Inpatient Monitoring Research Articles

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OBJECTIVES/SPECIFIC AIMS: To assess the association between probable OSA and the sudden unexpected death in epilepsy (SUDEP-7) risk profiling index in monitored adult inpatients with epilepsy. METHODS/STUDY POPULATION: We analyzed 49 consecutive adults (>18 years) with refractory epilepsy admitted to our inpatient epilepsy monitoring unit. The SUDEP-7 inventory was performed for all subjects. Probable OSA was identified using overnight oximetry, the Sleep Apnea Sleep Disorder Questionnaire (SA-SDQ), and STOP-BANG inventory. RESULTS/ANTICIPATED RESULTS: Thirty-nine percent of participants screened positive for probable sleep apnea. Patients with high SUDEP-7 scores were more likely to have a positive screen for OSA. DISCUSSION/SIGNIFICANCE OF IMPACT: OSA is an independent risk factor for sudden cardiac death. OSA may be a hitherto unrecognized contributor to sudden death risk in epilepsy. Further studies determining the relationship between OSA, neural circulatory control and SUDEP are warranted.

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OBJECTIVES/SPECIFIC AIMS: Deep brain stimulation is currently being evaluated as an experimental therapy for various psychiatric disorders, as well as being investigated as a method for mapping emotional brain functions. This growing area of research requires sensitive measures to quantify effects of stimulation on emotional processing. The current study examined the effects of acute stimulation to 2 limbic regions—the subcallosal cingulate (SCC) and the amygdala—on bias in the perception and evaluation of emotional facial expressions. We hypothesized that transient electrical stimulation to the limbic system would produce acute reductions in negative bias, consistent with its antidepressant effects in patients with severe depression. METHODS/STUDY POPULATION: The current study uses a novel affective bias task, developed to rapidly and covertly quantify emotional state. Over 4–6 minutes, patients rate the intensity and valence of static images of emotional facial expressions. We examined effects of electrical brain stimulation in 2 groups: patients with treatment-refractory depression undergoing SCC DBS therapy, and epilepsy patients undergoing amygdala stimulation via stereo-EEG electrodes during inpatient intracranial monitoring. DBS patients completed the task under stimulation and sham conditions during monthly visits over the first 6 months of therapy, as well as daily during a 1 week, blinded period of DBS discontinuation at the 6-month time point. Epilepsy patients completed the task under stimulation and sham conditions at a single visit. Mixed linear models and paired-samples t-test were used to investigate effects of stimulation as well as depression scale scores on affective bias ratings. RESULTS/ANTICIPATED RESULTS: Four SCC DBS patients showed significant effects of stimulation (p<0.0001) and depressive state (p<0.0001) on affective bias scores across 6 months of chronic DBS therapy, where emotional faces were perceived as less sad with stimulation ON, as well as during visits in which patients were nondepressed (typically later in the treatment course). Furthermore, 2 DBS patients showed rapid negative shifts in bias following acute blinded discontinuation of chronic stimulation, an effect which persisted over the 1-week period of discontinuation (t29=−2.58, p=0.015), in the absence of any self-reported change in mood. Likewise, 6 epilepsy patients showed significant positive shifts in affective bias with acute amygdala stimulation (t5=−4.75, p=0.005). Current analyses are investigating electrophysiological, autonomic and facial motor correlates to affective bias in these patients. DISCUSSION/SIGNIFICANCE OF IMPACT: Affective bias has revealed rapid, significant changes with stimulation at 2 limbic targets—one a white matter hub and one a nuclear subcortical structure—suggesting the task’s utility as an emotional outcome measure in brain stimulation studies. These stimulation-sensitive measures may provide a new metric to track treatment response to deep brain stimulation therapy for affective disorders. Future studies will determine whether affective bias can predict neuropsychiatric complications in patients undergoing stimulation mapping of brain circuitry ahead of resection surgery for epilepsy.

Performance on the Test of Memory Malingering is predicted by the number of errors on its first 10 items on an inpatient epilepsy monitoring unit

Objective: Performance validity testing is an increasingly vital component of neuropsychological evaluation, though administration of stand-alone performance validity tests (PVTs) can be time-consuming. As the Test of Memory Malingering (TOMM) is among the most commonly used and researched PVTs, much work has focused on creating abbreviated versions while preserving diagnostic accuracy. A recent addition to this effort, errors on the first 10 items of Trial 1 (TOMMe10), was analyzed for its utility in predicting TOMM performance. Method: Subjects were 180 veterans seen on a long-term epilepsy monitoring unit. TOMM learning trials, Word Memory Test (WMT), and WAIS-IV Digit Span (for Reliable Digit Span; RDS) were administered as part of a larger battery. Performance invalidity was classified using established cut scores. Diagnostic classification statistics were calculated predicting TOMM, WMT, and RDS performance, including sensitivity, specificity, receiver operating characteristics (ROC), and positive and negative predictive values for multiple TOMMe10 cut scores. Results: A cut score of ≥2 errors on TOMMe10 yielded the highest sensitivity (.88) while maintaining ≥.90 specificity when predicting TOMM (also supported by ROC analysis). This cut score was also optimal when validated against combinations of PVTs (e.g. two of TOMM, WMT, and RDS; WMT and/or RDS). Conclusions: TOMMe10 shows great promise in predicting future TOMM performance. In settings where time with patients is at a premium, ≥2 errors on TOMMe10 may be used as an early TOMM discontinue criteria, allowing examiners to use their limited time more effectively. The use of TOMMe10 in settings with varying TOMM failure base rates was discussed.

282 - Inpatient Weight Monitoring in Heart Failure—Quality Measures

282 - Inpatient Weight Monitoring in Heart Failure—Quality Measures

Inpatient glucose management programme in the Asian healthcare setting.

To implement an inpatient glucose management (IGM) programme in the general medical wards and evaluate its clinical efficacy. Consecutive patients admitted to selected medical wards over a 12-month period were included in the IGM programme. All patients with ≥3 capillary blood glucose (CBG) readings (>10.0mmol/L and/or <4.0mmol/L) over a 24-hour period were identified electronically. A multidisciplinary team of diabetes care providers would provide specialist input to these patients. The control group comprised of consecutive patients admitted over the preceding 12months. Outcome glucose measures include mean in-hospital glucose (MHG), mean patient-day glucose (MDG), proportion of CBG readings at predefined cut-offs and length of stay (LOS). Both the MHG and MDG were significantly lower following intervention (10.0±2.4mmol/L vs 11.2±2.6mmol/L, P<.001; 10.0±2.3mmol/L vs 11.2±2.6mmol/L, P<.001, respectively). Prevalence of hyperglycaemic events, defined by CBG >10.0mmol/L, was significantly lower at 36.5% versus 51.6% (P<.001). Hypoglycaemic events of CBG <4.0mmol/L remained infrequent at <1.0% before and after IGM programme. A greater proportion of glucose readings was controlled within the target range of 4.0-10.0mmol/L (62.6% vs 47.6%, P<.001). With the IGM programme in place, more patients received scheduled CBG monitoring, and a significant shortening of mean LOS by 3.2days was observed (P=.02). The IGM programme was effective in improving inpatient glycaemic monitoring and control in the general medical wards, with a significant reduction in LOS observed. These demonstrated the programme's potential to enhance quality and efficiency of patient care.

Socialization characteristics in persons with epilepsy.

The purpose of this report was to describe social behaviors and preferences in adults with epilepsy, including self-reported use of various socialization media (face-to-face and indirect communication) as well as perceived social barriers. 1320 consecutive persons with epilepsy (PWEs) confirmed through inpatient video-EEG monitoring were administered a questionnaire on the day of their first appointment. The questionnaire was designed to assess preferences in socialization practices, frequency of interpersonal contact, use of social media, and perceived barriers to socialization. The survey was developed to gain a better understanding of the socialization behaviors and preferences of our patients for the future development of customized activities in our wellness program. Our sample revealed higher rates of unemployment and single status as compared to the US Census of 2012. With regard socialization however, many were quite social (86% reported daily/weekly communication with friends and family via telephone, 71% saw relatives in person weekly, 68% saw friends weekly, and 65% reported using the computer daily/weekly to socialize). Facebook® was the preferred on-line social media. Indoor/solitary activities were most common with 63% stating they watch TV/read/use the computer followed by physical exercise and spending time outdoors (36%). The frequency of socialization with friends, relatives, and coworkers decreased with the respondents' age and the longer the respondent had carried the diagnosis of epilepsy. Respondents who were taking a greater number of AEDs or were considered refractory were less likely to consider participating in socialization-enhancing activities. The primary barriers to socialization that respondents endorsed were driving prohibition and medication side-effects. Respondents expressed the greatest interest in online support groups or educational programs (31%), office-based support groups (25%), and volunteering (19%). Although the respondents indicate that they do face barriers to socialization, a majority report frequent communication with relatives and friends via phone, in-person and social media. When designing wellness interventions with this group of patients in the future, online, as well as face to face options for support appear to be desired by a number of PWEs.

Clinical application of MOSkin dosimeters to rectal wall in vivo dosimetry in gynecological HDR brachytherapy

PurposeThree MOSkins dosimeters were assembled over a rectal probe and used to perform in vivo dosimetry during HDR brachytherapy treatments of vaginal cancer. The purpose of this study was to verify the applicability of the developed tool to evaluate discrepancies between planned and measured doses to the rectal wall. Materials and methodsMOSkin dosimeters from the Centre for Medical Radiation Physics are particularly suitable for brachytherapy procedures for their ability to be easily incorporated into treatment instrumentation. In this study, 26 treatment sessions of HDR vaginal brachytherapy were monitored using three MOSkin mounted on a rectal probe. A total of 78 measurements were collected and compared to doses determined by the treatment planning system. ResultsMean dose discrepancy was determined as 2.2±6.9%, with 44.6% of the measurements within ±5%, 89.2% within ±10% and 10.8% higher than ±10%. When dose discrepancies were grouped according to the time elapsed between imaging and treatment (i.e., group 1: ≤90min; group 2: >90min), mean discrepancies resulted in 4.7±3.6% and 7.1±5.0% for groups 1 and 2, respectively. Furthermore, the position of the dosimeter on the rectal catheter was found to affect uncertainty, where highest uncertainties were observed for the dosimeter furthest inside the rectum. ConclusionsThis study has verified MOSkin applicability to in-patient dose monitoring in gynecological brachytherapy procedures, demonstrating the dosimetric rectal probe setup as an accurate and convenient IVD instrument for rectal wall dose verification. Furthermore, the study demonstrates that the delivered dose discrepancy may be affected by the duration of treatment planning.

Chronic ambulatory electrocorticography from human speech cortex

Direct intracranial recording of human brain activity is an important approach for deciphering neural mechanisms of cognition. Such recordings, usually made in patients with epilepsy undergoing inpatient monitoring for seizure localization, are limited in duration and depend on patients’ tolerance for the challenges associated with recovering from brain surgery. Thus, typical intracranial recordings, similar to most non-invasive approaches in humans, provide snapshots of brain activity in acute, highly constrained settings, limiting opportunities to understand long timescale and natural, real-world phenomena. A new device for treating some forms of drug-resistant epilepsy, the NeuroPace RNS® System, includes a cranially-implanted neurostimulator and intracranial electrodes that continuously monitor brain activity and respond to incipient seizures with electrical counterstimulation. The RNS System can record epileptic brain activity over years, but whether it can record meaningful, behavior-related physiological responses has not been demonstrated. Here, in a human subject with electrodes implanted over high-level speech-auditory cortex (Wernicke's area; posterior superior temporal gyrus), we report that cortical evoked responses to spoken sentences are robust, selective to phonetic features, and stable over nearly 1.5 years. In a second subject with RNS System electrodes implanted over frontal cortex (Broca's area, posterior inferior frontal gyrus), we found that word production during a naming task reliably evokes cortical responses preceding speech onset. The spatiotemporal resolution, high signal-to-noise, and wireless nature of this system's intracranial recordings make it a powerful new approach to investigate the neural correlates of human cognition over long timescales in natural ambulatory settings.

Editorial Volume 16 Issue 2

The ability to predict the future would be a useful skill for anyone working in the acute medical unit. While crystal balls have not yet become standard issue for acute medicine trainees, a variety of tools now exist to help identify the likely outcome for patients referred for hospital admission – and enable their management to be planned. Two articles in this summer edition of Acute Medicine highlight this important issue. The team from Athens led by Sotirios Kakavas have investigated the prognostic value of beta-2 microglobulin in patients admitted to hospital with pulmonary embolism. Higher levels of this inflammatory protein were associated with a worse outcome, suggesting that it may have a role in identifying those patients who would benefit from management in a higher dependency setting. All patients in their cohort were admitted to hospital, which is clearly different to the established practice in many UK acute medical units where significant proportions of patients are now managed via ambulatory care. Identification of the low-risk patient who can safely be managed without in-patient monitoring will still require a different approach. However, the results of this study suggest that there may be a role for beta-2 microglobulin, either alone or in combination with other markers, in future prognostic modelling. The ALICE score, developed by the acute medicine team in Plymouth, appears to perform well in a variety of hospitals in predicting length of stay for patients admitted to hospital. The paper by Dan Wilding and Kate Evans indicates that a lower score predicts a shorter hospital stay, which could have significant implications. It is well established that unnecessary in-patient transfers can result in delays in care which may extend a patient’s time in hospital. Accurate, early identification of those patients who are most likely to be able to go home within 48-72hours may help to reduce transfers and improve the efficiency of the service. Of course, this will still be dependent on there being sufficient capacity to enable patients to remain on the acute medical unit for this time pending discharge, as well as good communication with bed management teams. The overnight transfer of patients whose discharge from hospital the next day was predicted and planned is a common source of frustration, when hospital capacity is under duress – as now seems to the case in most hospitals throughout the year. This edition includes just a single case report, although we have several lined up for future editions later in the year. Although liver abscess is not an uncommon problem, the case highlights the important issue of ‘source control’ in the management of sepsis. The patient described was clearly unwell at the time of admission, and deteriorated further, despite rapid initiation of antibiotics and other ‘sepsis 6’ measures. The clinical and radiological evidence of pneumonia was compelling, but recognition, and early drainage of the abscess resulted in a rapid improvement, as well as confirmation of the causative organism. Clues to the cause included a past history of complicated diverticular disease and mild derangement of liver function, but relatively little in the way of abdominal findings such that this would have been an easy diagnosis to miss, if the acute medicine team had not been alert to this possibility. We must never be afraid to challenge out initial presumptions, particularly when a patient’s condition fails to improve. I am delighted that Mark Holland has provided a ‘Viewpoint’ article for this edition, reflecting on his tenure as President of the Society for Acute Medicine. Mark hands over to Nick Scriven in the Autumn – no doubt, he will be feeling a sense of relief tinged with a little sadness, which I remember well when my time in the role came to an end in 2013. Mark has been a great asset to the Society and should be very proud of his achievements in raising the profile of the Speciality of Acute Medicine. I hope you enjoy whatever remains of summer, and that you can all manage some respite before the start of the ‘predictable’ pressures of the months which follow.

Postoperative Complications Predict 30-Day Readmission in Geriatric General Surgery Patients

The Affordable Care Act has placed unplanned patient readmissions under more scrutiny than ever. Geriatric patients, in particular, suffer a disproportionate amount of complications from any kind of hospitalization, including readmissions. This study seeks to identify risk factors in this population that predispose them to an unplanned readmission within 30 days after index surgery. The National Surgical Quality Improvement Program database was used to select patients 65 years and older, who underwent general surgery procedures in 2012. Patient demographics, comorbidities, complications, and readmissions were analyzed. A Cox regression survivorship model was used for multivariate analysis. A total of 7712 patients were reviewed; 617 patients (8.0%) had an unplanned readmission within 30 days of their operation. Cox regression revealed five different independent predictors of unplanned readmission within 30 days. They are age [P = 0.009, hazard ratio (HR) = 1.016, 95% confidence interval (CI) = 1.01-1.03], American Society of Anesthesiologists Class >2 (P = 0.037, HR = 1.22, CI = 1.024-1.475), operation time (minutes) (P = 0.001, HR = 1.001, CI = 1.00-1.002), any complication (P = 0.03, HR = 1.449, CI = 1.33-1.852), and deep vein thrombosis (P = 0.03, HR = 1.87, CI = 1.31-3.85). Using Cox regression to adjust for patient length of stay, age, American Society of Anesthesiologists class, any complication, operation time, and venous thromboembolism all independently increased the rate of unplanned readmissions. Patients who suffer any complication or a venous thromboembolism postoperatively are at a particularly high risk of readmission. These patients should be targeted for increased inpatient monitoring and included in preventable readmission programs after discharge.

Inpatient Continuous Glucose Monitoring and Glycemic Outcomes.

Continuous glucose monitoring (CGM) is commonly used in the outpatient setting to improve diabetes management. CGM can provide real-time glucose trends, detecting hyperglycemia and hypoglycemia before the onset of clinical symptoms. In 2011, at the time the Endocrine Society CGM guidelines were published, the society did not recommend inpatient CGM as its efficacy and safety were unknown. While many studies have subsequently evaluated inpatient CGM accuracy and reliability, glycemic outcome studies have not been widely published. In the non-ICU setting, investigational CGM studies have commonly blinded providers and patients to glucose data. Retrospective review of the glucose data reflects increased hypoglycemia detection with CGM. In the ICU setting, data are inconsistent whether CGM can improve glycemic outcomes. Studies have not focused on hospitalized patients with type 1 diabetes mellitus, the population most likely to benefit from inpatient CGM. This article reviews inpatient CGM glycemic outcomes in the non-ICU and ICU setting.

Teaching Neuro Images : A spiritual visual hallucination from a right parieto-occipital seizure

A 59-year-old woman with epilepsy reported episodes of dizziness, blurred vision, and an occasional stereotyped visual hallucination of a guardian angel. She had experienced this recurrent hallucination since childhood, and could draw it in detail (figure 1). MRI brain revealed a right parieto-occipital lesion (figure 2A). Inpatient EEG monitoring captured multiple seizures evolving over the right posterior quadrant. With one typical electrographic seizure (figure 2B), she awakened from stage II sleep, reporting seeing her guardian angel at bedside within 10 seconds of electrographic seizure offset. Among focal epilepsy patients, 0.4%–3.1% report ictal religious experiences.1

The yield of non-elective inpatient video-EEG monitoring in adults.

Inpatient video-EEG monitoring (VEM) can contribute to the diagnosis and treatment in many of the monitored patients. Most admissions to VEM are elective and are scheduled ahead before the monitoring session. To retrospectively evaluate the yield of non-elective VEM sessions. We retrospectively reviewed the VEM recordings and medical records of all the patients admitted to our one-bed VEM unit from June 2007 to June 2015. A VEM session was diagnostic when a seizure, an event or previously unreported interictal epileptiform discharges were recorded. The study group included 304 adults aged 18-92years (mean 40.4±17.4years), 181 (59%) women. The diagnostic yield of non-elective and elective VEM session was similar (66 and 69%, respectively). In non-elective VEM, fewer patients had known epilepsy (p=0.0001), session duration was shorter (p=0.0001), and seizures and interictal epileptiform discharges were recorded less frequently compared to elective VEM (p=0.005 and p=0.0001, respectively). Non-elective VEM can provide useful information in patients admitted to the neurology department with recent neurological or behavioral events. A timely and correct diagnosis in these patients can potentially reduce unnecessary use of antiepileptic drugs in patients with psychogenic nonepileptic seizures and the morbidity and mortality associated with undiagnosed seizures.

Same-Day Versus Next-Day Discharge Increased Pain on the Day After, But Not on the Day of or Four Weeks After, Total Hip Arthroplasty.

Goyal N, Chen AF, Padgett SE, Tan TL, Kheir MM, Hopper RH Jr, Hamilton WG, Hozack WJ. Otto Aufranc Award: a multicenter, randomized study of outpatient versus inpatient total hip arthroplasty. Clin Orthop Relat Res. 2016 Jun 10. [Epub ahead of print]. ### Question: In patients having total hip arthroplasty, does planned discharge on the same day versus the next day lead to different outcomes in terms of postoperative pain, complications, and health-care provider visits? ### Design: Randomized (allocation concealed)*, unblinded, controlled trial with 4 weeks of follow-up and intention-to-treat analysis. ClinicalTrials.gov NCT02230657. ### Setting: 2 high-volume, adult reconstruction centers in the United States. ### Patients: 220 patients <75 years of age (mean age, 60 years; 53% men) with a body mass index of <40 kg/m2 who underwent primary unilateral total hip arthroplasty through a direct anterior approach. The exclusion criteria included chronic opioid use, need for a walker or wheelchair, lack of assistance at home, or history of cardiopulmonary disease with need for acute inpatient monitoring. 100% of patients completed follow-up. ### Intervention: Planned …

Multidisciplinary Approach in the Treatment of a Rare Surgical Disease Trichobezoar in an 11-year-old Child: Clinical Case

Bezoars are rarely occurring foreign bodies of the gastrointestinal tract, only 0.5–1% of cases cause the mechanical intestinal obstructions. It is very difficult to diagnose bezoar on early stages. The presented clinical case demonstrates the opportunities of multidisciplinary approach in diagnosis and rehabilitation of children with trichobezoar. Two weeks before hospitalization, the girl began to make complaints about periodic abdominal pain, nausea, episodes of vomiting occurred immediately after ingestion. The child underwent complex examination (including esophagogastroduodenoscopy) which revealed a giant trichobezoar occupying the entire lumen of the stomach. Gastrotomy, removal from the stomach in the form of his «impression» trichobezoar (12×15 cm) was performed. During the in-patient monitoring at hospital, both medical assistance and psychological and pedagogical support was provided to the child and to his parents as well; consultations on emotional state of the child and optimizing the process of education in the family were delivered. The joint work of pediatricians, surgeons, and specialists in the psychological and pedagogical service makes it possible to determine the necessary volume of medical assistance, as well as the psychological reason for the occurrence of neurotic reactions to prevent the «hair tumor» formation in future.

Recurrent Syncope in a Young Male with Abnormal Repolarisation – Interesting Findings from Loop Recorder Interrogation

A 32-year-old man with no past medical or family history of note, presented with non-exertional syncope preceded by palpitations. He reported multiple similar episodes over a two-year period which had not been investigated. Baseline electrocardiography demonstrated typical atrial flutter with variable block, widened QRS (140ms) with a dominant R wave in V1 in conjunction with ≥2 mm ST segment elevation in V2 (saddle-back) and V3 (horizontal) without reciprocal changes. This pattern was highly suggestive of a channelopathy, in particular Brugada. He had inpatient cardiac monitoring which showed no change in his rhythm. Transthoracic echocardiogram revealed a normal left and right ventricular size and function, and cardiac MRI was normal including the absence of late gadolinium uptake. He was discharged with an implantable loop recorder, metoprolol and rivaroxaban. Four weeks later he represented with a further collapse. Interrogation of his device revealed atrial flutter with 1:1 conduction degenerating to ventricular tachycardia followed by ventricular fibrillation then asystole (for 15 seconds), before self-reverting to the original atrial flutter. An internal cardiac defibrillator was inserted. Two weeks post ICD insertion, he received an ICD discharge. Interrogation of the device again demonstrated 1:1 flutter degenerating into VT. Subsequently he was commenced on sotalol. He has been referred to a cardiac genetic clinic for primary arrhythmogenic screening and first-degree family members are being screened. Conclusions: We describe electrocardiogram findings in a young male with recurrent syncope and significant repolarisation abnormalities. He has had no further atrial flutter nor syncopal episodes since starting sotalol.

PATHOLOGICAL SIGNS OF EPILEPTIC AND NON-EPILEPTIC ORIGIN DETECTED IN AWAKE/SLEEP EEG PATTERNS DURING OUTPATIENT AND INPATIENT MONITORING: PROBLEMS OF INTERPRETATION

The aims of this study were: (a) to elucidate the role of prolonged computerized EEG in assessing the brain function in patients with focal lesions (stroke consequences, tumor, etc.), and (b) to summarize the experience of using outpatient and inpatient EEG monitoring in neurological practice. Materials and methods. The study included 99 patients with post-stroke and other focal lesions or with a neurological deficit (aphasia, paresis, etc.) or with focal slow-wave and paroxysmal (epileptiform) activity, or with suspected «epilepsy». The patients were monitored using the method of ECG in outpatient and / or neurological hospital settings. The diagnosis of symptomatic epilepsy was confirmed in 81 patients (86%), and not confirmed – in 13 patients (14%). The patients’ age ranged from 16 to 78 years (average 56); the male/female ratio was 37/57. Results . The outpatient and impatient Holter EEG monitoring revealed various EEG patterns both in norm and pathology. Among those: different epileptiform signs (detected in all groups of patients) with different occurrence rates: PLEDs – rhythmic delta, frontal – FIRDA, temporal – TIRDA, spikes and complexes on the left and / or right, generalized paroxysms and photosensitivity. Examples of these EEG patterns (awake and sleep) are presented. Of special interest is the epileptiform pattern where polyspikes are combined with K complexes in the 2nd stage of sleep. Both generalized and focal patterns – mostly typical for sleep EEG – are demonstrated. The method of multiple dipole localization (MDL) was used to directly localize the sources of the abnormal EEG activity (slow-wave and paroxysmal) in the brain. In this report, combined results of EEG and MRI indicating the sources of the abnormal electrical activity are presented to compare the localization of the spike activity with that of the rhythmic slow waves. Two major causes of functional deficiency in post-stroke aphasia and plegia (and similar disorders) are proposed. Firstly, it is the presence of an ischemic focus with a decreased cerebral blood flow in this zone that results in a focal slow-wave activity (delta focus). Secondly, a loss of function can be caused by a continuous discharge activity of brain neurons. An epileptogenic focus and a continuous paroxysmal activity can lead to over-stimulation of brain neurons. Conclusion . Monitoring and analyzing EEG indicators in outpatients significantly expand the capabilities of EEG and provide new information on the brain function. In respect to the differential diagnosis between epileptic and non-epileptic seizures, prolonged monitoring allows to obtain additional information from EEG records and better identify epilepsy-associated activities.

Timing of first event in inpatient long-term video-EEG monitoring for diagnostic purposes

BackgroundLong-term video-EEG monitoring (LTM) aims to record the habitual event and is a useful diagnostic tool for neurological paroxysmal clinical events. In our epilepsy monitoring unit (EMU) setting, admissions are usually planned to last up to five days. We ascertained time taken for the recording of a first event and determined correlations between different clinical characteristics and timings. MethodsWe retrospectively reviewed diagnostic and classification LTM recording performed at a tertiary epilepsy centre. ResultsSixty-three recordings were reviewed. Most subjects (89%) had events at least once a week prior to admission. In 40 (63%) a habitual event was recorded, mostly (93%) within the first two days. No events were recorded on day four or five. A few characteristics were associated with a trend for events occurring earlier (events more than once a week vs less than once a week, motor symptoms compared with aura or dyscognitive events, and reduction of antiepileptic drugs versus no reduction). ConclusionsOur finding suggests that, for diagnostic event recording in people with epilepsy or PNEA, a maximum recording time of three days is sufficient in two thirds of them, if event frequency is at least once a week. In the remaining third, prolonged recording up to five days did not result in capturing a clinical event. For these individuals, shorter admission could be planned, for example for 2days rather than 5days.

Impact of the FDA Warning for Azithromycin and Risk for QT Prolongation on Utilization at an Academic Medical Center.

A US Food and Drug Administration (FDA) drug safety communication was released in March 2013, warning prescribers of the risk of QT prolongation associated with azithromycin. Overall azithromycin utilization and adherence to an inpatient QTc monitoring guideline during 8-month time periods before and after the warning were assessed to evaluate the impact of this warning on inpatient azithromycin utilization and QTc monitoring. Fifty-five patients were included in the prewarning time period and 50 were included in the postwarning period. A significant reduction in utilization in days of therapy per 1,000 patient days was observed (31.2 prewarning vs 17.5 postwarning, p < .001) in these groups. No changes in QTc monitoring among patients receiving azithromycin were identified. FDA warnings of severe, life-threatening toxicities can have a profound impact on utilization and prescribing of medications, however they may not necessarily change monitoring practices.

Postpartum Preeclampsia

The reported prevalence of postpartum hypertension and postpartum preeclampsia is 0.3% to 27.5%. In contrast to classic pre-eclampsia, symptoms of postpartum pre-eclampsia manifest after childbirth. Most cases develop within 48 hours after birth, although the syndrome can occur up to 6 weeks after childbirth. Indeed, 10% of maternal deaths from hypertension occur during the postpartum period, possibly because this may be beyond the window of routine care for new mothers. Mothers with postpartum hypertension represent a significant number of the postpartum readmissions at the Texas Children's Pavilion for Women. However, there are no established predictive measures or preventative treatments for postpartum preeclampsia. Our goal is to reduce postpartum readmissions for postpartum hypertension and preeclampsia by using a formal management algorithm based on consensus practice guidelines and internal data. Statistical analysis of our readmission data identifies predictive risk factors that help identify which women may be at highest risk of a hypertensive readmission. By scoring each postpartum woman by number of risk factors, we can screen for high-scoring women and provide an appropriate intervention. Data indicate 47 readmissions in 2014 and 6 year to date postimplementation. In formalizing a management protocol, we can ensure that at-risk women consistently receive extra counseling on postpartum preeclampsia and monitoring home blood pressures. This along with early initiation of adjunctive blood pressure medications or additional inpatient monitoring may play an important role in reducing postpartum readmissions and improving maternal outcomes.