Publications by authors named "Nicholas Morris"

103 Publications

Andexanet Alfa for Factor Xa Inhibitor-Associated Intracerebral Hemorrhage: Does a Specific Reversal Agent Justify Its Cost?

Neurology 2021 Sep 23. Epub 2021 Sep 23.

Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000012857DOI Listing
September 2021

Seven-Year Follow-Up of an Online Critical Care Curriculum.

ATS Sch 2021 Jun 24;2(2):224-235. Epub 2021 Feb 24.

Division of Pulmonary and Critical Care Medicine, Department of Medicine.

In July of 2013, the University of Maryland launched MarylandCCProject.com. This free-access educational website delivers asynchronous high-quality multidisciplinary critical care education targeted at critical care trainees. The lectures, presented in real time on-site, are recorded and available on the website or as a podcast on iTunes or Android. Thus, the curriculum can be easily accessed around the world.

We sought to identify the impact this website has on current and former University of Maryland critical care trainees.

A 32-question survey was generated using a standard survey generation tool. The survey was e-mailed in the fall of 2019 to the University of Maryland Multi-Departmental Critical Care current and graduated trainees from the prior 7 years. Survey data were collected through December 2019. The questions focused on user demographics, overall experience with the website, scope of website use, and clinical application of the content. Anonymous responses were electronically gathered.

A total of 186 current trainees and graduates were surveyed, with a 39% ( = 72) response rate. Of responders, 76% (55) use the website for ongoing medical education. The majority use the website at least monthly. Most users (63%,  = 35) access the lectures directly through the website. All 55 current users agree that the website has improved their medical knowledge and is a useful education resource. Platform use has increased and includes users from around the world.

Based on our current data, the MarylandCCProject remains a valuable and highly used educational resource, impacting patient care both during and after critical care fellowship training.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.34197/ats-scholar.2020-0114OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8362725PMC
June 2021

Verticalization for Refractory Intracranial Hypertension: A Case Series.

Neurocrit Care 2021 Aug 17. Epub 2021 Aug 17.

Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.

Background: Severe intracranial hypertension is strongly associated with mortality. Guidelines recommend medical management involving sedation, hyperosmotic agents, barbiturates, hypothermia, and surgical intervention. When these interventions are maximized or are contraindicated, refractory intracranial hypertension poses risk for herniation and death. We describe a novel intervention of verticalization for treating intracranial hypertension refractory to aggressive medical treatment.

Methods: This study was a single-center retrospective review of six cases of refractory intracranial hypertension in a tertiary care center. All patients were treated with a standard-of-care algorithm for lowering intracranial pressure (ICP) yet maintained an ICP greater than 20 mmHg. They were then treated with verticalization for at least 24 h. We compared the median ICP, the number of ICP spikes greater than 20 mmHg, and the percentage of ICP values greater than 20 mmHg in the 24 h before verticalization vs. after verticalization. We assessed the use of hyperosmotic therapies and any changes in the mean arterial pressure and cerebral perfusion pressure related with the intervention.

Results: Five patients were admitted with subarachnoid hemorrhage and one with intracerebral hemorrhage. All patients had ICP monitoring by external ventricular drain. The median opening pressure was 30 mmHg (25th-75th interquartile range 22.5-30 mmHg). All patients demonstrated a reduction in ICP after verticalization, with a significant decrease in the median ICP (12 vs. 8 mmHg; p < 0.001), the number of ICP spikes (12 vs. 2; p < 0.01), and the percentage of ICP values greater than 20 mmHg (50% vs. 8.3%; p < 0.01). There was a decrease in total medical interventions after verticalization (79 vs. 41; p = 0.05) and a lower total therapy intensity level score after verticalization. The most common adverse effects included asymptomatic bradycardia (n = 3) and pressure wounds (n = 4).

Conclusions: Verticalization is an effective noninvasive intervention for lowering ICP in intracranial hypertension that is refractory to aggressive standard management and warrants further study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-021-01323-zDOI Listing
August 2021

Dynamic Intracranial Pressure Waveform Morphology Predicts Ventriculitis.

Neurocrit Care 2021 Jul 30. Epub 2021 Jul 30.

Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Ave, 8 Milstein - 300 Center, New York, NY, USA.

Background: Intracranial pressure waveform morphology reflects compliance, which can be decreased by ventriculitis. We investigated whether morphologic analysis of intracranial pressure dynamics predicts the onset of ventriculitis.

Methods: Ventriculitis was defined as culture or Gram stain positive cerebrospinal fluid, warranting treatment. We developed a pipeline to automatically isolate segments of intracranial pressure waveforms from extraventricular catheters, extract dominant pulses, and obtain morphologically similar groupings. We used a previously validated clinician-supervised active learning paradigm to identify metaclusters of triphasic, single-peak, or artifactual peaks. Metacluster distributions were concatenated with temperature and routine blood laboratory values to create feature vectors. A L2-regularized logistic regression classifier was trained to distinguish patients with ventriculitis from matched controls, and the discriminative performance using area under receiver operating characteristic curve with bootstrapping cross-validation was reported.

Results: Fifty-eight patients were included for analysis. Twenty-seven patients with ventriculitis from two centers were identified. Thirty-one patients with catheters but without ventriculitis were selected as matched controls based on age, sex, and primary diagnosis. There were 1590 h of segmented data, including 396,130 dominant pulses in patients with ventriculitis and 557,435 pulses in patients without ventriculitis. There were significant differences in metacluster distribution comparing before culture-positivity versus during culture-positivity (p < 0.001) and after culture-positivity (p < 0.001). The classifier demonstrated good discrimination with median area under receiver operating characteristic 0.70 (interquartile range 0.55-0.80). There were 1.5 true alerts (ventriculitis detected) for every false alert.

Conclusions: Intracranial pressure waveform morphology analysis can classify ventriculitis without cerebrospinal fluid sampling.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-021-01303-3DOI Listing
July 2021

In Newborn Infants a New Intubation Method May Reduce the Number of Intubation Attempts: A Randomized Pilot Study.

Children (Basel) 2021 Jun 26;8(7). Epub 2021 Jun 26.

Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036 Graz, Austria.

Severe desaturation or bradycardia often occur during neonatal endotracheal intubation. Using continuous gas flow through the endotracheal tube might reduce the incidence of these events. We hypothesized that continuous gas flow through the endotracheal tube during nasotracheal intubation compared to standard nasotracheal intubation will reduce the number of intubation attempts in newborn infants. In a randomized controlled pilot study, neonates were either intubated with continuous gas flow through the endotracheal tube during intubation (intervention group) or no gas flow during intubation (control group). Recruitment was stopped early due to financial and organizational issues. A total of 16 infants and 39 intubation attempts were analyzed. The median (interquartile range) number of intubation attempts and number of abandoned intubations due to desaturation and/or bradycardia were 1 (1-2) and 4 (2-5), ( = 0.056) and = 3 versus = 20, ( = 0.060) in the intervention group and control group, respectively. Continuous gas flow through the endotracheal tube during intubation seems to be favorable and there are no major unexpected adverse consequences of attempting this methodology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/children8070553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307684PMC
June 2021

Pain Trajectories Following Subarachnoid Hemorrhage are Associated with Continued Opioid Use at Outpatient Follow-up.

Neurocrit Care 2021 Jun 9. Epub 2021 Jun 9.

Department of Neurology, School of Medicine, University of Maryland, Baltimore, MD, USA.

Background: Subarachnoid hemorrhage (SAH) is characterized by the worst headache of life and associated with long-term opioid use. Discrete pain trajectories predict chronic opioid use following other etiologies of acute pain, but it is unknown whether they exist following SAH. If discrete pain trajectories following SAH exist, it is uncertain whether they predict long-term opioid use. We sought to characterize pain trajectories after SAH and determine whether they are associated with persistent opioid use.

Methods: We reviewed pain scores from patients admitted to a single tertiary care center for SAH from November 2015 to September 2019. Group-based trajectory modeling identified discrete pain trajectories during hospitalization. We compared outcomes across trajectory groups using χ and Kruskal-Wallis tests. Multivariable regression determined whether trajectory group membership was an independent predictor of long-term opioid use, defined as continued use at outpatient follow-up.

Results: We identified five discrete pain trajectories among 305 patients. Group 1 remained pain free. Group 2 reported low scores with intermittent spikes and slight increase over time. Group 3 noted increasing pain severity through day 7 with mild improvement until day 14. Group 4 experienced maximum pain with steady decrement over time. Group 5 reported moderate pain with subtle improvement. In multivariable analysis, trajectory groups 3 (odds ratio [OR] 3.5; 95% confidence interval [CI] 1.5-8.3) and 5 (OR 8.0; 95% CI 3.1-21.1), history of depression (OR 3.6; 95% CI 1.3-10.0) and racial/ethnic minority (OR 2.3; 95% CI 1.3-4.1) were associated with continued opioid use at follow-up (median 62 days following admission, interquartile range 48-96).

Conclusions: Discrete pain trajectories following SAH exist. Recognition of pain trajectories may help identify those at risk for long-term opioid use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-021-01282-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189709PMC
June 2021

Successful Postnatal Cardiopulmonary Resuscitation Due to Defibrillation.

Children (Basel) 2021 May 20;8(5). Epub 2021 May 20.

Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria.

An asphyxiated term neonate required postnatal resuscitation. After six minutes of cardio-pulmonary resuscitation (CPR) and two doses of epinephrine, spontaneous circulation returned, but was shortly followed by ventricular fibrillation. CPR and administration of magnesium, calcium gluconate, and sodium bicarbonate did not improve the neonate's condition. A counter shock of five Joule was delivered and the cardiac rhythm immediately converted to sinus rhythm. The neonate was transferred to the neonatal intensive care unit and received post-resuscitation care. Due to prolonged QTc and subsequently suspected long-QT syndrome propranolol treatment was initiated. The neonate was discharged home on day 14 without neurological sequelae.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/children8050421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161234PMC
May 2021

"Broken-hearted" carbon bowl electron shuttle reaction: energetics and electron coupling.

Chem Sci 2021 Apr 8;12(19):6600-6606. Epub 2021 Apr 8.

Department of Chemistry and Biochemistry, University of South Carolina Columbia South Carolina 29208 USA

Unprecedented one-step C[double bond, length as m-dash]C bond cleavage leading to opening of the buckybowl (π-bowl), that could provide access to carbon-rich structures with previously inaccessible topologies, is reported; highlighting the possibility to implement drastically different synthetic routes to π-bowls in contrast to conventional ones applied for polycyclic aromatic hydrocarbons. Through theoretical modeling, we evaluated the mechanistic pathways feasible for π-bowl planarization and factors that could affect such a transformation including strain and released energies. Through employment of Marcus theory, optical spectroscopy, and crystallographic analysis, we estimated the possibility of charge transfer and electron coupling between "open" corannulene and a strong electron acceptor such as 7,7,8,8-tetracyanoquinodimethane. Alternative to a one-pot solid-state corannulene "unzipping" route, we reported a nine-step solution-based approach for preparation of novel planar "open" corannulene-based derivatives in which electronic structures and photophysical profiles were estimated through the energies and isosurfaces of the frontier natural transition orbitals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1039/d0sc06755eDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132954PMC
April 2021

Neurologic Outcomes After Extracorporeal Cardiopulmonary Resuscitation: Recent Experience at a Single High-Volume Center.

ASAIO J 2021 Apr 21. Epub 2021 Apr 21.

From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland Division of Thoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland University of Maryland School of Medicine, Baltimore, Maryland Division of Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.

Extracorporeal cardiopulmonary resuscitation (ECPR)-veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest-has grown rapidly, but its widespread adoption has been limited by frequent neurologic complications. With individual centers developing best practices, utilization may be increasing with an uncertain effect on outcomes. This study describes the recent ECPR experience at the University of Maryland Medical Center from 2016 through 2018, with attention to neurologic outcomes and predictors thereof. The primary outcome was dichotomized Cerebral Performance Category (≤2) at hospital discharge; secondary outcomes included rates of specific neurologic complications. From 429 ECMO runs over 3 years, 57 ECPR patients were identified, representing an increase in ECPR utilization compared with 41 cases over the previous 6 years. Fifty-two (91%) suffered in-hospital cardiac arrest, and 36 (63%) had an initial nonshockable rhythm. Median low-flow time was 31 minutes. Overall, 26 (46%) survived hospitalization and 23 (88% of survivors, 40% overall) had a favorable discharge outcome. Factors independently associated with good neurologic outcome included lower peak lactate, initial shockable rhythm, and higher initial ECMO mean arterial pressure. Neurologic complications occurred in 18 patients (32%), including brain death in 6 (11%), hypoxic-ischemic brain injury in 11 (19%), ischemic stroke in 6 (11%), intracerebral hemorrhage in 1 (2%), and seizure in 4 (7%). We conclude that good neurologic outcomes are possible for well-selected ECPR patients in a high-volume program with increasing utilization and evolving practices. Markers of adequate peri-resuscitation tissue perfusion were associated with better outcomes, suggesting their importance in neuroprognostication.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MAT.0000000000001448DOI Listing
April 2021

Association of Refractory Pain in the Acute Phase After Subarachnoid Hemorrhage With Continued Outpatient Opioid Use.

Neurology 2021 05 25;96(19):e2355-e2362. Epub 2021 Mar 25.

From the Departments of Neurology (M.N.J., J.E.P., A.K., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), Emergency Medicine (W.-T.W.C.), Pharmacy Services (M.J.A.), Neurosurgery (J.M.S.), Pathology (J.M.S.), and Physiology (J.M.S.), and Program in Trauma, R. Adams Cowley Shock Trauma Center (M.N.J., J.E.P., W.-T.W.C., M.M., G.Y.P., N.B., N.A.M.), University of Maryland School of Medicine (M.C.S., A.F., A.K.), Baltimore; and Department of Neurology, Division of Neurocritical Care and Emergency Neurology (K.N.S.), Yale School of Medicine, New Haven, CT.

Objective: Little is known about the prevalence of continued opioid use following aneurysmal subarachnoid hemorrhage (aSAH) despite guidelines recommending their use during the acute phase of disease. We sought to determine prevalence of opioid use following aSAH and test the hypothesis that acute pain and higher inpatient opioid dose increased outpatient opioid use.

Methods: We reviewed consecutively admitted patients with aSAH from November 2015 through September 2019. We retrospectively collected pain scores and daily doses of analgesics. Pain burden was calculated as area under the pain-time curve. Univariate and multivariable regression models determined risk factors for continued opioid use at discharge and outpatient follow-up.

Results: We identified 234 patients with aSAH with outpatient follow-up. Continued opioid use was common at discharge (55% of patients) and follow-up (47% of patients, median 63 [interquartile range 49-96] days from admission). Pain burden, craniotomy, and racial or ethnic minority status were associated with discharge opioid prescription in multivariable analysis. At outpatient follow-up, pain burden (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.5-2.4), depression (OR 3.1, 95% CI 1.1-8.8), and racial or ethnic minority status (OR 2.1, 95% CI 1.1-4.0) were independently associated with continued opioid use; inpatient opioid dose was not.

Conclusion: Continued opioid use following aSAH is prevalent and related to refractory pain during acute illness, but not inpatient opioid dose. More efficacious analgesic strategies are needed to reduce continued opioid use in patients following aSAH.

Classification Of Evidence: This study provides Class II evidence that continued opioid use following aSAH is associated with refractory pain during acute illness but not hospital opioid exposure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000011906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166442PMC
May 2021

Triage of Patients with Intracerebral Hemorrhage to Comprehensive Versus Primary Stroke Centers.

J Stroke Cerebrovasc Dis 2021 May 14;30(5):105672. Epub 2021 Mar 14.

Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD USA.

Objectives: The management of patients admitted with intracerebral hemorrhage (ICH) mostly occurs in an ICU. While guidelines recommend initial treatment of these patients in a neurocritical care or stroke unit, there is limited data on which patients would benefit most from transfer to a comprehensive stroke center where on-site neurosurgical coverage is available 24/7. As neurocritical units become more common in primary stroke centers, it is important to determine which patients are most likely to require neurosurgical intervention and transfer to comprehensive stroke centers.

Materials And Methods: This is a retrospective observational cohort study conducted at an academic comprehensive stroke center in the United States. Four-hundred-fifty-nine consecutive patients transferred or directly admitted to the neurocritical care unit from 2016-2018 with the primary diagnosis of ICH were included. Univariate statistics and multivariate regression were used to identify clinical characteristics associated with neurosurgical intervention, defined as undergoing craniotomy, ventriculostomy, or endovascular embolization of an arteriovenous malformation (AVM).

Results: The following variables were associated with neurosurgical intervention in multivariate analysis: age (OR 0.38, 95% CI 0.27-0.55), admission Glasgow Coma Scale (OR 0.29, 95% CI 0.18-0.48), the presence of intraventricular hemorrhage (OR 2.82, CI 1.71-4.65), infratentorial location of ICH (OR 2.28, 95% CI 1.20-4.31), previous antiplatelet use (OR 2.04, 95% CI 1.24-3.34), and an AVM indicated on CT Angiogram (OR 2.59, 95% CI 1.19-5.63) were independently associated with the need for neurosurgical intervention. This was translated into a scoring system to help make quick triage decisions, with high sensitivity (99%, 95% CI 97-99%) and negative predictive value (98%, 95% CI 89-99%).

Conclusions: Using previously well described predictors of severity in ICH patients, we were able to develop a scoring system to predict the need for neurosurgical intervention with high sensitivity and negative predictive value.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105672DOI Listing
May 2021

A Severe Course of Relapsing-Remitting Acute-Onset Chronic Inflammatory Demyelinating Polyneuropathy in a Young Man.

Case Rep Neurol 2021 Jan-Apr;13(1):73-77. Epub 2021 Feb 4.

Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA.

Acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) is an immune mediated neuropathy characterized by progressive weakness and sensory impairment lasting over 2 months. Guillain-Barré-Strohl syndrome (GBS) is an immune mediated polyneuropathy with a similar presentation often over less than 4 weeks. While some have argued for the existence of recurrent GBS, most classify the syndrome as a form of relapsing-remitting CIDP. However, there are cases of GBS with treatment-related fluctuations that must be distinguished from A-CIDP as patients with A-CIDP require long-term immunotherapy. In this case report, we discuss a patient with multiple relapses over 3 years, who is more likely to have A-CIDP. His ganglioside profile, which has rarely been reported in A-CIDP, included high concentrations of anti-GM1, anti-GD1a, and anti-GD1b antibodies, which may account for his severe disease course.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000511956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923717PMC
February 2021

Teleneurology for Determination of Death by Neurologic Criteria: Adapting to the Times.

Neurology 2021 04 26;96(15):691-692. Epub 2021 Feb 26.

From the Department of Neurology (B.B.L., N.A.M.), Program in Trauma, University of Maryland School of Medicine, Baltimore; and Department of Neurology (J.C.M.B.), Columbia University College of Physicians and Surgeons, New York Neurological Institute, NY.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000011740DOI Listing
April 2021

Intraoperative hypotension and perioperative acute ischemic stroke in patients having major elective non-cardiovascular non-neurological surgery.

J Anesth 2021 04 9;35(2):246-253. Epub 2021 Feb 9.

Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, S11C00, Baltimore, MD, 21201, USA.

Purpose: The association between intraoperative hypotension and perioperative acute ischemic stroke is not well described. We hypothesized that intraoperative hypotension would be associated with perioperative acute ischemic stroke.

Methods: Four-year retrospective cohort study of elective non-cardiovascular, non-neurological surgical patients. Characteristics of patients who had perioperative acute ischemic stroke were compared against those of patients who did not have acute ischemic stroke. Multivariable logistic regression was used to determine whether hypotension was independently associated with increased odds of perioperative acute ischemic stroke.

Results: Thirty-four of 9816 patients (0.3%) who met study inclusion criteria had perioperative acute ischemic stroke. Stroke patients were older and had more comorbidities including hypertension, coronary artery disease, diabetes mellitus, active tobacco use, chronic obstructive pulmonary disease, cerebral vascular disease, atrial fibrillation, and peripheral vascular disease (all P < 0.05). MAP < 65 mmHg was not associated with increased odds of acute ischemic stroke when modeled as a continuous or categorical variable. MAP < 60 mmHg for more than 20 min was independently associated with increased odds of acute ischemic stroke, OR = 2.67 [95% CI = 1.21 to 5.88, P = 0.02].

Conclusion: Our analysis suggests that when MAP is less than 60 mmHg for more than 20 min, there is increased odds of acute ischemic stroke. Further studies are needed to determine what MAP should be targeted during surgery to optimize cerebral perfusion and limit ischemic stroke risk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00540-021-02901-3DOI Listing
April 2021

Development of Neurological Emergency Simulations for Assessment: Content Evidence and Response Process.

Neurocrit Care 2021 Jan 21. Epub 2021 Jan 21.

Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.

Objective: To document two sources of validity evidence for simulation-based assessment in neurological emergencies.

Background: A critical aspect of education is development of evaluation techniques that assess learner's performance in settings that reflect actual clinical practice. Simulation-based evaluation affords the opportunity to standardize evaluations but requires validation.

Methods: We identified topics from the Neurocritical Care Society's Emergency Neurological Life Support (ENLS) training, cross-referenced with the American Academy of Neurology's core clerkship curriculum. We used a modified Delphi method to develop simulations for assessment in neurocritical care. We constructed checklists of action items and communication skills, merging ENLS checklists with relevant clinical guidelines. We also utilized global rating scales, rated one (novice) through five (expert) for each case. Participants included neurology sub-interns, neurology residents, neurosurgery interns, non-neurology critical care fellows, neurocritical care fellows, and neurology attending physicians.

Results: Ten evaluative simulation cases were developed. To date, 64 participants have taken part in 274 evaluative simulation scenarios. The participants were very satisfied with the cases (Likert scale 1-7, not at all satisfied-very satisfied, median 7, interquartile range (IQR) 7-7), found them to be very realistic (Likert scale 1-7, not at all realistic-very realistic, median 6, IQR 6-7), and appropriately difficult (Likert scale 1-7, much too easy-much too difficult, median 4, IQR 4-5). Interrater reliability was acceptable for both checklist action items (kappa = 0.64) and global rating scales (Pearson correlation r = .70).

Conclusions: We demonstrated two sources of validity in ten simulation cases for assessment in neurological emergencies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-020-01176-yDOI Listing
January 2021

Comments on "Inter-facility transfer for patients with acute large vessel occlusion stroke receiving mechanical thrombectomy."

Am J Emerg Med 2021 02 25;40:199-200. Epub 2020 Nov 25.

The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajem.2020.11.057DOI Listing
February 2021

Risk Factors for Hypoglycemia with the Use of Enteral Glyburide in Neurocritical Care Patients.

World Neurosurg 2021 03 27;147:e63-e68. Epub 2020 Nov 27.

Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objective: Intravenous glyburide has demonstrated safety when used for attenuation of cerebral edema, although safety data are lacking for enteral glyburide when used for this indication. We aimed to determine the prevalence of and risk factors for hypoglycemia in neurocritical care patients receiving enteral glyburide.

Methods: We performed a retrospective case-control chart review (hypoglycemia vs. no hypoglycemia) of adult patients who received enteral glyburide for prevention or treatment of cerebral or spinal cord edema. Hypoglycemia was defined as a blood glucose <55.8 mg/dL. Descriptive statistics were used, with multivariate analysis to measure the association of risk factors and outcomes. Logistic regression was applied to outcomes with an exposure. Potential confounders were evaluated using the t-test or the Wilcoxon rank-sum test for continuous variables, and the χ test or the Fisher exact test for categorical variables.

Results: Seventy-one patients (60.6% men, median age 60 years) were included. The majority received 2.5 mg of enteral glyburide twice daily. Diagnoses included tumors (35.2%), intracerebral hemorrhage (28.2%), postspinal surgery (12.7%), and ischemic stroke (12.7%). Hypoglycemia occurred in 17 (23.9%) patients. Multivariate analysis identified admission serum creatinine (odds ratio, 27.2; [1.661, 445.3]; P < 0.05) as a risk factor for hypoglycemia, whereas body mass index >30 (odds ratio, 0.085; [0.008, 0.921]; P < 0.05) was protective.

Conclusions: Hypoglycemic episodes are common following enteral glyburide in neurocritical care patients. Both patients with and without diabetes mellitus are at risk of hypoglycemia. Elevated admission serum creatinine may increase the risk of hypoglycemia when utilizing glyburide for prevention or treatment of cerebral or spinal cord edema.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.11.107DOI Listing
March 2021

The Modified Fisher Scale Lacks Interrater Reliability.

Neurocrit Care 2021 08 16;35(1):72-78. Epub 2020 Nov 16.

Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA.

Background: The modified Fisher scale (mFS) is a critical clinical and research tool for risk stratification of cerebral vasospasm. As such, the mFS is included as a common data element by the National Institute of Neurological Disorders and Stroke SAH Working Group. There are few studies assessing the interrater reliability of the mFS.

Methods: We distributed a survey to a convenience sample with snowball sampling of practicing neurointensivists and through the research survey portion of the Neurocritical Care Society Web site. The survey consisted of 15 scrollable CT scans of patients with SAH for mFS grading, two questions regarding the definitions of the scale criteria and demographics of the responding physician. Kendall's coefficient of concordance was used to determine the interrater reliability of mFS grading.

Results: Forty-six participants (97.8% neurocritical care fellowship trained, 78% UCNS-certified in neurocritical care, median 5 years (IQR 3-6.3) in practice, treating median of 80 patients (IQR 50-100) with SAH annually from 32 institutions) completed the survey. By mFS criteria, 30% correctly identified that there is no clear measurement of thin versus thick blood, and 42% correctly identified that blood in any ventricle is scored as "intraventricular blood." The overall interrater reliability by Kendall's coefficient of concordance for the mFS was moderate (W = 0.586, p < 0.0005).

Conclusions: Agreement among raters in grading the mFS is only moderate. Online training tools could be developed to improve mFS reliability and standardize research in SAH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-020-01142-8DOI Listing
August 2021

Neuromuscular Electrical Stimulation and High-Protein Supplementation After Subarachnoid Hemorrhage: A Single-Center Phase 2 Randomized Clinical Trial.

Neurocrit Care 2021 08 4;35(1):46-55. Epub 2020 Nov 4.

Department of Medicine, University of Maryland School of Medicine, Baltimore, USA.

Introduction: Aneurysmal subarachnoid hemorrhage (SAH) survivors live with long-term residual physical and cognitive disability. We studied whether neuromuscular electrical stimulation (NMES) and high-protein supplementation (HPRO) in the first 2 weeks after SAH could preserve neuromotor and cognitive function as compared to standard of care (SOC) for nutrition and mobilization.

Methods: SAH subjects with a Hunt Hess (HH) grade > 1,modified Fisher score > 1 and BMI < 40 kg/m were randomly assigned to SOC or NMES + HPRO. NMES was delivered to bilateral quadricep muscles daily during two 30-min sessions along with HPRO (goal:1.8 g/kg/day) between post-bleed day (PBD) 0 and 14. Primary endpoint was atrophy in the quadricep muscle as measured by the percentage difference in the cross-sectional area from baseline to PBD14 on CT scan. All subjects underwent serial assessments of physical (short performance physical battery, SPPB) cognitive (Montreal Cognitive Assessment Scale, MoCA) and global functional recovery (modified Rankin Scale, mRS) at PBD 14, 42, and 90.

Results: Twenty-five patients (SOC = 13, NMES + HPRO = 12) enrolled between December 2017 and January 2019 with no between-group differences in baseline characteristics (58 years old, 68% women, 50% HH > 3). Median duration of interventions was 12 days (range 9-14) with completion of 98% of NMES sessions and 83% of goal HPRO, and no reported serious adverse events. There was no difference in caloric intake between groups, but HPRO + NMES group received more protein (1.5 ± 0.5 g/kg/d v 0.9 ± 0.4 g/kg/d, P < 0.01). Muscle atrophy was less in NMES + HPRO than the SOC group (6.5 ± 4.1% vs 12.5 ± 6.4%, P 0.01). Higher atrophy was correlated with lower daily protein intake (ρ = - 0.45, P = 0.03) and lower nitrogen balance (ρ = 0.47, P  = 0.02); and worse 3 month SPPB (ρ = -  0.31, P = 0.1) and mRS (ρ = 0.4, P  = 0.04). NMES + HPRO patients had a better median [25%,75] SPPB (12[10, 12] v. 9 [4, 12], P = 0.01) and mRS (1[0,2] v.2[1, 3], P = 0.04) than SOC at PBD 90.

Conclusions: NMES + HPRO appears to be feasible and safe acutely after SAH and may reduce acute quadriceps muscle wasting with a lasting benefit on recovery after SAH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-020-01138-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093316PMC
August 2021

Graphene-based encapsulation of liquid metal particles.

Nanoscale 2020 Dec 26;12(47):23995-24005. Epub 2020 Oct 26.

Air Force Research Laboratory, Materials and Manufacturing Directorate, Wright-Patterson Air Force Base, Dayton, OH, USA.

Liquid metals are a promising functional material due to their unique combination of metallic properties and fluidity at room temperature. They are of interest in wide-ranging fields including stretchable and flexible electronics, reconfigurable devices, microfluidics, biomedicine, material synthesis, and catalysis. Transformation of bulk liquid metal into particles has enabled further advances by allowing access to a broader palette of fabrication techniques for device manufacture or by increasing area available for surface-based applications. For gallium-based liquid metal alloys, particle stabilization is typically achieved by the oxide that forms spontaneously on the surface, even when only trace amounts of oxygen are present. The utility of the particles formed is governed by the chemical, electrical, and mechanical properties of this oxide. To overcome some of the intrinsic limitations of the native oxide, it is demonstrated here for the first time that 2D graphene-based materials can encapsulate liquid metal particles during fabrication and imbue them with previously unattainable properties. This outer encapsulation layer is used to physically stabilize particles in a broad range of pH environments, modify the particles' mechanical behavior, and control the electrical behavior of resulting films. This demonstration of graphene-based encapsulation of liquid metal particles represents a first foray into the creation of a suite of hybridized 2D material coated liquid metal particles.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1039/d0nr05263aDOI Listing
December 2020

Brain Death Determination: An Interprofessional Simulation to Determine Brain Death and Communicate with Families Focused on Neurology Residents.

MedEdPORTAL 2020 09 25;16:10978. Epub 2020 Sep 25.

Assistant Professor, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School.

Introduction: Significant variation exists in determining brain death despite an expectation of competence for all neurology residents. In addition, family discussions regarding brain death are challenging and may influence organ donation.

Methods: We developed two simulations of increasing complexity for PGY 2 and PGY 3 neurology residents. High-fidelity mannequins were used to simulate patients; standardized actors portrayed family members. In the first simulation, residents determined brain death and shared this information with a grieving family. In the second simulation, residents determined brain death in a more complicated scenario, requiring ancillary testing and accurate result interpretation. Following the determination, residents met with a challenging family. The residents worked with an interdisciplinary team and responded to the family's emotions, used active listening skills, and supported the family through next steps.

Results: Twelve residents completed the simulations. Prior to the simulation, three (25%) residents felt comfortable discussing a brain death diagnosis; following the simulation, eight (67%) residents felt comfortable/very comfortable discussing brain death. Prior to the simulation, eight (67%) residents stated they knew prerequisites for performing a brain death examination and seven (58%) agreed they knew indications for ancillary testing; these numbers increased to 100% following the simulation. The number of residents who felt comfortable performing the brain death exam increased from five (42%) to 10 (83%).

Discussion: This simulation of determining brain death and leading difficult family meetings was well-received by neurology residents. Further work should focus on the effects of simulation-based education on practice variation and organ donation consent rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15766/mep_2374-8265.10978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521065PMC
September 2020

Stroke Risk Following Takotsubo Cardiomyopathy.

Neurohospitalist 2020 Oct 8;10(4):277-280. Epub 2020 Jun 8.

Clinical and Translational Neuroscience Unit, Division of Cardiology, Department of Neurology, Feil Family Brain and Mind Research Institute, and Weill Cornell Medicine, New York, NY, USA.

Background And Purpose: Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is an increasingly recognized cause of left ventricular dysfunction. Previously considered a benign disease, Takotsubo cardiomyopathy may be a risk factor of ischemic stroke based on recent small, single-center case series. The strength and temporal profile of this association remains uncertain.

Methods: We performed a cohort-crossover study using administrative claims data on all emergency department visits and acute care hospitalizations from 2005 to 2015 in California, New York, and Florida. We identified patients with Takotsubo cardiomyopathy, excluding those with a prior or concomitant stroke diagnosis. We compared the risk of ischemic stroke in the first year after Takotsubo cardiomyopathy to the risk of ischemic stroke in the second year after Takotsubo cardiomyopathy. Takotsubo cardiomyopathy and ischemic stroke were ascertained using previously validated codes. Absolute risks and odds ratios (OR) were calculated using McNemar test for matched data.

Results: Among 5283 patients with Takotsubo cardiomyopathy (mean age, 67 years; 92% female), we identified 49 ischemic strokes during the first year after Takotsubo cardiomyopathy versus 19 ischemic strokes during the second year after. The risk of stroke was significantly higher in the year after Takotsubo cardiomyopathy (absolute increase, 0.6%; 95% CI: 0.2-0.9; OR: 2.6; 95% CI: 1.5-4.6) as compared to the control period.

Conclusion: We found a heightened risk of ischemic stroke in the year after a diagnosis of Takotsubo cardiomyopathy, although the absolute risk increase was small.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1941874420931230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495697PMC
October 2020

Multimodal imaging of biological tissues using combined MALDI and NAPA-LDI mass spectrometry for enhanced molecular coverage.

Analyst 2020 Oct;145(21):6910-6918

Department of Chemistry, The George Washington University, Washington, DC 20052, USA.

Mass spectrometry imaging (MSI) is a powerful analytical technique that enables detection, discovery, and identification of multiple classes of biomolecules, while simultaneously mapping their spatial distributions within a sample (e.g., a section of biological tissue). The limitation in molecular coverage afforded by any single MSI platform has led to the development of multimodal approaches that incorporate two or more techniques to obtain greater chemical information. Matrix-assisted laser desorption ionization (MALDI) is a preeminent ionization technique for MSI applications because the wide range of available matrices allows some degree of enhancement with respect to the detection of particular molecular classes. Nonetheless, MALDI has a limited ability to detect and image several classes of molecules, e.g., neutral lipids, in complex samples. Laser desorption ionization from silicon nanopost arrays (NAPA-LDI or NAPA) has been shown to offer complementary coverage with respect to MALDI by providing improved detection of neutral lipids and some small metabolites. Here, we present a multimodal imaging method in which a single tissue section is consecutively imaged at low and high laser fluences, generating spectra that are characteristic of MALDI and NAPA ionization, respectively. The method is demonstrated to map the distributions of species amenable to detection by MALDI (e.g., phospholipids and intermediate-mass metabolites) and NAPA (e.g., neutral lipids such as triglycerides and hexosylceramides, and small metabolites) in mouse brain and lung tissue sections.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1039/d0an00836bDOI Listing
October 2020

The effect of platelet transfusion on functional independence and mortality after antiplatelet therapy associated spontaneous intracerebral hemorrhage: A systematic review and meta-analysis.

J Neurol Sci 2020 Oct 1;417:117075. Epub 2020 Aug 1.

Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America.

Introduction: The practice of platelet transfusion to mitigate the deleterious effects of antiplatelet agents on spontaneous intracerebral hemorrhage (ICH) remains common. However, the effect of antiplatelet agents on patients with ICH is still controversial and transfusing platelets is not without risk. We performed a meta-analysis in order to determine the effect of platelet transfusion on antiplatelet agent associated ICH.

Methods: We queried PubMed, Embase, and Scopus databases to identify cohort studies, case-control studies, and randomized control trials. Study quality was graded by the Newcastle-Ottawa Scale and Cochrane Risk of Bias tool, as appropriate. Outcomes of interest included functional independence as measured by the modified Rankin Scale and mortality. We compared patients with antiplatelet agent associated ICH who received platelet transfusion to those that did not.

Results: We identified 625 articles. After reviewing 44 full text articles, 5 were deemed appropriate for meta-analysis, including 4 cohort studies and one randomized control trial. Considerable heterogeneity was present among the studies (I > 81% for all analyses). We did not find a significant effect of platelet transfusions on functional independence (Odds Ratio [OR] 1.3, 95% CI.0.45-3.9) or mortality (OR 0.58, 95% Confidence Interval [CI] 0.12-2.6).

Conclusion: We found no evidence for an effect of platelet transfusions on functional independence or mortality following antiplatelet associated ICH. More randomized trials are needed to evaluate platelet transfusion in patients with ICH and proven reduced platelet activity or those requiring neurosurgical intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jns.2020.117075DOI Listing
October 2020

Remote ablation chamber for high efficiency particle transfer in laser ablation electrospray ionization mass spectrometry.

Analyst 2020 Aug;145(17):5861-5869

Department of Chemistry, The George Washington University, Washington, DC 20052, USA.

Laser ablation electrospray ionization (LAESI) driven by mid-infrared laser pulses allows the direct analysis of biological tissues with minimal sample preparation. Dedicated remote ablation chambers have been developed to eliminate the need for close proximity between the sample and the mass spectrometer inlet. This also allows for the analysis of large or irregularly shaped objects, and incorporation of additional optics for microscopic imaging. Here we report on the characterization of a newly designed conical inner volume ablation chamber working in transmission geometry, where a reduced zone of stagnation was achieved by tapering the sample platform and the chamber outlet. As a result, the transmission efficiency of both large (>7.5 μm) and smaller particulates (<6.5 μm) has increased significantly. Improved analytical figures of merit, including 300 fmol limit of detection, and three orders of magnitude in dynamic range, were established. Particle residence time, measured by the FWHM of the analyte signal, was reduced from 2.0 s to 0.5 s enabling higher ablation rates and shorter analysis time. A total of six glucosinolates (sinigrin, gluconapin, progoitrin, glucoiberin, glucoraphanin, and glucohirsutin) were detected in plant samples with ion abundances higher by a factor of 2 to 8 for the redesigned ablation chamber.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1039/d0an00984aDOI Listing
August 2020

Histological demonstration of BSEP/ABCB11 inhibition in transient neonatal cholestasis: a case report.

BMC Pediatr 2020 07 9;20(1):340. Epub 2020 Jul 9.

Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 34/2, 8036, Graz, Austria.

Background: Idiopathic or transient neonatal cholestasis (TNC) represents a group of cholestatic disorders with unidentified origin and remains a diagnosis of exclusion. Dysfunction of hepatobiliary transporters mediating excretion of biliary constituents from hepatocytes may play a central role in the pathogenesis of cholestasis. Despite variants of bile salt (BS) export pump (BSEP/ABCB11) have already been described in TNC, the pathogenic role of BSEP dysfunction in TNC remained so far elusive.

Case Presentation: We report on a newly-identified heterozygous ABCB11 missense variant (c.1345G > A, p.Glu449Lys) which was associated with prolonged cholestasis in a term infant after a complicated neonatal period. Moreover, we show for the first time almost completely abolished BSEP expression on the hepatocellular membrane in TNC.

Conclusion: This report demonstrates for the first time a close association between the prolonged cholestasis in infancy and impaired BSEP expression on the hepatocyte canalicular membrane in a heterozygous carrier of newly-identified ABCB11 variant.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12887-020-02201-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346433PMC
July 2020

Factors associated with tracheostomy decannulation in patients with severe traumatic brain injury.

Brain Inj 2020 07 2;34(8):1106-1111. Epub 2020 Jul 2.

Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine , Baltimore, MD, USA.

Objective: To assess variables associated with decannulation in patients with traumatic brain injury (TBI).

Participants: 79 patients with TBI requiring tracheostomy and ICU admission from January 1 to December 31, 2014.

Design: Retrospective analysis.

Measures: Patients decannulated prior to 90 days were compared with patients who remained cannulated. Two Cox Proportional Hazards models were used to predict decannulation using variables prior to tracheostomy and throughout hospitalization.

Results: Median time to decannulation was 37 days (Interquartile Range [IQR] 29-67). Variables prior to tracheostomy associated with decannulation included diabetes (HR, 0.15; 95% CI, 0.03-0.84; =.03), craniotomy (HR, 0.25; 95% CI, 0.06-1.02; =.05) and acute kidney injury (AKI) (HR, 0.06; 95% CI, 0.01-0.48; =.01). Variables present throughout hospitalization included age (HR, 1.12; 95% CI, 1.01-1.21; =.03), ventilator days (HR, 0.74; 95% CI, 0.57-0.95; =.02), reintubation (HR, 0.07; 95% CI, 0.01-0.64; =.02), aspiration (HR, 0.01; 95% CI, 0.0-0.29, =.01), craniotomy (HR, 0.004; 95% CI, 0.0-0.39; =.02) and AKI (HR, 0.0; 95% CI, 0.0-0.21; =.01).

Conclusion: The presence of diabetes, craniotomy and acute kidney injury may inform the conversation surrounding chances for decannulation prior to tracheostomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/02699052.2020.1786601DOI Listing
July 2020

Extremely Preterm Infants Have a Higher Fat Mass Percentage in Comparison to Very Preterm Infants at Term-Equivalent Age.

Front Pediatr 2020 10;8:61. Epub 2020 Mar 10.

Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.

Early nutritional support of preterm infants is important because it influences long-term health and development. Body composition has an influence on cardiovascular disease, metabolic syndrome, and neurocognitive outcome in the long term. To assess body composition in preterm infants <32 weeks of gestation at term-equivalent age and to analyze the influence of an optimized nutritional approach. This is a prespecified secondary outcome analysis of a prospective observational study comparing the body composition in regard to gestational age. The preterm infants were classified according to gestational age as extremely preterm infants (<28 weeks gestation at birth) and very preterm infants (≥28 weeks gestation at birth) and according to weight percentile as appropriate for gestational age and small for gestational age. Body composition was determined by air displacement plethysmography using the PEA POD. The preterm infants obtained nutrition according to the ESPGHAN 2010 Guidelines. Seventy-four preterm infants were analyzed. The mean (SD) gestational age was 28.7 (2.4) weeks, and birth weight was 1,162 (372) g. Fat mass percentage was significantly higher in extremely preterm infants in comparison to very preterm infants [17.0, 95% confidence interval (CI) 15.9-18.1 vs. 15.5, 95% CI 14.7-16.2]. There was no significant difference of fat mass percentage according to weight percentiles. Extremely preterm infants had a significantly higher fat mass percentage compared to very preterm infants at term-equivalent age. There was no significant difference of fat mass percentage according to weight percentiles.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fped.2020.00061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7078645PMC
March 2020
-->