Predictive value of neurological examination for early cortical responses to somatosensory evoked potentials in patients with postanoxic coma

Bilateral absence of cortical N20 responses of median nerve somatosensory evoked potentials (SEP) predicts poor neurological outcome in postanoxic coma after cardiopulmonary resuscitation (CPR). Although SEP is easy to perform and available in most hospitals, it is worthwhile to know how neurological signs are associated with SEP results. The aim of this study was to investigate whether specific clinical neurological signs are associated with either an absent or a present median nerve SEP in patients after CPR. Data from the previously published multicenter prospective cohort study PROPAC (prognosis in postanoxic coma, 2000–2003) were used. Neurological examination, consisting of Glasgow Coma Score (GCS) and brain stem reflexes, and SEP were performed 24, 48, and 72 h after CPR. Positive predictive values for predicting absent and present SEP, as well as diagnostic accuracy were calculated. Data of 407 patients were included. Of the 781 SEPs performed, N20 s were present in 401, bilaterally absent in 299, and 81 SEPs were technically undeterminable. The highest positive predictive values (0.63–0.91) for an absent SEP were found for absent pupillary light responses. The highest positive predictive values (0.71–0.83) for a present SEP were found for motor scores of withdrawal to painful stimuli or better. Multivariate analyses showed a fair diagnostic accuracy (0.78) for neurological examination in predicting an absent or present SEP at 48 or 72 h after CPR. This study shows that neurological examination cannot reliably predict absent or present cortical N20 responses in median nerve SEPs in patients after CPR

Discussions about treatment restrictions in chronic neurologic diseases A structured review

Objective: Many incurable neurologic diseases have predictable complications during their course or at their end stage. Timely discussions of potential treatment restrictions may improve the quality of treatment decisions toward the end of life. What is known about the actual practice of these discussions? Methods: We performed a literature search in MEDLINE, EMBASE, and CINAHL for empirical studies about discussions and decisions to restrict treatment in the course of 6 conditions: motor neuron disease (amyotrophic lateral sclerosis [ALS]), primary malignant brain tumors, multiple sclerosis, stroke, Parkinson disease, and dementia (Alzheimer disease). Results: In 10 of 43 studies, the actual practice of decision-making was studied; in the remaining 33, caregivers were interviewed about this practice. Three scenarios were described: 1) acute devastating disease (severe stroke); 2) stable severe neurologic deficit with complications (post-stroke brain damage); and 3) chronic progressive disease with complications (dementia and ALS). We found no studies concerning the other conditions. In all 3 scenarios, discussions and decisions seemed to be mostly triggered by the occurrence of life-threatening situations, either caused by the disease itself (1), or complications (2 and 3, including many patients with ALS). Some ALS studies showed that timely discussion of treatment options improved end-of-life decision-making. Conclusions: The actual practice of discussions about treatment restrictions in chronic neurologic disease has hardly been studied. The currently available empirical data suggest that discussions are mainly triggered by life-threatening situations, whereas anticipation of such situations may be beneficial for patients and their families. Neurology (R) 2012;78:590-59

Survival and recovery of consciousness in anoxic-ischemic coma after cardiopulmonary resuscitation

Objective. In patients who remain unconscious after cardiopulmonary resuscitation (CPR) poor outcome may be predicted with several tests. To use these tests, knowledge of a priori chances of poor outcome after varying periods of unconsciousness is needed. This study is aimed at providing such data. Design and patients. Data regarding survival and recovery of consciousness were extracted from registry-based and prospective cohort studies of patients with anoxic-ischemic coma. A survival analysis was done using Kaplan-Meier estimates and 28-day outcomes were calculated for all patients unconscious after 24 h and 72 h, and 5 days, 7 days and 14 days after CPR. Patient characteristics and outcomes in our cohort were compared with those of published patient series. Results. After 28 days, 27% of 172 patients from the two cohort studies were alive and conscious, 9% were still unconscious, and 64% had died. The proportion of patients who regained consciousness decreased from 34% of those unconscious within the first 6 h post-CPR to 13% of those still unconscious after 2 weeks. The proportion surviving in an unconscious state increased from 6% of patients who were unconscious initially to 33% of those still unconscious after 2 weeks. The chance of survival remained unchanged up to 7 days after CPR, irrespective of the duration of unconsciousness. Patient characteristics and outcomes in our cohort were comparable to data available from the literature. Conclusions. The a priori chances of (poor) outcome vary with the duration of unconsciousness after CPR. This study provides data for different time-intervals after CP

Experiences and reflections of patients with motor neuron disease on breaking the news in a two-tiered appointment: a qualitative study

Breaking bad news should be fine-tuned to the individual patient, contain intelligible information, include emotional support and offer a tailor-made treatment plan. To achieve this goal in motor neuron disease (MND), neurologists of the amyotrophic lateral sclerosis (ALS) centre Amsterdam deliver the message on 2 separate visits within 14 days. To evaluate how patients with MND react to and view disclosure of the diagnosis, in this 2-tiered approach. Non-participating observations and in-depth interviews with patients were conducted in 1 tertiary ALS referral centre. Qualitative analysis consisted of inductive analysis of observation reports and verbatim typed out interviews. 10 2-tiered appointments were observed and 21 Dutch patients with MND interviewed. They experienced the straightforward message to be suffering from a fatal disease as devastating, yet unavoidable. The prospect of a short-term second appointment offered structure for the period immediately following the diagnosis. The time between appointments provided the opportunity for a first reorientation on their changed perspective on their life. The second appointment allowed for detailed discussions about various aspects of MND and a tailor-made treatment plan. The 2-tiered approach fits well with the way in which Dutch patients with MND process the disclosure of their diagnosis, gather information and handle the changed perspective on their life. It may serve as a model for other life-limiting disease

Advance care planning in progressive neurological diseases: Lessons from ALS

Background: There is increasing awareness of the need for an integrated palliative care approach in chronic progressive neurological diseases. Advance care planning (ACP) is an integral part of this approach. As a systematically organized and ongoing communication process about patients' values, goals and preferences regarding medical care during serious and chronic illness, ACP aims to involve patients in decision-making before they become cognitively and communicatively incapable. However, it remains underutilized in daily neurological practice except for speciality clinics such as ALS centers. Our aim was to study ACP in the tertiary ALS center Amsterdam and to investigate patients' reflections on it. Subsequently we used this knowledge to formulate recommendations for integration of ACP in the care of patients with other chronic progressive neurological diseases. Methods: Non-participating observations of all appointments of patients with amyotrophic lateral sclerosis (ALS) or progressive muscular atrophy (PMA) with the treating physician, in various stages of disease, during 6 consecutive months, followed by single in-depth interviews, and an inductive analysis. Results: Twenty-eight Dutch patients participated, varying in age, gender, disease onset and severity of physical decline. ACP started directly when the diagnosis was given, by means of a general outlook on the future with progressive disability and immediate introduction to a customized multidisciplinary team. During follow-up ACP was realized by regular appointments in which monitoring of the patient's status and clear communication strategies formed the basis of tailor-made discussions on treatment options. Patients accepted this policy as careful professional guidance. Conclusions: ACP is a professional communication process throughout the whole course of progressive disease. It is feasible to integrate ACP into follow-up of patients with ALS and PMA from diagnosis onwards. Supported by recent literature, we argue that such a well-structured approach would also enhance the quality of care and life of patients with other chronic progressive neurological diseases

The effect of the introduction of the Amsterdam Trauma Workflow Concept on mortality and functional outcome of patients with severe traumatic brain injury

The purpose of this study was to analyze the effect of the introduction of an all-in workflow concept that included direct computed tomography (CT) scanning in the trauma room on mortality and functional outcome of trauma patients with severe traumatic brain injury (TBI) admitted to a level-1 trauma center. To this end, a retrospective comparison was made of a 1-year cohort prior to the implementation of the all-in workflow concept (Pre-CT in trauma room cohort [Pre-TRCT]) and a 1-year cohort after the implementation (Post-TRCT). All severely injured TBI patients aged 16 years or older that were presented in our level-1 trauma center and that underwent a CT of the head were initially included. Severe TBI was defined as an Abbreviated Injury Scale (AIS) score of >2 of the head region following trauma. Primary outcome parameter was TBI-related mortality during primary hospital admission. Secondary outcome parameter was the functional outcome based on GOS-Extended. A total of 59 patients were included in the Pre-TRCT and 49 in the Post-TRCT. Median age was 49 years in the Post-TRCT and 44 years in the Pre-TRCT (not significant [NS]). Median ISS was similar (ISS = 25). Median Head-AIS was higher in the Post-TRCT (5 vs. 4, NS). Initial CT scanning was completed faster in the Post-TRCT. There was a significant difference of 23% mortality in favor of the Post-TRCT for TBI-related mortality during primary hospital admission (p < 0.05). For acute neurosurgical interventions, time until intervention tended to be faster in the Post-TRCT (NS). Functional outcomes for survivors were higher in the Post-TRCT (6 vs. 5, NS