Depressed Level Of Consciousness Research Articles

Utility of whole brain radiation therapy for leptomeningeal carcinomatosis.

Although whole brain radiation therapy (WBRT) is commonly used as first-line treatment for leptomeningeal carcinomatosis, the prognosis is uncertain despite treatment. Moreover, the benefit of WBRT for leptomeningeal carcinomatosis has not been adequately evaluated. Therefore, this study aimed to clarify the utility of WBRT for leptomeningeal carcinomatosis. Consecutive patients who received WBRT for leptomeningeal carcinomatosis or brain metastasis from solid tumors between January 2008 and July 2017 were retrospectively evaluated. The overall survival, symptom relief, and adverse events were compared between patients with leptomeningeal carcinomatosis and those with brain metastasis after WBRT. Of the 277 treated patients, 204 patients (22 with leptomeningeal carcinomatosis and 182 with brain metastasis) were included in the study. The median overall survival was 440days (95% confidence interval [CI] 0-931days) for patients with leptomeningeal carcinomatosis and 322days (95% CI 196-448days) for those with brain metastasis (p = 0.972 on the log-rank test). On evaluating the overall survival of patients with leptomeningeal carcinomatosis, the prognostic factors of performance status 0-1, no extracranial metastasis, and no symptoms at the time of WBRT showed a significant survival advantage on univariate analysis. Among patients with leptomeningeal carcinomatosis, those with headache and nausea often showed improvement while those with depressed levels of consciousness and seizures did not. On comparing all-grade adverse events, vomiting and seizures were more frequent in patients with leptomeningeal carcinomatosis than in those with brain metastasis. WBRT was generally well tolerated and effective for treating patients with leptomeningeal carcinomatosis.

Efficacy and economic evaluation of delivery of care with tele-continuous EEG in critically ill patients: a multicentre, randomised controlled trial (Tele-cRCT) study protocol

IntroductionSome critically ill patients are confirmed by continuous electroencephalography (cEEG) monitoring that non-convulsive seizure (NCS) and/or non-convulsive status epilepticus (NCSE) are causes of their depressed level of consciousness. Shortage of...

Atezolizumab-Induced Aseptic Meningitis in Patients with NSCLC

IntroductionDuring treatment with immune checkpoint inhibitors, immune-related adverse events sometimes occur, and their management is a critical concern associated with such treatment. Encephalitis and meningitis are some of the critical immune-related adverse events. Atezolizumab is an immune checkpoint inhibitor that inhibits the programmed cell death-ligand. Encephalitis and meningitis were reported in 0.8% of the patients in the atezolizumab versus docetaxel in patients with previously treated NSCLC. However, none of the reports have clarified the details concerning atezolizumab-induced encephalitis and meningitis, including their background, time of onset, treatment, and therapeutic course. We herein report about three patients who experienced atezolizumab-induced meningitis in our department. MethodsOf the 29 patients who received atezolizumab in our department between October 2015 and September 2018, three developed aseptic meningitis. We retrospectively examined their clinical, radiologic, and cytologic features. ResultsIn all three cases, a depressed level of consciousness followed fever in cycle 1, days 15 and 16 after administration of atezolizumab. Cerebrospinal fluid examination revealed that the number of cells was not increased despite the protein level being high. No definite malignant cells were identified in the cerebrospinal fluid in any of the three cases. Only one patient exhibited abnormal enhancement along the lines of the corpus callosum on magnetic resonance imaging. On the basis of these findings, the patients were diagnosed with atezolizumab-induced meningitis. After the administration of methylprednisolone (1000 mg for 3 d), they promptly became conscious and alert. ConclusionAtezolizumab-induced meningitis may have some specific features, such as a characteristic development period, findings in magnetic resonance imaging, and premonitory symptoms.

Why Physicians Prescribe Prophylactic Seizure Medications after Intracerebral Hemorrhage: An Adaptive Conjoint Analysis

Background: Seizures are a morbid complication of intracerebral hemorrhage (ICH) and increase the risk for herniation, status epilepticus, and worse patient outcomes. Prophylactic levetiracetam is administered to approximately 40% of patients with ICH. It is unclear which patients are consciously selected for treatment by physicians. We sought to determine how patients are selected for treatment with prophylactic levetiracetam after ICH. Methods: We administered an adaptive conjoint analysis using decision making software to an NIH Stroke Trials Network Working Group. The adaptive conjoint analysis determines the most influential attributes for making a decision in an iterative, algorithm-driven process. We asked respondents which would most influence a decision to administer prophylactic levetiracetam. The attributes and their levels were taken from published phenotypes associated with prophylactic seizure medications and the likelihood of seizures after ICH: hematoma location (lobar or basal ganglia), hematoma volume (<=10 mL or >10 mL), level of consciousness (Glasgow Coma Scale 5-12 or Glasgow Coma Scale 13-15), age (<65 or ≥65 years), and race (White or Caucasian or Black/African American). The algorithm terminated when the attributes were ranked from most to least influential. Results: The study sample included 27 respondents who completed the adaptive conjoint analysis out of 42 who responded to the survey with a mean age of 43.4 ± 9.4 years. The attribute with the greatest weight was hematoma location (30%), followed by reduced level of consciousness (24%), hematoma volume (19%), race (14%), and age (13%). Ranks of attributes were different (P < .001). Conclusions: The decision to administer prophylactic levetiracetam to patients with ICH is driven by lobar hematoma location and depressed level of consciousness. Future research on prophylactic seizure medication could focus on patients most likely to receive it.

Medical management of acute loss of vision in tuberculous meningitis: A case report

Blindness and vision impairment are unpredictable complications of tuberculous meningitis (TBM) that are often unrecognized in the acute stages of illness due to inability to assess vision in patients with depressed levels of consciousness or confusion. We present a patient with definite TBM confirmed by positive Xpert MTB/RIF assay of cerebrospinal fluid (CSF) who developed binocular blindness two weeks after diagnosis and initiation of standard anti-tuberculosis treatment (ATT). Ophthalmological exam demonstrated complete bilateral abducens nerve palsies, impaired pupillary responses to light, normal optic discs, and visual acuity of hand motion only in each eye. Brain CT showed progressive enlargement of the third and lateral ventricles. We managed the patient medically with dexamethasone, acetazolamide, and substitution of moxifloxacin for ethambutol. Serial brain CTs confirmed gradual resolution of hydrocephalus. The patient had complete neurological recovery at six months except for residual blindness in the right eye. Visual acuity in the left eye recovered to normal (20/20). The assessment and management of vision impairment in TBM is discussed.

Intubation for Psychogenic Non-Epileptic Attacks: Frequency, Risk Factors, and Impact on Outcome

PurposePatients with psychogenic non-epileptic attacks (PNEA) sometimes receive aggressive treatment leading to endotracheal intubation. We sought to identify the frequency, risk factors, and impact on outcome of intubation for PNEA. MethodsWe retrospectively reviewed all PNEA patients admitted via the emergency department (ED) who had an episode of PNEA documented by continuous video electroencephalography (vEEG) at Henry Ford Hospital between January 2012 and October 2017. Patients with comorbid epilepsy were excluded. Clinical features, treatments, and vEEG reports were compared between intubated and non-intubated patients. ResultsOf 80 patients who were admitted via the ED and had PNEA documented by vEEG, 12 (15%) were intubated. Compared with non-intubated PNEA patients, intubated patients had longer duration of convulsive symptoms (25 [IQR 7-53] vs 2 [IQR 1-9] minutes, P = 0.01), were less likely to have a normal Glasgow Coma Scale score of 15 (33% vs 94%, P < 0.001), received higher doses of benzodiazepines (30 [IQR 16-45] vs 10 [IQR 5-20] mg of diazepam equivalents, P = 0.004), and were treated with more antiepileptic drugs (AEDs, 2 [IQR 1-3] vs 1 [IQR 1-2], P = 0.01). Hospital length of stay was longer (3 [IQR 3-5] vs 2 [IQR 2-3], P = 0.001), and the rate of complications (25% vs 4%, P = 0.04) and re-hospitalization from a recurrent episode of PNEA within 30 days was higher among intubated PNEA patients (17% vs 0%, P = 0.02). ConclusionFifteen percent of patients hospitalized for vEEG-documented PNEA were intubated. Intubated patients had longer length of stay, more in-hospital complications, and a high rate of re-hospitalization from recurrent PNEA symptoms. Prolonged duration of convulsive symptoms, depressed level of consciousness, and aggressive treatment with benzodiazepines were associated with intubation for PNEA.

Abstract 386: Prehospital Capnography in Non-Intubated Traumatic Brain Injury Patients: Association Between End-Tidal CO2 and Level of Consciousness

Background: The EMS traumatic brain injury (TBI) guidelines encourage limiting prehospital intubation (ETI) to patients with profoundly depressed level of consciousness (LOC) and who cannot protect their airway or adequately ventilate without ETI. Thus, EMS providers may manage many TBI patients without intubating even when they have significant alterations in LOC. Monitoring End-Tidal CO2 by placing sensors in the nares (NC-CO2) of non-intubated patients may give providers valuable information about ventilatory status and trends. Study Objective: To evaluate the association between LOC and NC-CO2 in non-intubated TBI patients. Methods: Non-intubated cases from 6 EMS agencies reporting continuous monitor data (Philips MRx™) in the EPIC Study (NIH 1R01NS071049) were evaluated (4/13-3/17). Glasgow Coma Scale (GCS) was available from the EMS record in call cases. Comparisons in patient-level mean, median, lowest and highest NC-CO2 levels were made across GCS categories using clinically meaningful thresholds: &lt;15, &lt;12, &lt;9, and 3. Statistics: Wilcoxon rank-sum test. Results: Included were 106 cases [median age: 47 (range: 9-91), 66% male]. The Table shows the NC-CO2 patterns and comparisons across the GCS categories. In no case was there a significant difference in NC-CO2 between the better vs. worse mental status cohort. Conclusion: We believe this is the first evaluation of the association between NC-CO2 and mental status in TBI. Patients that had significant (and even profound) decreases in LOC, but whom paramedics chose not to intubate, had remarkably similar NC-CO2 patterns compared to those with normal or near-normal mental status. This may support the overall approach of limiting ETI to those with airway/ventilatory compromise or impending hypoxia as there was no evidence of increasing NC-CO2, indicative of hypercapnia, in the non-intubated patients even when they had very depressed LOC.

Real World Chart Review of Blinatumomab to Treat Patients with High Disease Burden of Relapsed or Refractory B-Cell Precursor Acute Lymphoblastic Leukemia

Introduction: Blinatumomab is a bispecific, CD19-directed CD3 T-cell engager (BiTE®) that activates endogenous cytotoxic T cells to kill target B cells and is FDA-approved for the treatment of relapsed or refractory (R/R) B-cell precursor acute lymphoblastic leukemia (B-ALL). Subgroup analyses of pivotal trials revealed lower response rates and higher risk of cytokine release syndrome (CRS) in blinatumomab recipients with high pre-treatment tumor (B-ALL) burden. It has therefore been hypothesized that cytoreduction prior to blinatumomab initiation may improve response and reduce risk of severe CRS in patients (pts) with high baseline B-ALL burden. We therefore sought to describe pt and disease characteristics at diagnosis, patterns of pre-blinatumomab cytoreduction, and treatment outcomes in pts with high burden of R/R B-ALL treated with blinatumomab at our institution. Methods: We retrospectively reviewed medical records of adult (≥ 18 years-old) pts with morphologic R/R B-cell ALL (i.e. ≥5% BM blasts and/or radiographically evident EM disease) treated with blinatumomab at Memorial Sloan Kettering Cancer Center (MSKCC) between January 2011 and March 2019 and characterized pts with ≥ 50% bone marrow (BM) blasts by morphology or ≥ 15,000 peripheral blood blasts/µL as having "high-burden" B-ALL. CRS and neurologic toxicity (NTX) were graded per Common Terminology Criteria for Adverse Events v5.0. Objectives included describing cytoreductive therapy given pre-blinatumomab and determining rates of NTX and CRS (any grade and grade ≥3) and morphologic complete response (CR) following 1-2 cycles of blinatumomab. Results: We identified 14 pts with high-burden R/R B-ALL prior to blinatumomab. These pts had a median age of 52 years (range, 23 - 69 years) and median BM blasts of 73% (range, 52 - &gt;95%, n=12 pts with evaluable BM). Of these 14 pts, 8 received cytoreductive therapy prior to blinatumomab initiation. Cytoreductive regimens included dexamethasone alone (n=4), cyclophosphamide + dexamethasone (n=2), dexamethasone and vincristine (n=1), or cyclophosphamide + vincristine + dexamethasone (n=1). One pt transitioned to hospice care prior to completing cycle 1 (C1) of blinatumomab and was considered non-evaluable for response. CR was achieved in 6 of the 13 evaluable pts, including 4 of 7 evaluable pts who received cytoreductive therapy and 2 of 6 pts who did not receive cytoreductive therapy. One pt achieved CR in BM but exhibited refractory extramedullary disease. CRS was observed during C1 of blinatumomab in 11/14 pts (grade 1, n=7; grade 2, n=3; grade 3, n=1). The pt with grade 3 CRS had received blinatumomab without cytoreductive therapy. In 4 pts, blinatumomab was temporarily discontinued for management of CRS. NTX of any grade occurred in 4/13 pts during C1, including 1 pt w/grade 3 NTX (depressed level of consciousness), and was reversible in all cases; the pt with grade 3 NTX had full resolution of symptoms following brief interruption of blinatumomab and administration of dexamethasone. Conclusions: Real-world clinical experience with blinatumomab in pts with high-burden B-ALL at a single institution suggested an efficacy and safety profile comparable to what has been reported in the overall population in clinical trials. Compared to published clinical trial experience, rates and severity of CRS following blinatumomab were similar and rates of NTX appeared slightly higher in this small series. Administration of cytoreductive therapy prior to blinatumomab for pts with high-burden B-ALL appears safe, with no additional toxicities. Larger studies will be required to assess whether pts with high-burden B-ALL treated (vs not treated) with cytoreductive therapy prior to blinatumomab exhibit significantly higher rates of CR. Disclosures King: Incyte: Other: Advisory Board; Genentech: Other: Advisory Board ; Astrazeneca: Other: Advisory board. Bolanos:Amgen Inc.: Employment. Velasco:Amgen Inc.: Employment. Tu:Amgen Inc.: Employment. Zaman:Amgen Inc.: Employment. Geyer:Dava Oncology: Honoraria; Amgen: Research Funding. Park:Allogene: Consultancy; Amgen: Consultancy; AstraZeneca: Consultancy; Autolus: Consultancy; GSK: Consultancy; Incyte: Consultancy; Kite Pharma: Consultancy; Novartis: Consultancy; Takeda: Consultancy.

Clinical Activity of REGN1979, a Bispecific Human, Anti-CD20 x Anti-CD3 Antibody, in Patients with Relapsed/Refractory (R/R) B-Cell Non-Hodgkin Lymphoma (B-NHL)

Clinical Activity of REGN1979, a Bispecific Human, Anti-CD20 x Anti-CD3 Antibody, in Patients with Relapsed/Refractory (R/R) B-Cell Non-Hodgkin Lymphoma (B-NHL)

Updates on the Sedation for Gastrointestinal Endoscopy.

Sedation, defined as the depressed level of consciousness, induced by drug administration, is widely used for gastrointestinal endoscopy to relieve a patient’s anxiety and discomfort. In addition, successful procedure is anticipated with control of unintended movements. Endoscopic sedation, however, cannot be free from the risk of serious adverse events, e.g., cardiopulmonary compromise. Therefore, principles on personnel, facility and equipment, as well as performance itself, should be followed to prevent unfavorable incidents. In this article, sedation guidelines for the Accreditation of Qualified Endoscopy Units, issued by the Korean Society of Gastrointestinal Endoscopy, are presented.

Basilar Artery Occlusion: Diagnosis and Acute Treatment.

To provide the latest updates in the diagnosis, management, and prognosis in patients with basilar artery occlusion (BAO). The diagnosis of BAO requires a high index of suspicion among patients with sudden onset depressed level of consciousness, quadraparesis (or hemiparesis), and cranial nerve dysfunction. Computed topography with angiography is currently the diagnostic modality of choice for the diagnosis of BAO. Given the often catastrophic nature of BAO, intravenous thrombolysis combined with mechanical thrombectomy should be offered in eligible patients. Despite a lack of data from randomized clinical trials, good outcomes are possible, especially in patients without early evidence of infarction. Aggressive treatment with intravenous thrombolysis and mechanical thrombectomy should be considered in eligible patients with BAO, but there remains a dearth of information from randomized clinical trials.

ENDOSCOPIC INTRAVENTRICULAR HEMORRHAGE REMOVAL: CLINICAL OBSERVATION AND TECHNICAL FEATURES

The study objective is to describe a successful endoscopic therapy for a patient with hypertensive ventricular hemorrhage complicated by occlusive third ventricular hydrocephalus. Materials and methods. A 71-year-old patient with hypertensive hemorrhage into the III and IV ventricles, complicated by non-communicating hydrocephalus, was brought to hospital on the 1st day of the disease onset. Non-communicating hydrocephalus was accompanied by clinical signs of decompensation, depressed level of consciousness up to moderate coma (Glasgow Coma Scale score of 7). Specialists performed emergency endoscopic aspiration of blood clots from the III and IV ventricles and third ventriculostomy. Results. Endoscopically it was possible to remove the clots from the third ventricle and through the cerebral aqueduct from the fourth ventricle. Resuscitation and intensive care measures resulted in a favorable outcome: the patient was released with a moderate neurological deficit – left oculomotor nerve dysfunction. After 4 months, the patient required a ventriculoperitoneal shunt due to disresponsive form of hydrocephalus. Conclusion. Endoscopic aspiration allows removing hematomas from the third and fourth ventricles via the lateral ventricle effectively and safely.

Surgical management for large hypertensive basal ganglionic hemorrhage: single center experience

PurposeWe aim to summarize the role of surgical treatment of spontaneous basal ganglionic hemorrhage based on prospective analysis of our patients and determine the factors that favor the outcome.MethodsA prospective analysis was done of 66 patients from January 2014 to June 2017. Inclusion criteria for the patients in this study were as follows: patients aged between 15 and 60 years; CT scan showed basal ganglionic hematoma with or without intraventricular extension within 24 h post ictus; hematoma volume was Glasgow Coma Scale (GCS) scores ≥ 5, and stable vital signs. Surgical techniques are open craniotomy.ResultsA total of 66 patients underwent surgical intervention consisting of 47 (71.2%) men and 19 (28.8%) women. Their age varies from 15 to 60 with mean age ± SD (range) 46.53 ± 13.24 (18.0–60.0). According to GCS, patients were categorized into three groups: GCS 5–8, 21 (31.8%) patients; GCS 9–12, 30 (45.5%) patients; and GCS 13–15, 15 (22.7%) patients. The favorable outcome group was slightly younger (p value 0.050*). Also, the volume and extension of hematoma into the ventricular system, hydrocephalic dilatation, and midline shift greater than 5 mm had a significantly worse outcome with statistically significant difference.ConclusionThe early surgical management with removal of the hematoma led to dramatic reduction of ICP and improved the prognosis. Patients with signs of brain herniation, a midline shift > 5 mm, hydrocephalic dilatation, ventricular hemorrhage, and a depressed level of consciousness have a poor prognosis.Trial registration17300234 registered 9/2018

Lessons to be learned from toxicological analyses in intoxicated patients and seized materials at an electronic music dance festival

Medical problems related to illicit drug use are frequently encountered at electronic dance music (EDM) events. In this prospective study, the medical problems and toxicological analyses on intoxicated persons and seized materials are described jointly. The aim of this study is to find out to what extent these efforts may assist in developing prevention strategies and organising on-site care at EDM events.The most frequently encountered clinical presentation in the 121 included patients was: agitation/aggression (26%), drunkenness (25%), depressed level of consciousness (24%) and hallucinations (9%). Only five patients were transported by ambulance to a hospital.In 100 of the 121 included patients (83%) an ethanolemia of at least 0.50 g/L was measured (with ethanol as the only drug found in 47 cases). 3,4-methylenedioxymethamphetamine (MDMA) was detected in 54% of the blood samples, cocaine in 11%, gamma-hydroxybutyric acid (GHB) in 11%, amphetamine in 7%, ketamine in 6% and a new psychoactive substance (NPS) in 4%. Except for 8 MDMA-users poly drug use was found in all these cases.The 178 seized samples most frequently contained MDMA (31%), cannabis (28%) or no active substance (15%). In 11 samples (6%) an NPS was detected. Of particular interest was a tablet containing 4-chloromethamphetamine (a previously unknown neurotoxic NPS), 4-chloroamphetamine, para-methoxyamphetamine, para-methoxymethamphetamine and ethylone.Our data show that at EDM events ethanol and MDMA are still the party drugs causing most health hazards and that NPS only play a minor role. Regarding the toxicological efforts, we recommend to analyse all seized materials from an EDM event, but only blood samples from the most severely intoxicated patients.

Herpes Simplex Virus and Tuberculosis-Associated Encephalitis in Northeast of Iran

Background: Encephalitis is associated with high rates of mortality and morbidity; however, its pathophysiology is yet to be determined. Objectives: A prospective cohort study of patients with clinically diagnosed encephalitis was performed to investigate herpes simplex virus (HSV) or tuberculosis infection in encephalitis patients. Methods: Overall, 114 patients were enrolled according to clinical profile and were tested for the presence of HSV-1 and 2 or tuberculosis using TaqMan real-time PCR method on cerebrospinal fluid (CSF). Results: Thirty patients were clinically diagnosed with HSV infection, whose CSF samples were sent for HSV qRT-PCR test. The results showed that 10 (33.3) subjects were HSV-1 or 2-positive. Out of 84 patients who were tested for tuberculosis encephalitis, and tuberculosis qRT-PCR was carried out on their CSF, 3 (3.6) cases were positive. No significant differences were found in gender and age between HSV or tuberculosis-negative and positive groups. The main symptoms in HSV positive subjects were fever and depressed level of consciousness. No cases of tuberculosis infection were diagnosed in direct CSF smear test. Conclusions: Since infectious encephalitis is a life-threatening problem and tuberculosis and HSV are progressing in the developing countries, health authorities, physicians and researchers should address this problem more seriously © 2019, Author(s). © 2019, Author(s).

Advanced radiological investigations and findings amongst community assault victims admitted to a tertiary South African hospital

Community assault (CA) has been increasing in certain Cape Town suburbs over the past decade. There are limited CA-related imaging data. The aim of this study was to review CA-related advanced radiological investigations and findings at a Level 1 South African Trauma Centre. A retrospective study at Tygerberg Hospital, Cape Town, from 1 January through 30 June 2013. All advanced radiological investigations performed on CA victims at the time of admission were retrieved and analysed by patient demographics, imaging investigations and radiological findings. Sixty-two patients (n=62) with a median age of 25 years were included; CT brain was acquired in 90% (n=56) and was abnormal in 68% (n=42). Craniofacial fractures were demonstrated in 60% (n=37), with involvement of the paranasal sinuses in 32% (n=20) and the base of skull in 19% (n=12). Almost half (n=28/62; 45%) had intracranial haemorrhage, which was intra-axial in 36% (n=22/62), extra-axial in 34% (n=21/62) and both intra- and extra-axial in 23% (n=14/62). Cerebral oedema was present in 29% (n=18/62), with herniation in 10% (n=6/62). Non-cranial CT was acquired in 52% (n=32/62), of whom 19 (n=19/32; 59%) also underwent CT brain. CT abdomen was acquired in approximately a quarter of the cohort (n=16/62, 26%), demonstrating abnormalities in 15 (24%). Fifteen cervical spine CTs were performed (n=15/62; 24%) demonstrating no acute bony injury. We recommend a high index of suspicion for severe intracranial injury in CA victims and urgent tertiary referral of those with a depressed level of consciousness. Prospective work is required to determine the long-term outlook for survivors.

Traumatic Posterior Atlantoaxial Dislocation without Related Fractures of C1 - C2 in a Patient with Traumatic Brain Injury: Case Report and Literature Review

It is exceptionally rare to have posterior atlanto axial dislocation without an associated atlas or odontoid fracture and very few cases have been reported in literature. We present a case of a 50 year old female pedestrian who was hit by car while crossing a road. She presented with a depressed level of consciousness and the Glasgow coma score of 12/15, pupils were equal and reactive to light and all limbs were moving equally. She had an extensive abrasion on the forehead which extended into scalp. CT scan showed a posterior dislocation of the atlas with respect of axis with no associated fractures of C 1 and C2. She had traumatic subarachnoid hemorrhage in the basal cisterns and multiple brainstem contusions. Closed reduction of the dislocation was done successfully under fluoroscopy guidance. MRI was done post reduction because funds were not available initially and it showed increased signal in the tectorial membrane and transverse and alar ligaments with mild cord oedema at the cervicomedullary junction. However, the patient post reduction began to deteriorate and eventually passed away before definitive treatment of her cervical-spine injury. The case is reported in view of its rarity and to review literature on this uncommon condition.

Pulmonary complications in patients with brain injury: crosstalk between brain and lung

Background Pulmonary complications after severe brain injury often happened. It could include neurogenic pulmonary edema, acute lung injury/acute respiratory distress syndrome (ALI/ARDS) and ventilator-associated pneumonia. Objective This review is to summarize research advances in recent years in pulmonary complications in patients with brain injury. Content Direct brain injury, depressed level of consciousness and inability to protect the airway, decreased mobility, and secondary neurological injury results from severe brain damage are main causes of pulmonary complications of severe brain damage patients in neurological department. Prevention strategies was implemented to avoid the development of these life-threatening pulmonary complications and current therapy methods are discussed. Trend The mechanism, specific treatment methods of pulmonary complications in patients with brain injury still need further research. Key words: Brain injury; Pulmonary edema; Ventilator-associated pneumonia; Acute lung injury; Acute respiratory distress syndrome

57-Year-Old Woman With Fever and Confusion

57-Year-Old Woman With Fever and Confusion

Predictors of mortality in older patients admitted to a geriatric hospital.

The identification of older patients at risk of mortality is important to provide properly tailored care and effectively manage healthcare resources. The present study aimed to identify predictors of all-cause mortality related to geriatric patients' clinical, functional and sociodemographic status at admission. A retrospective study was carried out of patients admitted to a geriatric hospital from January to May 2013. A total of 208 patients were enrolled in the study. The outcome measure was 4-year mortality. The mortality rate was 26%. We found that age, red blood cells count and white blood cells count, as well as C-reactive protein level, albumin level and high-density lipoprotein cholesterol level significantly correlated with mortality. Furthermore, the presence of clinical symptoms, such as pressure ulcers and depressed level of consciousness, was predictive of poor outcome. Multidimensional aspects of aging that are assessed in the Comprehensive Geriatric Assessment - activities of daily living, instrumental activities of daily living, Barthel scale, Mini-Mental State Examination and The Clock Drawing Test - appeared to be strong predictors of 4-year mortality. The expression to estimate the probability of mortality based on the examined variables correctly classified nearly 85% of the analyzed cases. Early detection of high-risk patients is of particular significance to reach a better survival rate among older adults. Clinicians should put more stress on the comprehensive surveillance of geriatric patients, rather than focusing solely on the treatment of chronic diseases. Geriatr Gerontol Int 2019; 19: 70-75.