Persisting vasculitis after pneumococcal meningitis

Introduction: Bacterial meningitis is associated with a high mortality and a high incidence of neurological sequelae. Parainfectious vasculitis leading to ischemic brain damage is a known complication of bacterial meningitis but its treatment is uncertain. Methods and Results: We report the case of a 53-year-old man with pneumococcal meningitis who developed numerous ischemic lesions in the brainstem and basal ganglia caused by parainfectious vasculitis. Clinical and radiological improvement was observed after delayed corticosteroid initiation. Symptomatic vasculitis relapsed after steroid withdrawal and stabilized after reintroduction of the immunosuppressive therapy. Although the cerebrospinal fluid (CSF) contained high levels of MMP-9 at the time of symptomatic vasculitis, a significant decrease of the enzyme accompanied the introduction of corticotherapy and the regression of vasculitic symptoms. No relation between the level of MMP-9 and the white blood cell count in CSF could be found. Conclusion: Parainfectious vasculitis may respond to late corticosteroid treatment. MMP-9 level in CSF may be a marker of vasculitic complication in bacterial meningiti

Bench testing of a new hyperbaric chamber ventilator at different atmospheric pressures

Purpose: Providing mechanical ventilation is challenging at supra-atmospheric pressure. The higher gas density increases resistance, reducing the flow delivered by the ventilator. A new hyperbaric ventilator (Siaretron IPER 1000) is said to compensate for these effects automatically. The aim of this bench test study was to validate the compensation, define its limits and provide details on the ventilator's output at varied atmospheric pressures. Methods: Experiments were conducted inside a multiplace hyperbaric chamber at 1, 2.2, 2.8 and 4 atmospheres absolute (ATA), with the ventilator connected to a test lung. Transducers were recalibrated at each ATA level. Various ventilator settings were tested in volume and pressure control modes. Measured tidal volumes were compared with theoretical predictions based on gas laws. Results: Results confirmed the ventilator's ability to provide compensation, but also identified its limits. The compensation range could be predicted and depended on the maximal flow attainable, decreasing linearly with increasing atmospheric pressure. With settings inside the range, tidal volumes approximated set values (mean error 10±5%). With settings outside the range, the volume was limited to the predicted maximal value calculated from maximal flow. A practical guide for clinicians is provided. Conclusion: The IPER 1000 ventilator attempted to deliver stable tidal volume by adjusting the opening of the inspiratory valve in proportion to atmospheric pressure. Adequate compensation was observed, albeit only within a predictable range, which can be reliably predicted for each setting and ATA level combination. Setting a tidal volume outside this range can result in an unwanted decrease in minute ventilatio

A Risk Analysis Method to Evaluate the Impact of a Computerized Provider Order Entry System on Patient Safety

Objectives: Quantitative evaluation of safety after the implementation of a computerized provider order entry (CPOE) system, stratification of residual risks to drive future developments. Design: Comparative risk analysis of the drug prescription process before and after the implementation of CPOE system, according to the Failure Modes, Effects and Criticality Analysis (FMECA) method. Measurements: The failure modes were defined and their criticality indices calculated on the basis of the likelihood of occurrence, potential severity for patients, and detection probability. Criticality indices of handwritten and electronic prescriptions were compared, the acceptability of residual risks was discussed. Further developments were proposed and their potential impact on the safety was estimated. Results: The sum of criticality indices of 27 identified failure modes was 3813 for the handwritten prescription, 2930 (−23%) for CPOE system, and 1658 (−57%) with 14 enhancements. The major safety improvements were observed for errors due to ambiguous, incomplete or illegible orders (−245 points), wrong dose determination (−217) and interactions (−196). Implementation of targeted pop-ups to remind treatment adaptation (−189), vital signs (−140), and automatic edition of documents needed for the dispensation (−126) were the most promising proposed improvements. Conclusion: The impact of a CPOE system on patient safety strongly depends on the implemented functions and their ergonomics. The use of risk analysis helps to quantitatively evaluate the relationship between a system and patient safety and to build a strategy for continuous quality improvement, by selecting the most appropriate improvements to the syste

Tonic-Clonic Activity at Subarachnoid Hemorrhage Onset: Impact on Complications and Outcome

Objective: Tonic-clonic activity (TCA) at onset complicates 3% to 21% of cases of subarachnoid hemorrhage (SAH). The impact of onset TCA on in-hospital complications, including seizures, remains unclear. One study associated onset TCA with poor clinical outcome at 6 weeks after SAH, but to our knowledge no other studies have confirmed this relationship. This study aims to assess the impact of onset TCA on in-hospital complications, poor functional outcome, mortality, and epilepsy at 3 months. Methods: Analysis of a prospective study cohort of 1479 SAH patients admitted to Columbia University Medical Center between 1996 and 2012. TCA within 6 hours of hemorrhage onset was identified based on accounts of emergency care providers or family witnesses. Results: TCA at onset was described in 170 patients (11%). Patients with onset TCA were younger (P = 0.002), presented more often with poor clinical grade (55% vs. 26%, P<0.001) and had larger amounts of cisternal, intraventricular, and intracerebral blood than those without onset TCA (all, P<0.001). After adjusting for known confounders, onset TCA was significantly associated with in-hospital seizures (OR 3.80, 95%-CI: 2.43–5.96, P<0.001), in-hospital pneumonia (OR 1.56, 95%-CI: 1.06–2.31, p = 0.02), and delayed cerebral ischemia (OR 1.77, 95%-CI: 1.21–2.58, P = 0.003). At 3 months, however, onset TCA was not associated with poor functional outcome, mortality, and epilepsy after adjusting for age, admission clinical grade, and cisternal blood volume. Conclusions: Onset TCA is not a rare event as it complicates 11% of cases of SAH. New and clinically relevant findings are the association of onset TCA with in-hospital seizures, pneumonia and delayed cerebral ischemia. Despite the increased risk of in-hospital complications, onset TCA is not associated with disability, mortality, and epilepsy at 3 months

Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study

Introduction: Seizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE. Methods: We retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year. Results: Thirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5) severely disabled, and 10% (N = 3) had no or minimal disability. Death or unresponsive wakefulness was associated with catastrophic etiology (p = 0.03), but none of the other collected variables. Conclusions: cIV-PTB effectively aborts SRSE and complications are infrequent; outcome in this highly refractory cohort of patients with devastating underlying etiologies remains poor. Phenobarbital may be particularly helpful when weaning cIV-PTB

Les anticorps antigangliosides sont-ils augmentés par la chirurgie lombaire ?

Les anticorps antigangliosides sont-ils augmentés par la chirurgie lombaire? Dans notre pratique clinique nous avons été confrontés à deux patients dont la présentation suggérait une neuropathie. Ils avaient un dosage des anticorps antigangliosides élevé et ont reçu des immunoglobulines intraveineuses. Ils ont développé des effets secondaires de ce traitement (méningite aseptique, insuffisance rénale). Tous deux avaient bénéficié dans les mois précédant l'hospitalisation d'une chirurgie lombaire. Nous nous sommes posé la question de savoir si la chirurgie lombaire pouvait induire une augmentation des anticorps antigangliosides. Nous avons recruté 11 patients et avons dosé les anticorps antigangliosides avant l'intervention, 3 jours et 1 mois après la chirurgie. Les résultats ne montrent pas de modification des dosages suite à la chirurgie, qui malgré le possible relarguage d'antigènes n'induit pas la production d'anticorps de novo. Certains patients ont un taux d'anticorps élevé avant la chirugie et cela relativise la découverte fortuite de taux élevé d'anticorps

L'intoxication au monoxyde de carbone en 2009

Carbon monoxide (CO) is the leading cause of death by poisoning in developed countries. In 2006, 23 deaths and more than 130 hospitalisations related to CO poisoning have been reported in Switzerland. Impairment in oxygen transport through competitive antagonist action on hemoglobin is well known. Other mechanisms, in particular CO induced mitochondrial dysfunction, participate in CO toxicity. CO intoxications carry a high risk of immediate mortality and long-term neuropsychiatric or cardiac sequelae which justify the need of early diagnosis and treatment. Administration of supplemental oxygen is the cornerstone of treatment of CO poisoning. Hyperbaric oxygen therapy must be considered for the treatment of severe intoxications

Case Report and Review of the Literature: Fatal Reversible Cerebral Vasoconstriction Syndrome

Background: A fatal outcome occurs in 2% of patients with Reversible Cerebral Vasoconstriction Syndrome (RCVS). Due to its rarity, guidelines for the management of the most severe forms of RCVS are lacking. Case presentation: Here, we describe the case of a 55 year-old woman who died from complications of RCVS and reviewed patients with fatal outcome reported in the literature. In our patient, the first episode of neurological deterioration was preceded by an increase of cerebral blood flow velocities assessed with transcranial Doppler. A fatal evolution could not be prevented despite therapeutic escalation consisting of multiple non-invasive and invasive treatments including cervical sympathetic bloc and continuous arterial infusion of nimodipine at the site of severe vasoconstriction. Conclusion: This case and the review of literature illustrate the challenges in the management of patients with severe RCVS. We describe here how monitoring of cerebral blood flow might help anticipate clinical worsening at the beginning of the disease and propose novel invasive and non-invasive therapeutic strategies based on monitoring of neurophysiological parameters