Neuroleptic Malignant Syndrome: Complications, Outcomes, and Mortality

OBJECTIVE: Our study objective was to identify real-world rates of complications, mortality, and outcomes in patients with neuroleptic malignant syndrome (NMS) over the last decade in the United States. METHODS: A total of 1346 patients were obtained from the nationwide inpatient sample for the years 2002-2011. Common complications known to be associated with NMS were identified. Multivariable regression analyses were used to identify predictors of mortality. RESULTS: The most prevalent complication was rhabdomyolysis (30.1%). Other common complications were acute respiratory failure (16.1%), acute kidney injury (17.7%), sepsis (6.2%), and other systemic infections. Unadjusted mortality rate was 5.6%. Older age, acute respiratory failure, acute kidney injury, sepsis, and comorbid congestive heart failure were significant predictors of mortality. Acute respiratory failure was the strongest independent mortality predictor (p \u3c 0.001). CONCLUSION: In our large sample population-based study on NMS, we were able to identify the rates of several preselected complications and the mortality. The identification of independent mortality predictors in this study can guide physicians in the management and prognostication of this rare syndrome

Predictors of Prolonged Hospital Stay in Status Migrainosus

BACKGROUND: Patients with status migrainosus often need to be admitted due to the severity of their headaches. Their hospitalization is often prolonged due to poor headache control. Large sample studies looking into the factors associated with prolonged length of stay (pLOS) in status migrainosus are lacking. METHODS: We utilized the Nationwide Inpatient Sample database to identify 4325 patients with primary discharge diagnosis of status migrainosus. Length of inpatient stay (LOS) of more than 6 days (90th percentile of LOS) was defined as pLOS. Patient demographics, hospital characteristics, mood disorders, anxiety disorder, and common medical comorbidities were identified. Multivariable logistic regression was used to identify factors associated with pLOS. RESULTS: We found 402 patients with pLOS. Female gender, African American race, mood disorder, obesity, opioid abuse, congestive heart failure, and chronic renal failure were significant independent predictors of pLOS. Median inflation-adjusted cost of hospitalization was USD$3829 (interquartile range: 2419-5809). CONCLUSION: We were able to identify several factors associated with pLOS in status migrainosus. Most of the factors we found were similar to those known to increase the prevalence and severity of migraine in the general population. Knowledge of these factors may help physicians identify high-risk patients to institute early migraine abortive and prophylactic treatment in order to shorten the length of hospital stay

Role of pial collateral flow in acute ischemic stroke outcomes.

Objective: In the patients with acute ischemic stroke (AIS) due to middle cerebral artery (MCA) occlusion who underwent endovascular treatment (ET), we explored the relationship between digital subtraction angiography (DSA) pial collateral status and clinical outcomes. Background: Collateral flow can influence the pace and extent of evolution to irreversible tissue damage and thus have a significant impact on the clinical outcome of patients with AIS. Design/Methods: We reviewed the data of all patients with acute MCA occlusion treated with ET within the past 5 years. Baseline DSA collaterals were classified as - no (0), poor (1), intermediate (2) and good (3). Clinical outcomes were assessed using the National Institute of Health Stroke Scale (NIHSS) at 24-48 hours and at the time of discharge. Multivariable regression analysis was done to evaluate association of DSA collateral score with the outcome. The regression model was adjusted for age, baseline NIHSS, infusion of intravenous (IV) thrombolytic (tPA) and symptom-onset to angiographic recanalization time. Results: 50 patients with the MCA occlusion were treated with ET and 25 (50%) patients received IV tPA prior to ET. Median baseline NIHSS score was 19.5. Median time from the onset to IV tPA was 122 minutes and from onset to angiographic recanalization was 277 minutes. Every 1-point increase in the DSA collateral score was associated with 4.5-point reduction in NIHSS at 24-48 hours and 4.9 point reduction in NIHSS at the time of discharge (standard error 1.4, p\u3c0.01 for both). Conclusions: In the patients with acute ischemic stroke due to MCA occlusion, better collaterals on the DSA are independently associated with improved neurological outcome at 24-48 hour after ET and at the time of discharge. This concept needs to be explored further in a larger dataset that will also include additional imaging parameters

Left atrial dilatation: A cohort analysis with strong implications for future atrial fibrillation and stroke monitoring

Objective: To evaluate the high risk association of Left Atrial Dilatation (LAD) on routine echocardiography with Atrial Fibrillation (AF) and stroke. Background: AF increases the risk of thromboembolism five-fold. LAD is a known predictor of AF. It is necessary to better understand the association of LAD, AF and stroke to determine if screening with cardiac monitoring as a prevention measure for stroke is potentially warranted in patients with LAD and no history of cryptogenic stroke. Design/Methods: A retrospective review of all patients with an echocardiogram performed within Henry Ford Health System from Mar 6th to Sept 6th 2016 was conducted. Patients were categorized based on the degree of LAD (mild, moderate and severe). Chi-squared tests and two-sample t-tests were used to compare characteristics and multivariate logistic regression analyses were done with AF and stroke as outcomes in two separate models adjusting for the exposure variables. Results: From a total of 8679 patients, 54% were female and 41% were African American. The mean age was 64.9 years (SD=16.9). Patients were divided into normal LA size (55%), mild LAD (15%), moderate LAD (12%) and severe LAD (18%). Patients with any LAD were older (70.7±15.0 vs 60.1±17.0

Burden of herpes simplex virus encephalitis in the United States

Herpes simplex virus encephalitis (HSVE) is a disease of public health concern, but its burden on the healthcare of United States has not been adequately assessed recently. We aimed to define the incidence, complications and outcomes of HSVE in the recent decade by analyzing data from a nationally representative database. Healthcare Cost and Utilization Project databases were utilized to identify patients with primary discharge diagnosis of HSVE. Annual hospitalization rate was estimated and several preselected inpatient complications were identified. Regression analyses were used to identify mortality predictors. Key epidemiological factors were compared with those from other countries. Total 4871 patients of HSVE were included in our study. The annual hospitalization rate was 10.3 ± 2.2 cases/million in neonates, 2.4 ± 0.3 cases/million in children and 6.4 ± 0.4 cases/million in adults. Median age was 57 years and male:female incidence ratio was 1:1. Rates of some central nervous system complications were seizures (38.4%), status epilepticus (5.5%), acute respiratory failure (20.1%), ischemic stroke (5.6%) and intracranial hemorrhage (2.7%), all of which were significantly associated with mortality. In-hospital mortality in neonates, children and adults were 6.9, 1.2 and 7.7%, respectively. HSVE still remains a potentially lethal infectious disease with high morbidity and mortality. Most recent epidemiological data in this study may help understanding this public health disease, and the patient outcome data may have prognostic significance

Left atrial dilatation: A cohort analysis with strong implications for future atrial fibrillation and stroke monitoring

Introduction: Atrial fibrillation (AF) increases the risk of thromboembolism five-fold. Left atrial dilatation (LAD) is a known predictor of AF. It is necessary to better understand the association of LAD, AF and stroke to determine if screening with cardiac monitoring as a prevention measure for stroke is potentially warranted in patients with LAD and no history of cryptogenic stroke. Aim: To evaluate the high risk association of LAD on routine echocardiography with AF and stroke. Methods: A retrospective review of all patients with an echocardiogram performed within Henry Ford Health System from Mar 6th to Sept 6th 2016 was conducted. Patients were categorized based on the degree of LAD (mild, moderate and severe). Chisquared tests and two-sample t-tests were used to compare characteristics and multivariate logistic regression analyses were done with AF and stroke as outcomes in two separate models adjusting for the exposure variables. Results: From a total of 8679 patients, 54% were female and 41% were African American. The mean age was 64.9 years (SD=16.9). Patients were divided into normal LA size (55%), mild LAD (15%), moderate LAD (12%) and severe LAD (18%). Patients with any LAD were older (70.7±15.0 vs 60.1±17.0

The Evolution and Application of Cardiac Monitoring for Occult Atrial Fibrillation in Cryptogenic Stroke and TIA

OPINION STATEMENT: The evaluation of the stroke and transient ischemic attack (TIA) patient has been historically predominated by the initial evaluation in the hospital setting. As the etiology of stroke has eluded us in approximately one third of all acute events, the medical community has been eager to seek the answer to this mystery. In recent years, we have seen an explosion of innovations and trends allowing for a more detailed post stroke assessment strategy aimed at the identification of occult atrial fibrillation as the etiologic cause for the cryptogenic event. This has been achieved through the evolution and aggressive application and study of prolonged and advanced cardiac monitoring. This review is aimed to clarify and elucidate the standard and novel cardiac monitoring methods that have become available for use by the medical community and expected in the higher level care of cryptogenic stroke and TIA patients. These cardiac monitoring methods and devices are as heterogeneous as our patient population and have their own advantages and disadvantages. Many factors may be taken into consideration in choosing the appropriate cardiac monitoring method and are highlighted for consideration in this review. With a judicious approach to investigating the cryptogenic stroke population, and applying a wealth of novel treatment options, we may move forward into a new era of stroke prevention

Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States

OBJECTIVE: Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost. PATIENTS AND METHODS: Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs. RESULTS: From 2002-2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ±$54,983). The proportion of males was lower (31%), but a higher cost of $3385 (±$685; p \u3c .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11-23) and each day increase in hospitalization was associated with a cost increase of $3228 (±$19; p \u3c .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients \u3c 40 years old, the increase in cost for patients 40-59 years old was $3829 (±$914; p \u3c .001), and $4573 (±$1033; p \u3c .001) for patients 60-79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (±$1722; p \u3c .001). Several central nervous system complications were also associated with increased cost. CONCLUSION: aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies

Trends of hospitalization cost of aneurysmal subarachnoid hemorrhage in the United States

Background: Recent large scale studies describing the trends of hospitalization cost secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We performed this study to discover these trends and the factors affecting the cost of hospitalization. Methods: The Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from year 2002 to 2013 was searched for patients with a primary diagnosis of subarachnoid hemorrhage International Classification of Diseases - Ninth Revision (ICD-9) code 430) who underwent either clipping or coiling of an aneurysm. Patients with traumatic intracranial hemorrhage, arteriovenous malformation, arteriovenous fistula, cost of care ≤ 0, discharge to another hospital, and any missing variables were excluded. The cost of hospitalization was calculated using total charge and cost-to-charge ratio provided by HCUP, and then was adjusted for inflation (for the year 2016) utilizing the Consumer Price Index inflation calculator. Univariate and multivariable linear regression analysis was performed on selected variables to identify the factors associated with a higher cost of care. The multivariable model was adjusted for calendar year, medical comorbidities (using the Charlson Comorbidity Index), hospital location (urban or rural) and hospital teaching status (teaching or non-teaching). Results: We identified 20,905 patients with aSAH over the course of the 12 years. The mean and the median costs of hospitalization were $80,859 and$66,274, respectively. The median cost increased from $53,697 in 2002 to$73,901 in 2013 (p\u3c0.001). Cost was also noted to increase by $2690 with the male gender,$18,877 with the presence of an acute ischemic stroke, $33,942 with the presence of respiratory failure and$18,464 with the requirement of ventriculostomy (all p\u3c0.001). Every decade increase in age was associated with $3022 reduction in the cost (P\u3c0.001). Conclusion: Among the factors we studied, higher hospitalization cost was independently associated with the male gender and the presence of ischemic stroke, respiratory failure and the requirement of ventriculostomy. Older age was associated with a lower hospitalization cost