We aimed to determine the prevalence, morbidity, and mortality outcomes of AD in Hispanics.

Methods: We surveyed Healthcare Cost and Utilization Project (HCUP) from 2005 to 2015 to identify patients older than 50 years who were admitted for any reason and had AD diagnosis. Prevalence, demographics, age brackets, in-hospital deaths, disease severity, and hospital length of stay (LOS) were compared between the Hispanics and Non-Hispanics.

Results: Among 14,135,560 Hispanic discharges, 2.76% had AD, compared with 207,515,260 discharges in Non-Hispanic with 2.61% AD, p < 0.001. Hispanics had significantly more AD in all age brackets, especially over 90 years of age, p < 0.001. A significantly higher prevalence of AD in both Hispanic Females (3.27% vs. 3.10%) and Males (2.17% vs. 2.04%) was noticed, p < 0.001. In northeast and south regions of the country and urban hospitals, AD was more among Hispanics (p < 0.001). Hispanic patients were younger (81.8 ± 7.77 vs. 82.6 ± 7.50, p < 0.001), had longer LOS (6.41 ± 7.72 vs. 6.08 ± 7.05, p < 0.001), had higher hospital charges ($45,989 vs. $37,688, p < 0.001). Hispanic AD patients had higher disease severity and mortality risk (p < 0.001). However, the inpatient mortality was not different between the Hispanic and non-Hispanics. Multivariate analysis showed that Hispanics had the highest AD prevalence in the inpatient setting (OR, 1.38; 95% CI, 1.37-1.39, p < 0.001).

Conclusion: The prevalence of AD was significantly higher in inpatient Hispanics than non-Hispanics. Hispanic AD patients had a younger age compared with non-Hispanic AD. Disease severity and mortality risks were higher in Hispanics with AD than non-Hispanics with AD. However, no difference was seen in mortality rate during admission in Hispanics vs. non-Hispanics.
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http://dx.doi.org/10.1016/j.clineuro.2021.106753DOI Listing
August 2021

Neurological and Systemic Manifestations of Severe Scorpion Envenomation.

Cureus 2021 Apr 27;13(4):e14715. Epub 2021 Apr 27.

Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

Scorpion envenomation is a life-threatening toxicological emergency and considered as a major public health problem, especially in endemic regions (India, Africa, Latin America); it is generally characterized by low resources and tropical or subtropical weather. Scorpion envenomation is especially fatal in the first hours, usually due to respiratory and/or cardiovascular collapse. The neurologic manifestations, triggered by multiple neurotoxic mechanisms, are varied and complex and mostly reported in children. The aim of this review is to clarify the epidemiologic characteristics and clinical manifestations as well as diagnosis and management of neurologic complications following scorpion envenomation. The management of patients with severe clinical forms is based on early recognition of the sting, antivenom serum administration, and cardiorespiratory and systemic support.
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http://dx.doi.org/10.7759/cureus.14715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8158070PMC
April 2021

Neurologic Compromise in COVID-19: A Literature Review.

J Neurol Res 2020 Oct 4;10(5):164-172. Epub 2020 Sep 4.

Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, TX, USA.

Coronavirus disease 2019 (COVID-19) disease caused by a new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been associated with many neurological symptoms. The purpose of this article is to describe the neurological manifestations so far reported and their probable pathogenesis. We conducted a literature review on EMBASE, MEDLINE and SCIELO databases using the terms "COVID-19", "COVID", "neurological", "neurologic", "manifestations", "implications", "Guillain-Barre syndrome", "encephalopathy". A total of 33 articles including clinical series, retrospective studies, and case reports were selected and thoroughly reviewed to describe neurological manifestations of COVID-19. There are several neurological manifestations of SARS-CoV-2 infection with different clinical presentations, severity, and prevalence. The most critical ones, such as cerebrovascular disease, encephalopathy, and Guillain-Barre syndrome, were less common and usually associated with previous medical history, known risk factors for cerebrovascular disease or advanced age. The main hypotheses for the spread of the virus are through the hematogenous route or the cribriform plate of the ethmoid bone or a disseminated severe immune response by a cytokine storm. The presence of neurological disturbances associated with laboratory tests alterations is an important clue for the physicians to promptly recognize neurological manifestations of SARS-CoV-2.
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http://dx.doi.org/10.14740/jnr619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040461PMC
October 2020

Fewer Hospital Visits for Acute Stroke and Acute Coronary Syndrome During the COVID-19 Pandemic: A Reality or a Myth?

J Neurol Res 2020 Jun 1;10(3):53-55. Epub 2020 Jun 1.

Stroke Program, Department of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.

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http://dx.doi.org/10.14740/jnr601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040453PMC
June 2020

Psychological Implications of Mandatory Testing for Severe Acute Respiratory Syndrome Coronavirus 2 During the Global COVID-19 Pandemic.

J Neurol Res 2020 Dec 9;10(6):207-208. Epub 2020 Dec 9.

Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.

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http://dx.doi.org/10.14740/jnr634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040458PMC
December 2020

The History of Epilepsy: From Ancient Mystery to Modern Misconception.

Cureus 2021 Mar 17;13(3):e13953. Epub 2021 Mar 17.

Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

Epilepsy is an ancient disease, which has fascinated and frightened scientists and laymen alike. Before the working knowledge of the central nervous system, seizures were shrouded in mystery. In antiquity, this disease was accredited to gods and demonic possession, causing those with epilepsy to be feared and isolated. Epilepsy patients continued to face discrimination through the mid-20th century. This discrimination ranged from lack of access to health insurance, jobs, and marriage equality to forced sterilizations. Despite the strides that have been made, there are still many misconceptions globally regarding epilepsy. Studies show that patients with epilepsy in communities that understand the pathology and cause of seizures are generally more successful in social and educational environments. While there has been progress, there is more work which needs to be done to educate people across the globe about the pathology of epilepsy.
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http://dx.doi.org/10.7759/cureus.13953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051941PMC
March 2021

Primary payer status in patients with seizures: A nationwide study during 1997-2014 in the United States.

Epilepsy Res 2021 Jul 5;173:106501. Epub 2021 Mar 5.

Department of Neurology and Neurosurgery, UT Health Science Center, San Antonio, TX, United States. Electronic address:

Objective: In countries where health coverage is not universal, there is ample evidence of disparities in healthcare, often associated with insurance. People with seizures, similar to those living with any complicated chronic medical comorbidity, need further health-related attention to improve their quality-of-life outcomes.

Methods: We conducted a retrospective cohort study of the National Inpatient Sample (NIS) component of the Healthcare Cost and Utilization Project (HCUP) national database between 1997-2014. The analysis focused on the mortality rate, and patients with a principal admission diagnosis of seizure at the time of discharge were identified. Primary Payer Status (PPS) included Medicare, Medicaid, private, and uninsured. Multivariate linear regression modeling was conducted to examine the contribution of the predictive variables to in-hospital mortality.

Results: Between 1997-2014, 4,594,213 seizure-related discharges was recorded. The overall mean patient age was 41.69 ± 0.98 years, and 58.1 % were female. The average age during this period decreased significantly in Medicare, increased substantially in uninsured, without significant change in Medicaid and private. Patients in Medicare had the highest length of stay (LOS) (4.49 ± 0.29 days), and uninsured (2.79 ± 0.15) had the least. Over time, there was a significant increase in the number of seizure discharges in Medicare, Medicaid, and private insurance. However, there was a significant decrease in in-hospital mortality in Medicare, Medicaid, and private, with the most prominent decline in Medicare. Risk-adjusted for age, gender, LOS, illness severity, and time, regression results showed Medicare has a significantly higher association with less in-hospital mortality compared with other insurances.

Conclusions: Our study showed a significant increase in the number of seizure diagnoses at discharge in Medicare, Medicaid, and private in the United States between 1997-2014; however, there was a decrease in the in-hospital mortality rate across all insurance payers. Uninsured patients had the highest mortality rate after Medicare without risk justification. Risk-stratified models confirmed Medicare was significantly associated with a less in-hospital mortality rate.
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http://dx.doi.org/10.1016/j.eplepsyres.2020.106501DOI Listing
July 2021

Resolution of cryptogenic new onset refractory status epilepticus with tocilizumab.

Epilepsy Behav Rep 2021 4;15:100431. Epub 2021 Feb 4.

Departments of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States.

New onset refractory status epilepticus (NORSE) was defined by the International League Against Epilepsy as occurring in patients presenting without a prior diagnosis of epilepsy or other neurological disease, with seizures that persist beyond 24 h. There is still a need to develop new treatment strategies for NORSE, particularly for those patients who are least responsive to conventional medical therapies. We present a case of a young female patient without any medical history presenting with status epilepticus, which was refractory not only to anti-seizure medications and anesthetics, but also to conventional immunomodulatory therapies. After nine weeks of electroclinical seizure activity, the patient responded to two doses of tocilizumab.
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http://dx.doi.org/10.1016/j.ebr.2021.100431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972955PMC
February 2021

Hospital Outcomes in Uninsured Patients With Disease and Disorders of Nervous System: A National Cohort Study During a Decade in the United States.

Cureus 2021 Mar 4;13(3):e13702. Epub 2021 Mar 4.

Department of Epidemiology and Public Health, Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, IRN.

Objectives Health insurance is associated with better outcomes in the admitted patient population, even after adjusting for other factors such as race and socioeconomic status. However, the literature is limited on the relationship between insurance status and hospital outcomes in patients hospitalized with the disease of nervous system. Methods This cross-sectional study used the Nationwide Inpatient Sample (NIS) database to achieve the results. All Major Diagnostic Category (MDC) codes from patients discharged for disease and disorders of nervous system between the years 2005 to 2014 were queried and analyzed for the impact of lack of insurance on patient outcome. Results Among 4,737,999 discharges, 5.6% had no insurance. The hospital mortality rate among uninsured and insured patients was 4.1% and 3.7%, respectively (P<0.001). In the multivariate analysis, hospital mortality of uninsured patients was higher in the elderly (aOR: 4.74[CI:4.52-4.97], P<0.001), those with comorbidities (aOR: 2.23[CI:2.18-2.27], P<0.001), Asians (aOR: 1.16[CI:1.12-1.20]. P<0.001), in rural areas (aOR: 1.44[ 95%CI:1.41-1.48], P<0.001) and those in the lowest household income quartile (aOR: 1.03[CI:1.01-1.05], P<0.001). The average length of stay (LOS) was shorter for the uninsured (4.79±8.26 vs 4.96±7.55 days, P<0.001). Conclusions The findings suggest that lack of health insurance is correlated with hospital mortality in patients hospitalized with disease and disorders of nervous system, with an increased disparity in vulnerable populations.
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http://dx.doi.org/10.7759/cureus.13702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935226PMC
March 2021

Intelligent Energy Management and Multi-Objective Power Distribution Control in Hybrid Micro-grids based on the Advanced Fuzzy-PSO Method.

ISA Trans 2021 Jun 13;112:199-213. Epub 2020 Dec 13.

Department of Power and Control Engineering, Shiraz University, Shiraz, Iran. Electronic address:

A micro-grid consisting of distributed generation resources (DGRs) with a hybrid energy storage system (HESS) composed of batteries and super-capacitors was studied. A control strategy based on the particle swarm optimization (PSO) and energy management algorithms was proposed to facilitate power distribution in the micro-grid and to improve the reliability, control levels, and penetration of micro-grids in the current electrical grids. The proposed operational strategy is based on the power predicted using the load profile and power generation resources. Energy management strategies were then presented by solving a multi-objective problem by the PSO algorithm and submitting the optimization results to the fuzzy controller and power distribution management (PDM) unit. The optimizer, the PDM unit, and the fuzzy controller provide a comprehensive operating procedure for the islanded and grid-connected micro-grids, taking into account their stability against grid fluctuations. In another part of this strategy, an auxiliary power control unit (APCU) was proposed for supporting the HESS and increasing the reliable performance of this unit. The proposed structure was applied to the net power (P) of the islanded and grid-connected micro-grids. The net power was divided into high-frequency (super-capacitor) and low-frequency (battery and APCU) components. The proposed algorithm and simulation results were analyzed using MATLAB/Simulink.
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http://dx.doi.org/10.1016/j.isatra.2020.12.027DOI Listing
June 2021

The persistent pandemic of violence against health care workers.

Am J Manag Care 2020 12 1;26(12):e377-e379. Epub 2020 Dec 1.

University of Texas Health Science Center at San Antonio, Mailbox 7483, San Antonio, TX 78229. Email:

Violence against health care workers is an ever-present threat that has been increasing over the past several years. The majority of physicians and nurses report that they have been victims of workplace violence at least once throughout their careers. Such violent attacks negatively affect the delivery, quality, and accessibility of health care. Certain factors such as substance abuse and intense emotions increase an individual's risk of committing an act of workplace violence against a health care worker. Encountering violent individuals has legal implications and can compromise the moral framework of physicians. With action from institution administrations, advocates, leaders, and government, this issue that detrimentally affects health care can be combatted and reduced. By implementing required staff training, increasing security, strengthening the doctor-patient relationship, using medical chaperones, and reforming policy, positive changes can be made to protect health care workers and the health care system.
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http://dx.doi.org/10.37765/ajmc.2020.88543DOI Listing
December 2020

Lost to Follow-Up: Complications of an Invasive Giant Prolactinoma.

Cureus 2020 Aug 15;12(8):e9763. Epub 2020 Aug 15.

Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, USA.

Invasive giant prolactinomas are a rare type of prolactin-secreting tumors. Most lactotroph adenomas, including giant prolactinomas, consist of the sparsely granulated subtype and respond well to medical therapy with dopamine agonists. Proptosis due to intra-orbital tumor extension and ischemic infarction are two rare complications associated with these tumors. We report a case of a 51-year-old woman with a 30-year history of a macroprolactinoma who was lost to follow-up and returned with severe proptosis, a 10-cm invasive sellar mass on imaging, and markedly elevated serum prolactin levels, consistent with invasive giant prolactinoma. She was initially managed with dopamine agonists followed by palliative debulking of the tumor, which microscopically demonstrated a highly proliferative neoplasm predominantly consisting of sparsely granulated lactotroph adenoma with a minor component of the rare and aggressive acidophil stem cell adenoma subtype. Postoperatively, she developed a large left middle cerebral artery infarct and ultimately died. This case is notable in that it demonstrates the aggressive nature of invasive giant prolactinomas when not treated and highlights two rare findings in patients with this tumor: orbital invasion and ischemic infarct.
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http://dx.doi.org/10.7759/cureus.9763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489779PMC
August 2020

Impact of Ruptured Aneurysm Circulation on Mortality: A Nationwide Inpatient Sample Analysis.

J Stroke Cerebrovasc Dis 2020 Oct 15;29(10):105124. Epub 2020 Jul 15.

Department of Neurosurgery, University of Texas Health at San Antonio, Texas, USA. Electronic address:

Objective: This study investigates the effect of aneurysm circulation on mortality and patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) within the United States.

Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization Project (HCUP), with ICD-10 codes for non-traumatic SAH between 2015-2016. Aneurysms were stratified as either anterior or posterior circulation. Multivariate logistic regression was used to find the impact of selected variables on the odds of mortality.

Results: The NIS reported 1,892 cases of non-traumatic SAH within the study period that were predominantly anterior circulation (82.6%), female (68.6%), white (57.7%), with mean age of 59.07 years, and in-hospital mortality of 21.4%. Anterior circulation aneurysms were associated with lower severity of initial illness (p = 0.014) but higher likelihood of vasospasm (p = 0.0006) than those of the posterior circulation. In a multivariate logistic regression analysis, mortality was associated with posterior circulation aneurysms (OR: 1.42; CI 95% 1.005-20.10, p = 0.047), increasing age (OR: 1.035; 95% CI 1.022-1.049; p < 0.0001), and shorter hospital stays (OR: 0.7838; 95% CI 0.758-0.811; p < 0.0001). Smoking history (OR: 0.825; 95% CI 0.573-1.187, p > 0.05) and vasospasm (OR: 1.005; 95% CI 0.648-1.558; p > 0.05) were not significantly associated with higher odds of mortality.

Conclusions: Mortality following aneurysmal SAH is associated with posterior circulation aneurysms, and increasing age, but not smoking history or vasospasm. These findings may be useful for prognostication and counseling patients and families.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105124DOI Listing
October 2020

Perception of medical students and residents about virtual interviews for residency applications in the United States.

PLoS One 2020 31;15(8):e0238239. Epub 2020 Aug 31.

Department of Neurology, University of Texas Health at San Antonio, San Antonio, Texas, United States of America.

Introduction: Residency applications via virtual-interview could potentially mitigate the extensive cost and time required for customary in-person interviews. We outline the perception of medical students and residents on the use of virtual-interview for residency applications in lieu of in-person interviews.

Methods: We obtained 1824 responses from medical students and residents through an online questionnaire between March2019-Feb2020 in Texas-United States. The survey had 11 statements (five in favor of in-person interviews and 6 in favor of virtual interviews) that respondents could rank on a 5-point Likert scale. All statements' scores were summed based on the response given by each participant to create a total score between 11 and 55. The perception of the two groups was analyzed using an independent sample T-test and ANOVA.

Results: We received a total of 1711 responses from medical students and 113 from medical residents. Respondents were more female (82.2% of medical students and 47.8% of residents), with a mean age of 22.87±3.42 years old for medical students and 28.72±4.35 years old for residents. Both groups preferred in-person interviews; however, the residents were significantly more in favor (P = 0.03). Both groups agree that virtual-interviews should be as an option, though this was considerably higher in the medical students (P = 0.001). In the multivariate analysis, "travel distance" and "type of medical school" had a significant impact on choosing the virtual-interviews in both groups (p<0.01).

Conclusions: In-person interviews are favored by both medical students and residents compared to virtual-interview services in normal circumstances. However, both groups agree that programs should offer the option of having virtual-interviews as an available choice. Distance to an interview location and the type of medical school were the factors that had a significant impact on perception of using virtual-interviews. Knowing about the applicants' attitude toward residency interviews and the national circumstances are essential when preparing the interview guides. Our findings are limited by the small sample size and the low response rate. Further extensive studies are warranted to better understand the perception of residency applicants toward virtual-interviews to improve the interview process in the United States.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238239PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458290PMC
October 2020

The Life of a Black Medical Trainee in the United States: Past, Present, Future.

J Natl Med Assoc 2021 Feb 3;113(1):43-45. Epub 2020 Aug 3.

Associate Professor of Neurosurgery and Neurology, Director of Neuro ICU, University of Texas Health at San Antonio, San Antonio, TX, USA.

An Introduction To The History Of Black Medical Trainees: In these unprecedented times, Black medical professionals must deliver excellent medical care and uphold the highest standards of their profession while living through a devastating pandemic. They must do so in a time when the country tries to reconcile with generations of racism and injustice. The current social environment in America is particularly challenging for medical trainees such as medical students and resident physicians who must focus on their educational requirements and careers in settings that are often averse to addressing topics such as racism. This plight is not new for Black medical trainees, as they have been fighting for centuries to obtain an equitable seat at the table of medical education. Throughout the 19th century and early 20th century, Black physicians were repeatedly disenfranchised from the predominantly white medical societies, most notably the American Medical Association (AMA), which was established in 1847. Racially integrated medical organizations such as the National Medical Society of Washington D.C. (NMS), which was founded in 1870, were developed to challenge discriminatory practices of the American Medical Association against Black practitioners. The inception of the National Medical Association (NMA) in 1895 allowed Black doctors to advocate for disadvantaged patient populations and focus efforts on health issues pertinent to the underserved.

The Struggles Of The Black Trainee: However, Black and underrepresented minorities continue to face challenges with medical school matriculation and retention. A 2015 AAMC report showed that Black male medical school matriculants failed to increase significantly between 1978 and 2014. From 2006 to 2018, the number of Black medical school matriculants increased from 6.7% to 7.1%.

Solutions For Improving Medical Education For The Black Trainee: To improve these matriculation statistics, it is critical that institutions integrate innovative measures such as robust recruitment pipelines to expose underrepresented high school and college students to the medical field, as well as seek diversity actively in administration to dismantle the ingrained ideologies of systemic racism rooted in healthcare and medical education. To combat the institutionalized racism that has plagued medical education throughout its existence, collaboration as a unified front is essential to achieving the equity and social justice in healthcare that patients deserve.
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http://dx.doi.org/10.1016/j.jnma.2020.07.004DOI Listing
February 2021

Presentation with Anosmia and Ageusia: Possible Hidden Carriers of COVID-19.

South Med J 2020 08;113(8):399-400

From the Department of Neurosurgery, and Barshop Institute for Longevity and Aging Studies, University of Texas Health Science Center at San Antonio.

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http://dx.doi.org/10.14423/SMJ.0000000000001123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8055087PMC
August 2020

Creutzfeldt-Jakob Disease: In-hospital demographics report of national data in the United States from 2016 and review of a rapidly-progressive case.

Clin Neurol Neurosurg 2020 10 22;197:106103. Epub 2020 Jul 22.

University of Texas Health Science Center at San Antonio Long School of Medicine, San Antonio, TX, USA; Department of Neurosurgery, Neurology, and Anesthesiology at University Health System, San Antonio, TX, USA. Electronic address:

Background: This report highlights a rapidly progressive case of Creutzfeldt-Jakob Disease (CJD) whose time from symptom onset to death spanned less than two months. We also explore the most recently available in-patient demographics data for discharges with CJD in the United States.

Methods: We reviewed a CJD case and systematically analyzed a retrospective cohort of CJD discharges using the Healthcare Cost and Utilization Project (HCUP) to evaluate the existing national data on the status of CJD demographics and dispositions in the United States in 2016.

Results: An estimated total of 710 hospital discharges with a diagnosis of CJD were seen across the United States in 2016. According to HCUP, the average age of patients was 66.15 ± 11.54 years with 48.6 % female. Average time to intubation from admission to hospital was 4.71 ± 7.32 days with a rate of intubation of 6.34 %. The mean hospital cost was $19,901.25 ± $18,743.48. The rate of in-hospital mortality was 8.45 %. No significant geographical differences were noted (p = 0.49). No significant differences were seen among incidence in specific ethnic groups (p = 0.33) or income quartiles (p = 0.90).

Conclusions: Our data shows that the incidence of CJD in 2016 appears to be equally distributed among individuals in the United States by demographic categories. Additionally, our case-study from 2019 illustrates an important example for diagnosing a rapidly-progressing case of CJD.
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http://dx.doi.org/10.1016/j.clineuro.2020.106103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7703375PMC
October 2020

Transient Ischemic Attack: The Trend and Readmissions in the United States.

J Stroke Cerebrovasc Dis 2020 Aug 3;29(8):104915. Epub 2020 Jun 3.

Associate Professor of Neurosurgery and Neurology, Director of Neuro ICU, University of Texas Health at San Antonio. Electronic address:

Introduction: Transient ischemic attack (TIA) is a temporary event of neurological dysfunction. Patients with TIA may be discharged from the Emergency Department or following an observational admission since their symptoms have resolved. Some portion of these patients, however, return to the hospital due to various reasons. The aim of our study is to find the trend of TIA readmissions in the United States.

Materials And Methods: Using the Healthcare Cost and Utilization Project (HCUP) database, we analyzed TIA discharges and TIA readmissions between 2009-2014 using the statistical z-test.

Results And Statistical Analysis: We recorded a total of 985,851 hospitalizations of patients discharged with TIA with a significant decrease from 2009 to 2014 (p<0.001). Patients had a mean age of 70.4 years and were mainly women (58.43%, P<0.01). HCUP reported 34,503 discharges due to TIA readmissions within 7 days (3.73%) and 91,261 discharges due to readmissions within 30 days (9.83%); both values showed a significant decrease during the study period. Summation of the TIA readmissions found that acute cerebrovascular disease was the leading cause of readmission, followed by another TIA in both seven and thirty days.

Conclusion: Between 2009-2014 the rate of TIA and TIA readmissions has significantly decreased in the United States, especially in the female gender. Acute cerebrovascular disease and another TIA have been the leading cause of hospital readmissions. With a better understanding of the risk factors associated with hospital readmissions, it is possible to reduce the impending burden of these patients on the healthcare system.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104915DOI Listing
August 2020

Protective Effects of Obstructive Sleep Apnea on Outcomes After Subarachnoid Hemorrhage: A Nationwide Analysis.

Neurosurgery 2020 10;87(5):1008-1015

Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah.

Background: Obstructive sleep apnea (OSA) is typically associated with an increased risk of cardiovascular and cerebrovascular disease. Recent studies, however, have suggested that hypercapnia and chronic intermittent hypoxia may potentially provide protection against ischemic events like stroke.

Objective: To evaluate the impact of OSA with presentation, hospital course, and treatment outcomes of patients with subarachnoid hemorrhage (SAH).

Methods: Data for patients with SAH between the years 2011 and 2015 were extracted from the Nationwide Inpatient Sample (NIS) and stratified based on diagnosis codes for OSA. Univariate analysis was used to assess the prevalence of comorbidities in OSA patients diagnosed with SAH and several covariates, including patient demographics, aneurysmal treatment, in-hospital morality rate, length of stay, and costs. Multivariate logistic regression models analyzed the relationship between several comorbidities, including OSA, tobacco use, and hypertension, and poor outcomes after SAH.

Results: Data from 49 265 SAH patients were used in this study, of which 2408 (4.9%) also had a concomitant OSA diagnosis. Patients with OSA compared to all other SAH patients had a significantly lower in-hospital mortality rate, as well as statistically significant lower odds of vasospasm, stroke, and poor outcomes. Additionally, hypercholesterolemia, obesity, and tobacco use disorder were also associated with more favorable outcomes.

Conclusion: SAH patients with OSA are significantly less likely to have a poor outcome when compared to non-OSA patients, despite having an increased risk of several comorbidities.
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http://dx.doi.org/10.1093/neuros/nyaa242DOI Listing
October 2020

Incidence of brain death in the United States.

Clin Neurol Neurosurg 2020 08 7;195:105885. Epub 2020 May 7.

Neurointensive Care Unit, Sanatorio Pasteur, Intensive Care Unit, Hospital San Juan Bautista, Chacabuco 675, 2nd Floor, Catamarca, Argentina. Electronic address:

Objectives: The epidemiological analysis of brain death (BD) can assist physicians in their development of relevant guidelines regarding training and action protocols. This study aims to find the incidence of BD in the United States.

Patients And Methods: This is a cross-sectional study between 2012 and 2016 in the United States. BD data were extracted from the Healthcare Cost and Utilization Project (HCUP) and compared with those of all in-hospital Cardio-Pulmonary Deaths (ih-CPD).

Results: There were 69,735 BD (0.039%) and 3,309,955 ih-CPD (1.85%) with one BD for every fifty ih-CPD. The number of BD increased from 12,575 in 2012 to 15,405 in 2016 (p < 0.0001), with an average of 39 BD per 100,000 discharges and a mean age of 47.83 ± 20.93 years old. Both groups were mainly male and ethnically white; however blacks had the highest rate of BD per capita (p < 0.0001). The most frequently reported cause for BD was the Central Nervous System diseases (50.17%).

Conclusions: In recent years, the incidence of BD has increased in the United States. Knowing the incidence of BD and the establishment of long-term programs that raise awareness about BD may increase the number of potential organ donors in the future.
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http://dx.doi.org/10.1016/j.clineuro.2020.105885DOI Listing
August 2020
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