A case of acute generalized exanthematous pustulosis associated with polyarteritis nodosa, responding to systemic steroids

A patient with a known biopsy of polyarteritis nodosa diagnosis presented with cyclic fevers, acute kidney injury, and progression of rash from macular to pustular, worsening despite being on antibiotics, without evidence of infection on multiple cultures. The patient had a pathological diagnosis from a skin biopsy of acute generalized exanthematous pustulosis syndrome, with a total resolution of rash, fevers, and acute kidney injury on treatment with pulse steroids

Abstract TP297: Type II Myocardial Infarction is Significantly Associated with Admission NIHSS and Discharge Disposition Following Ischemic Stroke

Introduction: Troponin elevations due to Type II myocardial infarction (T2MI) are associated with increased mortality after hemorrhagic stroke but there is little data on stroke severity or outcome following ischemic stroke. Methods: All stroke discharges from UH-Case Medical Center between 1/2013- 4/2015 were reviewed for demographics, vascular risk factors, admission stroke severity, labs, echocardiogram results and discharge disposition. Troponin levels were normal (0.5ng/ml). A T2MI was diagnosed by a trending troponin elevation; patients with T1MI were excluded. Analyses used SPSS. Results: Troponin levels were normal in 65%, high in 28% and critical in 7% in 1655 patients (1052 ischemic stroke, 434 intracerebral hemorrhage, 169 subarachnoid hemorrhage) and were associated with admission stroke severity (figure). Ischemic stroke patients were mean age 69 yrs (20-101), 50.4% female with mean admission NIHSS 9.3 (0-36). T2MI was associated with higher NIHSS >10 (p=.000), SCr (p=.000) and age (p=.005), lower LDL (p=.000) and SBP (p=.012), and history of AF (p=.021), CAD (p=.000), and HF (p=.000). The significant association with admission NIHSS (p=.002) persisted after adjustment for age (p = .056), gender, LDL (p = .007), CAD (p= .023), heart failure (p = .003), atrial fibrillation, systolic BP, A1C, BMI, and SCr (p=.009). Initial troponin levels for the 8.3% who died or DC to hospice were high in 43% and critical in 24%. Initial and peak troponin levels were significantly associated with DC disposition (p=.000). Conclusion: Elevated troponin due to T2MI is significantly associated with admission ischemic stroke severity, persisting after adjustment of other risk factors, and predicts a poorer outcome. Troponin levels should be obtained on admission for acute stroke to establish the diagnosis of T2MI and capture its impact as a major comorbid condition

Adult Critical Care Electroencephalography Monitoring for Seizures: A Narrative Review

Electroencephalography (EEG) is an important and relatively inexpensive tool that allows intensivists to monitor cerebral activity of critically ill patients in real time. Seizure detection in patients with and without acute brain injury is the primary reason to obtain an EEG in the Intensive Care Unit (ICU). In response to the increased demand of EEG, advances in quantitative EEG (qEEG) created an approach to review large amounts of data instantly. Finally, rapid response EEG is now available to reduce the time to detect electrographic seizures in limited-resource settings. This review article provides a concise overview of the technical aspects of EEG monitoring for seizures, clinical indications for EEG, the various available modalities of EEG, common and challenging EEG patterns, and barriers to EEG monitoring in the ICU

Status epilepticus-time is brain and treatment considerations

Purpose of review Status epilepticus is a neurological emergency associated with high morbidity and mortality. There is a lack of robust data to guide the management of this neurological emergency beyond the initial treatment. This review examines recent literature on treatment considerations including the choice of continuous anesthetics or adjunctive anticonvulsant, the cause of the status epilepticus, and use of nonpharmacologic therapies. Recent findings Status epilepticus remains undertreated and mortality persists to be unchanged over the past 30 years. New anticonvulsant choices, such as levetiracetam and lacosamide have been explored as alternative emergent therapies. Anecdotal reports on the use of other generation anticonvulsants and nonpharmacologic therapies for the treatment of refractory and super-refractory status epilepticus have been described. Finally, recent evidence has examined etiology-guided management of status epilepticus in certain patient populations, such as immune-mediated, paraneoplastic or infectious encephalitis and anoxic brain injury. Randomized clinical trials are needed to determine the role for newer generation anticonvulsants and nonpharmacologic modalities for the treatment of epilepticus remains and evaluate the long-term outcomes associated with continuous anesthetics

Big data and predictive analytics in neurocritical care

To describe predictive data and workflow in the intensive care unit when managing neurologically ill patients. In the era of Big Data in medicine, intensive critical care units are data-rich environments. Neurocritical care adds another layer of data with advanced multimodal monitoring to prevent secondary brain injury from ischemia, tissue hypoxia, and a cascade of ongoing metabolic events. A step closer toward personalized medicine is the application of multimodal monitoring of cerebral hemodynamics, bran oxygenation, brain metabolism, and electrophysiologic indices, all of which have complex and dynamic interactions. These data are acquired and visualized using different tools and monitors facing multiple challenges toward the goal of the optimal decision support system. In this review, we highlight some of the predictive data used to diagnose, treat, and prognosticate the neurologically ill patients. We describe information management in neurocritical care units including data acquisition, wrangling, analysis, and visualization

Review and Updates on the Treatment of Refractory and Super Refractory Status Epilepticus

Refractory and super-refractory status epilepticus (RSE and SRSE) are life-threatening conditions requiring prompt initiation of appropriate treatment to avoid permanent neurological damage and reduce morbidity and mortality. RSE is defined as status epilepticus that persists despite administering at least two appropriately dosed parenteral medications, including a benzodiazepine. SRSE is status epilepticus that persists at least 24 h after adding at least one appropriately dosed continuous anesthetic (i.e., midazolam, propofol, pentobarbital, and ketamine). Other therapeutic interventions include immunotherapy, neuromodulation, ketogenic diet, or even surgical intervention in certain cases. Continuous electroencephalogram is an essential monitoring tool for diagnosis and treatment. In this review, we focus on the diagnosis and treatment of RSE and SRSE

Harnessing Big Data in Neurocritical Care in the Era of Precision Medicine

Purpose of review To survey the literature around "big data" and "artificial intelligence" use, its challenges, and examples in clinical and research domains within neurocritical care. Recent findings Innovations in digital data storage and integration technology have motivated the active development of data-driven tools for neurocritical care practice. There has been progress towards harmonization of data dictionaries within the field to boost generalizability of studies. Numerous collaborative groups have cultivated datasets that will enable further study of disease detection, prediction, and management of critically ill neurologic patients. Essential to the effective analysis of big data in neurocritical care are the increasing relationships between clinicians and data scientists. There are multiple challenges related to the efficient and ethical use of big data, including data complexity, database stewardship and governance, data quality, and safe implementation of data-driven conclusions. Continued efforts towards optimally harnessing data will be crucial in neurocritical care. Critically ill neurologic patients generate an abundant amount of data in the course of routine management. Clinical research is evolving from benefiting the "average patient" to aiming to deliver more precise treatment to the individual patient. In neurocritical care, this has manifested through big data-for triage decisions, enhancing workflow, event detection, and outcome prediction

Electroencephalogram Monitoring in Critical Care

Seizures are common in critically ill patients. Electroencephalogram (EEG) is a tool that enables clinicians to provide continuous brain monitoring and to guide treatment decisions-brain telemetry. EEG monitoring has particular utility in the intensive care unit as most seizures in this setting are nonconvulsive. Despite the increased use of EEG monitoring in the critical care unit, it remains underutilized. In this review, we summarize the utility of EEG and different EEG modalities to monitor patients in the critical care setting