Level Of Consciousness Research Articles

Sleep Hygiene for the Prevention of Hospital Delirium in Neurocritical Care Patients

Background Delirium is a state of altered level of consciousness often leading to confusion, inattention, and changes to levels of cognition. Delirium increases average length of stay in the hospital and costs the US health care system approximately $148 billion each year in associated medical costs. Sleep hygiene is an important factor in delirium prevention for all hospitalized patients. Objectives This quality improvement project was designed to increase implementation of an evidence-based sleep hygiene bundle in the neurocritical care population in order to decrease rates of hospital-acquired delirium. Methods This project followed the Plan, Do, Study, Act (PDSA) framework to facilitate a continuous quality improvement intervention at a mid-Atlantic academic medical center in the neurocritical care population. The continuous quality improvement included the incorporation of “sleep” as a topic into the daily rounding checklist, thus optimizing the ability to improve adherence to a multicomponent sleep hygiene bundle. The intervention includes the preintervention-postintervention occurrences of delirium and use of the daily rounding checklist. Results Nursing adherence to documentation of delirium assessments was high at approximately 99%. Following the intervention, there was a 41% decrease in the number of patients who screened positive for hospital-acquired delirium. Discussion The improvement in cases of hospital-acquired delirium may be attributed to the project intervention. Recommendations for future interventions include analysis of training on sleep plans, focus on nursing education regarding delirium assessment tools, or a measure of staff and/or patient satisfaction related to the intervention.

Effect of five different body positions on lung function in stroke patients with tracheotomy

ABSTRACT Background In stroke patients with tracheotomy, reduced lung function heightens pulmonary infection risk. Body position can affect lung function; however, its impact in stroke patients with tracheostomy remains unclear. Objective To investigate the influence of five body positions on pulmonary function in stroke patients with tracheotomy. Methods Pulmonary function was assessed in five body positions (supine, supine 30°, supine 60°, sitting, and prone) in 47 stroke patients who underwent tracheotomy. Diaphragmatic excursion during quiet breathing (DEQ), diaphragmatic thickening fraction during quiet breathing (DTFQ), and diaphragmatic excursion during coughing (DEC) were measured using ultrasound. Peak cough flow (PCF) was measured using an electronic peak flow meter. Results Different positions had a significant impact on DEQ, DEC, and PCF in stroke patients with tracheotomy, although not on DTFQ. DEQ showed no significant differences between supine 60°, sitting, and prone positions. Both DEC and PCF reached their maximum values in the sitting position. In the sub-group analysis, DEQ in females did not show significant differences across different positions. Both males and females exhibited significantly higher PCF in the sitting compared to supine position. The lung function of obese patients was significantly better in the sitting than in the supine and supine 30° position. Regardless of the patient’s level of consciousness and whether the brainstem was injured, lung function in the sitting position was significantly higher than in the supine position. Conclusions Body posture influences lung function in stroke patients with tracheotomy. Patients should adopt a sitting position to enhance pulmonary function.

A Retrospective Study of Tracheostomy Care and Decannulation of the Patients in a Palliative Care Center.

Background: World Health Organization defines palliative care as a multidisciplinary approach to enhancing patients physical, psychological, and emotional well-being. Our study investigated palliative care unit decannulation rates and factors affecting success. Methods: The data of patients hospitalized in the palliative care clinic between 2017 and 2019 were analyzed retrospectively. Demographic data, diagnoses, comorbidities, nutritional status, Norton and Braden Scale scores, day of hospitalization, and discharge direction of the patients were recorded. All patients were evaluated and treated by a multidisciplinary team. Results: One hundred two tracheostomy patients were monitored. Patients in the palliative care clinic had an average stay of 22.19 ± 13.67 days (median: 21, min: 4, max: 66). Forty-one patients were decannulated. Statistically significant age difference was observed between decannulated and non-cannulated groups, with the decannulated group having a significantly lower mean age (52.10 ± 20.54, median: 53) compared to the non-decannulated group (61.48 ± 18.07) (z = -2.516, P = .012). The mean Braden scale score of the decannulated group (14.29 ± 2.50) was significantly higher than that of the non-decannulated group (12.20 ± 2.82) (z = 3.823, P < .001), and the mean Norton scale score of the decannulated group (11.34 ± 2.50) was significantly higher than that of the non-decannulated group (9.46 ± 2.46) (z = 3.472, P = .001). Conclusion: Patients with tracheostomy can be easily followed and decannulated in palliative care clinics. It is important that a multidisciplinary team is involved in palliative care units. Age, immobility, Norton and Braden scales, and level of consciousness are factors affecting the success of decannulation.

Time to Treatment and Outcomes of Hemorrhagic Stroke, Comparing Patients Entering Surgery before and after 120 Minutes Upon Arrival at the Emergency Department Pattani Hospital

Background: The duration between a patient’s hospital arrival and the point at which they enter surgery for hemorrhagic stroke affects survival, length of stay, health care costs, and outcome (Glasgow Outcome Scale). Therefore, a study to explore the effects of time on these outcomes is warranted. Objective: To compare treatment outcomes of patients with hemorrhagic stroke having entered surgery before and after 120 minutes upon arrival at the emergency department. Materials and Methods: A therapeutic and interventional study with a retrospective observational cohort design at Pattani Hospital in patients with hemorrhagic stroke who received treatment between October 2018 and April 2023. A retrospective review of medical records, which collected clinical characteristics and the time to treatment. Glasgow Outcome Scale was evaluated at 72 hours, two weeks, one month, and date of hospital discharge. Length of stay, health care costs, and survival status at date of hospital discharge were analyzed. Comparative analysis was performed by Fisher’s exact probability test and t-test, and prognostic analysis was performed by risk ratio. Results: Of all the patients in the present study, 49 and 182 received treatment before and after 120 minutes, respectively, upon arrival at the emergency department. Clinical characteristics of gender, age, underlying conditions, regular medications, and level of consciousness were not significantly different between the two groups. Patients who entered surgery within 120 minutes of arrival had more occurrences of basal ganglia hemorrhage compared with those who received surgery thereafter. Furthermore, patients who received surgery within 120 minutes had a 11.4% increased chance of survival. The number needed to treat (NNT) hemorrhagic stroke patients with a time to treatment of under 120 minutes is 9. However, there was an associated increase in complications, health care cost, and length of stay. The Glasgow Outcome Scale improvement was greater only in the two-week follow-up period. These results were similar when subarachnoid hemorrhage and anticoagulating medication used were excluded. Conclusion: Patients with hemorrhagic stroke who receive early surgical treatment have lower mortality rates. Adequate provision of personnel and facilities for delivering prompt care should be made available. Measures should be taken to reduce the complications of patients who receive surgical treatment after 120 minutes upon arrival at the emergency department.

Exercise-Associated Hyponatremic Encephalopathy, Rhabdomyolysis, and Acute Kidney Injury While Hiking in the Grand Canyon.

We present an unusual case of concomitant exercise-associated hyponatremic encephalopathy (EAHE), exertional rhabdomyolysis (ER), and acute kidney injury (AKI) in a Grand Canyon hiker. Our case patient, an adult 41-year-old male, consumed an excessive amount of water during his descent into the Canyon during hot weather. The next day, he was unable to hike out due to severe leg pain and disorientation, and ultimately evacuated by helicopter, having a grand mal seizure in flight. Despite having no serum sodium level, medics administered an intravenous (IV) bolus of 3% hypertonic saline (HTS) before transporting him to the hospital. There, he was diagnosed with EAHE (serum sodium, 114 mmol⋅L-1), ER, bilateral compartment syndromes, and mild AKI. The life-threatening EAHE was immediately corrected with more IV HTS, the limb-threatening compartment syndromes by surgical fasciotomies, and eventually, the AKI by oral and IV fluids. This case demonstrates the seriousness of overconsumption of water, as well as the potential complications of muscle damage when a deconditioned person does prolonged, strenuous exercise. Furthermore, it also illustrates the importance of considering EAHE within the differential diagnosis for acute alterations in level of consciousness. Lastly, it shows the importance to prioritize patient treatments for conditions that are an immediate threat to life or limb.

Chronic subdural hematoma: Management, sequelae with its predictive factors, and health-related quality of life of survivors

Objectives: The objective of the study is to identify the risk factors associated with chronic subdural hematoma (CSDH) in the Pakistani population, to compare various surgical techniques commonly used in its management, and to analyze the outcomes of patients, including early, that is, at the time of discharge, and late, that is, the disability status of patients on follow-up after ≥6 weeks. Materials and Methods: This retrospective study was carried out at a tertiary care hospital in Pakistan between March 2023 and October 2023 and included 100 patients with CSDH. All patients underwent surgical procedures, and outcomes were assessed at six weeks. Results: The mean age of the patients diagnosed with CSDH in this study was 53.81 ± 11.54 years. The most commonly reported symptom was an altered level of consciousness (30%), but most patients presented with more than one symptom (50%). Mortality was associated with only 10% of cases, and 90% reported no complications or significant morbidity. The most commonly used surgical technique was two burr-hole drainage (67%). The risk of recurrence was increased with the presence of comorbidities (P = 0.001) and remarkably reduced with intraoperative subdural drain placement (P = 0.000). Conclusion: The choice of surgical technique had no influence on the length of stay in the hospital or functional status post-discharge but surgery with intraoperative subdural drain placement proved to yield definitive favorable outcomes.

Clinical and Radiological Parameters Affecting the Yield of Routine Electroencephalography in Various Indications.

To highlight the significance of various clinical and radiological parameters in association with specific electroencephalographic (EEG) patterns in order to prioritize EEG referrals. This retrospective, cross-sectional study was conducted in the neurology department of King Fahad University Hospital, Alkhobar, and involved a review and analysis of EEG and medical records pertaining to 604 patients referred for routine EEG. The data were analyzed using SPSS version 22. An association between various parameters and EEG yield was established. Factors associated with the yield of abnormal EEG patterns were diverse, like generalized tonic-clonic seizures (GTCs) (P =.05), status epilepticus (SE) (P =.05), altered level of consciousness (ALC) (P =.00), abnormal movement (P =.00), cardiac arrest (P =.00), prior history of epilepsy (P =.04), chronic renal disease (CRD) (P =.03), abnormal neurological exam (P =.00), and cortical lesions on brain imaging (P =.00). Among the abnormal EEG patterns, epileptiform activity (EA) in EEG was associated with focal seizures (P =.03), GTCs (P =.00), falls (P =.05), cardiac arrest (P =.00), a history of epilepsy (P =.00), and hypoxic ischemic injury (P =.03). Encephalopathy in EEG was also associated with focal sz (P =.02), GTCs (P =.00), SE (P =.01), ALC (P =.00), cardiac arrest (P =.00), history of stroke (P =.01), and epilepsy (P =.00). Among the studied parameters, patient level of consciousness, neurological exam findings, and neuroimaging findings, with some discrepancies, were found to be the most consistent in predicting the EEG yield. The study demonstrated the value of a proper neurological exam and careful selection of patients to gain the optimum benefit from the routine EEG.

The Development of Postoperative Hydrocephalus following Midline Posterior Cranial Fossa Tumors with Hydrocephalus Surgery with Preoperative Ventriculoperitoneal (V-P) shunt in Pediatric Patients

Background: Posterior cranial fossa tumors are the most common tumors in children and constitute about two-thirds of pediatric brain tumors. Such pediatric patient presents with symptoms and signs of raised intracranial pressure. All pediatric patients were diagnosed with midline posterior cranial fossa tumors with hydrocephalus. The ventriculoperitoneal shunt was done before definitive surgery for all patients. Definitive surgery was done later on. These patients were followed up to the 7th postoperative day following definitive surgery. We assessed the development of postoperative hydrocephalus. Objectives: The objective of the study was to assess the development of postoperative hydrocephalus of midline posterior cranial fossa tumors with hydrocephalus after definitive surgery following ventriculoperitoneal (V-P) shunt in pediatric patients. Methods: This cross-sectional experimental study was conducted in the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, and the Department of Pediatrics Neurosurgery, National Institute of Neurosciences &amp; Hospital, Dhaka from March 2018 to September 2019. A total of 43 pediatric patients were included in this study. All pediatric patients were diagnosed with midline posterior cranial fossa tumors with hydrocephalus. The ventriculoperitoneal shunt was done before definitive surgery. Later on, definitive surgery was performed. Follow-up of these patients was done up to the 7th postoperative day. The development of postoperative hydrocephalus was observed. Data were processed and then analyzed. Demographic data were expressed in numbers and percentages. The development of postoperative hydrocephalus was expressed in number and percentage. Logistic regression was done to predict the relationship between the dependent variable (development of hydrocephalus) and independent variables (age, sex, and the extent of tumor removal). The odds ratio (OR) was calculated by using the Chi-square test. The chi-square test gave a Wald statistic by observing at the 95% CI of the odds ratio. Statistical significance was set to p-value &lt;0.05. Results: A total of 43 pediatric patients were included in the study from March 2018 to September 2019. In the study, the maximum patients were in the age group 11-15 years. The mean age of the patients was 8.25 years ± 4.14. The male-to-female ratio was 1.26:1. The study showed preoperative clinical features which includes headache 40 (93%), vomiting 37 (86%), visual disturbance 24 (55.8%), altered level of consciousness 3 (7.0%), gait disturbance 30 (69.8%), swallowing disturbance 9 (20.9%), papilledema 38 (88.4%), lower cranial nerves palsy 8 (18.6%). Among them, 25 patients developed postoperative complications after definitive surgery. Development of postoperative hydrocephalus was found in 2 (4.65%) patients. Logistic regression was found to be statistically non-significant in this study. Conclusion: The development of postoperative hydrocephalus of midline posterior cranial fossa tumors with hydrocephalus after definitive surgery following ventriculoperitoneal (V-P) shunt in pediatric patients was not the major complication among others. Bang. J Neurosurgery 2024; 13(2): 86-95

Essential thrombocythemia complicated by multivessel intracranial dolichoectasia with subarachnoid hemorrhage and recurrent cerebral infarction

BackgroundPatients with essential thrombocythemia (ET) can develop systemic thrombotic and hemorrhagic vascular complications due to increased and dysfunctional platelets.Case presentationWe encountered a 49-year-old Japanese woman with a history of essential ET, cerebral infarction, hypertension, and hyperlipidemia. She had been taking anagrelide (2.5 mg/day) and aspirin (100 mg/day) and had vomited at home. At the time of admission to our hospital, she was in a deep stupor. We thought these symptoms were caused by intracranial hypertension. Head computed tomography showed severe subarachnoid hemorrhage (SAH) at the interhemispheric fissure, hematoma at the corpus callosum, and intraventricular hemorrhages. Digital subtraction angiography demonstrated multiple dilated, stenotic, tortuous intracranial arteries, and a dissecting aneurysm at the right anterior cerebral artery (ACA). The dissecting aneurysm measured 7.7 × 15.5 mm, and a bleb was observed. Our diagnosis was ruptured ACA dissecting aneurysm and diffuse intracranial arterial dolichoectasia (DIADE). We performed stent-assisted coil embolization of the aneurysm. She remained apathetic and manifested unilateral apraxia and alien limb syndrome due to a partial callosal disconnection. Two months thereafter her symptoms gradually improved, her consciousness level and limb function improved, and her modified Rankin scale (mRS) score was 2. However, when we tapered her antiplatelet therapy, she again developed an acute cerebral infarct.ConclusionsThis is the first presentation of a patient with ET complicated by DIADE, both of which can result in ischemic and hemorrhagic vascular complications including SAH. As antithrombotic therapy in patients with DIADE and ET may be associated with higher hemorrhage rates, its effects must be monitored carefully.

RSBagging: An ensemble classifier detecting the after-effects of ischemic stroke through EEG connectivity and microstates.

Stroke can lead to significant after-effects, including motor function impairments, language impairments (aphasia), disorders of consciousness (DoC), and cognitive deficits. Computer-aided analysis of EEG connectivity matrices and microstates from bedside EEG monitoring can replace traditional clinical observation methods, offering an automatic approach to monitoring the progression of these after-effects. This EEG-based method also enables quicker and more efficient assessments for medical practitioners. In this study, we employed Functional Connectivity features that extract spatial representation and Microstate features that focus on the time domain representation to monitor the after-effects of ischemic stroke patients. As the dataset from stroke patients is heavily imbalanced across various clinical after-effects conditions, we designed an ensemble classifier, RSBagging, to address the issue of classifiers often favoring the majority classes in the classification of imbalanced datasets. The experimental results demonstrate that different connectivity matrices are effective for three classification tasks: consciousness level, motor disturbance, and stroke location. Using our RSBagging model, all three tasks achieve over 98% accuracy, sensitivity, specificity, and F1-score, significantly outperforming the existing classifiers SVM, XGBoost, and Random Forest. Therefore, the RSBagging classifier based on connectivity matrices offers an effective method for monitoring the after-effects in stroke patients.

Surgical Management of Penetrating Carotid Artery Injury: Preoperative Level of Consciousness Does Matter.

The optimal surgical management of penetrating carotid artery injuries (PCAI) remains controversial. This study aimed to examine the association between operative techniques for PCAI and the incidence of stroke. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program (2016-2021) database. We included patients (≥16 years old) with severe penetrating injuries to the common or internal carotid arteries (CCA/ICA) who underwent one of the following operative procedures: primary suture repair, ligation, and arterial reconstruction with a graft. Multivariate logistic regression analysis with cluster-adjusted robust standard errors was performed to estimate the adjusted odds ratio (AOR) for postoperative stroke stratified by the initial Glasgow Coma Scale (GCS). A total of 429 patients were included (329 underwent primary suture repair, 82 underwent ligation, and 81 underwent arterial reconstruction with a graft). The median age was 31 years (interquartile range [IQR]: 24-43) and median GCS on arrival was 11 (IQR: 3-15). On multivariate analysis after adjusting for potential confounders, ligation of CCA/ICA was significantly associated with increased odds of stroke in patients with initial GCS ≥9 (AOR: 4.40, 95% confidence interval [CI]: 1.16-16.58, p=0.029), whereas there was no significant association in patients with GCS <9 (AOR: 0.77, 95% CI: 0.28-2.11, p=0.37). No significant association was identified between arterial reconstruction with a graft and stroke, irrespective of the initial GCS. The study findings suggest that the preoperative level of consciousness may help in planning operative strategies for PCAI. In patients with an initial GCS ≥ 9, definitive repair of the CCA/ICA, including arterial reconstruction with a graft, should be pursued instead of ligation.

Can Eye Tracking Help Assess the State of Consciousness in Non-Verbal Brain Injury Patients?

Background/Objectives: Developments in eye-tracking technology are opening up new possibilities for diagnosing patients in a state of minimal consciousness because they can provide information on visual behavior, and the movements of the eyeballs are correlated with the patients' level of consciousness. The purpose of this study was to provide validation of a tool, based on eye tracking by comparing the results obtained with the assessment obtained using the Coma Recovery Scale-Revised (CRS-R). Methods: The mul-ti-center clinical trial was conducted in Poland in 2022-2023. The results of 46 patients who were not able to communicate verbally due to severe brain injury were analyzed in this study. The state of consciousness of patients was assessed using the Minimally Conscious State Detection test (MCSD), installed on an eye tracker and compared to CRS-R. The examinations consisted of performing the MCSD test on patients five times (T1-T5) within 14 days. Collected data were processed based on the FDA and GCP's regulatory requirements. Depending on the nature of the data, the mean and standard deviation, median and lower and upper quartiles, and maximum and minimum values were calculated. Passing-Bablok regression analysis was used to assess the measurement equiva-lence of the methods used. Results: There was no difference between the MCSD and CRS-R in the raw change between T5 and T1 time points, as well as in the total % of points from all time points. The MCSD results from each time point show that at least the first two measurements serve to famil-iarize and adapt the patient to the measurement process, and the third and next measurement should be considered reliable. Conclusions: The results indicated a significant relationship be-tween the scores obtained with MCSD and CRS-R. The results suggest that it seems reasonable to introduce an assessment of the patient's state of consciousness based on eye-tracking technology. The use of modern technology to assess a patient's state of consciousness opens up the opportunity for greater objectivity, as well as a reduction in the workload of qualified personnel.

Latino Tú Latino Yo: Group Threat and Group Consciousness in California

This paper examines the rise of group consciousness in California during the 1990s. Many scholars have studied the increase in political participation in California and have alluded to an increase in group consciousness, but studies have not captured whether or not this actually exists. In this paper, I use seven surveys conducted between 1989 and 2004 and leverage the timing of these surveys to examine the role of perceived discrimination on Latino group consciousness in California. I hypothesize that the impact of political threat motivated an increase in group consciousness, which is driven by Latinos who perceived the discriminatory nature of California’s proposition politics in the 1990s. I find support for the hypothesis that perceived discrimination is positively associated with group consciousness during this time. However, the relationship between perceived group discrimination and group consciousness weakens after the threatening time period, even though reported levels of group consciousness continued to increase. This finding suggests that group threat may activate group consciousness even after feelings of threat have subsided.

Cerebral ptosis: An ominous sign in stroke—A retrospective study

AbstractIntroductionCerebral ptosis is defined as the drooping of eyelids due to lesions in the cerebral hemispheres. Cerebral ptosis is due to either unilateral or bilateral hemispheric damage without brainstem involvement. Ischemic strokes are the most common etiology leading to hemispheric damage.AimsTo assess the prevalence of cerebral ptosis in ischemic strokes and to correlate the presence of cerebral ptosis with the outcome of the patients. To also assess the demographic profile of these patients.Materials and MethodsThis is a retrospective study from June 2022 to August 2024. All patients diagnosed as acute stroke presenting with cerebral ptosis within day 3 of stroke were included. Patients with a reduced level of consciousness, brainstem involvement, and those with signs of impending herniation were excluded. The modified Rankin scale (mRS) on the day of admission and the day of discharge were compared.ResultsThere were 26 patients with cerebral ptosis among 649 patients admitted with anterior circulation stroke (prevalence 4.01%). 84.6% (n = 12) had right hemisphere involvement and 15.4% (n = 4) had left side involvement. 88.5% (n− = 23) had middle cerebral artery territory involvement and 7.7% (n = 2) had internal carotid artery territory involvement. The mean mRS on admission was 4.42 and 4.81 on discharge (paired t‐test 0.015). mRS 6 (death) was observed in four patients.ConclusionCerebral ptosis is a supranuclear disorder with the most common etiology being vascular insult to the cerebral hemisphere. It is an ominous and rare clinical sign. Identification of this entity is important, and it is not to be confused with a reduced level of consciousness.

Spectrum of delayed post-hypoxic leukoencephalopathy syndrome: A systematic review

BACKGROUND Delayed post hypoxic leukoencephalopathy syndrome (DPHLS), also known as Grinker’s myelinopathy, is a rare but significant neurological condition that manifests days to weeks after a hypoxic event. Characterized by delayed onset of neurological and cognitive deficits, DPHLS presents substantial diagnostic and therapeutic challenges. AIM To consolidate current knowledge on pathophysiology, clinical features, diagnostic approaches, and management strategies for DPHLS, providing a comprehensive overview and highlighting gaps for future research. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines, we systematically searched PubMed, ScienceDirect and Hinari databases using terms related to delayed post-hypoxic leukoencephalopathy. Inclusion criteria were original research articles, case reports, and case series involving human subjects with detailed clinical, neuroimaging, or pathological data on DPHLS. Data were extracted on study characteristics, participant demographics, clinical features, neuroimaging findings, pathological findings, treatment, and outcomes. The quality assessment was performed using the Joanna Briggs Institute critical appraisal checklist. RESULTS A total of 73 cases were reviewed. Common comorbidities included schizoaffective disorder, bipolar disorder, hypertension, and substance use disorder. The primary causes of hypoxia were benzodiazepine overdose, opioid overdose, polysubstance overdose, and carbon monoxide (CO) poisoning. Symptoms frequently include decreased level of consciousness, psychomotor agitation, cognitive decline, parkinsonism, and encephalopathy. Neuroimaging commonly revealed diffuse T2 hyperintensities in cerebral white matter, sometimes involving the basal ganglia and the globus pallidus. Magnetic resonance spectroscopy often showed decreased N-acetylaspartate, elevated choline, choline-to-creatinine ratio, and normal or elevated lactate. Treatment is often supportive, including amantadine, an antioxidant cocktail, and steroids. Hyperbaric oxygen therapy may be beneficial in those with CO poisoning. Parkinsonism was often treated with levodopa. Most of the patients had substantial recovery over the course of months and many cases had some residual neurocognitive deficits. CONCLUSION DPHLS remains a complex and multifaceted condition with various etiologies and clinical manifestations. Early recognition and appropriate management are crucial to improving patient outcomes. Future research should focus on standardizing diagnostic criteria, using advanced imaging techniques, and exploring therapeutic interventions to improve understanding and treatment of DPHLS. Conducting prospective cohort studies and developing biomarkers for early diagnosis and monitoring will be essential to advance patient care.

An Elderly Lady with Tetany and Brain Calcification

We present the case of a 59-year-old Bangladeshi lady who presented in Intensive Care Unit with tetany and altered level of consciousness. Tetany resolved after giving IV calcium injection. Initial laboratory investigations showed hypocalcemia. Non-contrast CT brain showed irregular bilateral symmetrical calcifications in basal ganglia, thalami, cerebellum and corona radiata. Subsequent laboratory test revealed low parathyroid hormone level. So, she was diagnosed as Fahr’s syndrome due to secondary hypoparathyroidism. This is a rare neurological disorder characterized by metabolic, biochemical, neuroradiological and neuropsychiatric abnormalities due to symmetrical and bilateral intracranial calcifications. Bangladesh Crit Care J September 2024; 12 (2): 160-162

TTR associated leptomeningeal amyloidosis in a Sri Lankan patient

ObjectivesThis case report aims to contribute to the expanding genotypic-phenotypic spectrum of TTR associated leptomeningeal amyloidosis. MethodsNeuroimaging and targeted TTR Sanger sequencing were performed on a 52-year-old female presenting with cognitive and motor symptoms. ResultsThe proband, a Sri Lankan woman, presented with a gradually progressive cognitive decline, followed by a rapid deterioration in motor function and level of consciousness. She had a significant family history of an undiagnosed neurological disorder, characterized by cognitive impairment and early death occurring in the fifth decade of life. Analysis of cerebrospinal fluid (CSF) demonstrated elevated protein levels. CT scan of the brain showed extensive leptomeningeal calcifications and hydrocephalus, and gadolinium enhanced magnetic resonance imaging (MRI) demonstrated extensive leptomeningeal enhancement in the brain and spinal cord.Genetic analysis revealed c.113 A > G, p.D38G mutation in TTR, a rare mutation with characteristic clinic-radiological central nervous system features. DiscussionLeptomeningeal amyloidosis represents the least common subtype of familial transthyretin amyloidosis, which is a life-threatening condition. Among the over 150 identified mutations, few are specifically associated with central nervous system disease. The genetic spectrum and clinical phenotypes including neuroimaging findings continue to expand. It is important to maintain a high index of suspicion for leptomeningeal amyloidosis, particularly when the presentation is not acute or when there are relapsing-remitting symptoms. Consideration of family history and early genetic testing are essential to facilitate appropriate treatment and genetic counselling.

Exploring bispectral index as an alternative to polysomnography for long-term sleep monitoring in disorders of consciousness.

Sleep plays a crucial role in neuroplasticity and recovery from brain injury, particularly in disorders of consciousness (DoC), including unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS). Traditional sleep monitoring methods like polysomnography (PSG) are complex and often impractical for long-term use in clinical settings. This study aimed to explore the utility of the Bispectral Index (BIS) as a more practical alternative for monitoring sleep patterns in DoC patients. We conducted simultaneous PSG and BIS monitoring on 38 DoC patients (19 UWS and 19 MCS). The study focused on analyzing sleep timing distribution, the effectiveness of BIS in differentiating sleep stages, and its correlation with consciousness levels. Our findings revealed that DoC patients exhibited irregular and fragmented sleep patterns, necessitating extended monitoring periods. The BIS effectively differentiated various sleep stages, with significant differences in BIS values observed across these stages. However, BIS values did not show significant differences between UWS and MCS patients, indicating that BIS primarily indicates wakefulness rather than cognitive awareness. DoC patients have disturbed sleep-wake cycles that require prolonged monitoring. BIS can well distinguish sleep stages in DoC patients, and the distribution of values is similar to that of normal subjects. However, BIS could not distinguish the level of consciousness of DoC patients. The study demonstrates the potential of BIS as a practical tool for long-term sleep monitoring in DoC patients, offering a less intrusive alternative to traditional methods.

The right to education under the conditions of martial state

The right to education is one of the fundamental human rights approved in the Constitution of Ukraine. However, the war conditions taking place on the territory of Ukraine create significant challenges for ensuring this right. In this article, we analyze the problems that arise in the context of ensuring the provisions of Article 53 of the Constitution of Ukraine in conditions of war and offer ways to solve them. This article highlights the importance of ensuring the right to education under martial law in Ukraine and suggests practical measures to achieve this goal. The study of this topic contributes to the development of effective strategies for managing educational processes in wartime conditions. Ensuring the right to education in the conditions of martial law in Ukraine becomes a particularly acute problem due to active hostilities and occupation of territories. Military operations are accompanied by violations of human rights, including the right to education, which is contrary to international standards. Military aggression forces the evacuation of schools, universities and other educational institutions, which disrupts the educational process and creates difficulties for obtaining an education. The results of military operations have serious psychological consequences for children, youth and teaching staff, which negatively affects their learning and work capacity. The article analyzes the problem of ensuring the right to education under martial law. The challenges faced by Ukraine in providing educational opportunities during the war are investigated. Special attention is paid to strategies for protecting the right to education, including the role of international law, humanitarian aid programs and innovative approaches to education. Based on this analysis, recommendations are provided to improve the situation with the right to education in the conditions of military conflict. The problems of education during the legal regime of martial law are analyzed, the need to continue measures to guarantee the constitutional right to education is emphasized, since education is considered extremely important for the progress of society, the future of the country directly depends on the level of education, talents, culture and consciousness of the young generation.

Baseline level of interleukin-6 is associated with the risk of acute coronary syndrome development in SARS-CoV‐2 infection

BackgroundAcute coronary syndrome (ACS) is frequently reported in patients with coronavirus disease 2019 (COVID-19). Cytokine storm induced by interleukin-6 (IL-6) has been suggested to potentially cause myocardial injury in COVID-19. We investigated the association between baseline level of IL-6 and development of ACS in COVID-19 patients.MethodsDemographic and clinical data of hospitalized COVID-19 patients from 2020 to 2022 were reviewed. Extracted data including patient characteristics, laboratory biomarkers, and systemic inflammation indexes in patients with or without ACS were reviewed and analyzed. Logistic regression models were applied to analyze predictors of ACS development and receiver-operating characteristic (ROC) curves were used to assess discriminatory power of IL-6 and other risk factors for predicting ACS development.ResultsAmong 1,753 COVID-19 patients, 37 cases experienced ACS and 159 patients without main COVID-19 complications were randomly selected as controls. ACS patients were older (p = 0.001) and suffered from more comorbidities including diabetes (43% vs. 18%, p = 0.001), hypertension (40.5% vs. 24.5%, p = 0.050), ischemic heart disease (49% vs. 9%, p = 0.001), and hyperlipidemia (19% vs. 5%, p = 0.010). Also, decreased level of consciousness (31.6% vs. 2.5%, p = 0.001), ICU admission (65% vs. 2%, p = 0.001), and mortality events (70% vs. 0.6%, p = 0.001) were more prevalent in the ACS group. Baseline levels of IL-6 (p = 0.001), D-dimer (p = 0.026), troponin (p = 0.001), blood urea nitrogen (p = 0.002), and creatinine (p = 0.008) were higher in ACS patients but erythrocyte sedimentation rate (p = 0.013), hemoglobin (p = 0.033), and red blood cells (p = 0.028) were lower compared with controls. Also, age (OR: 1.06, p = 0.019), IL-6 (OR: 1.44, p = 0.047), and cardiovascular disease (CVD) (OR: 3.66, p = 0.043) were associated with ACS development. The area under the curve (AUC) of IL-6 and combined predictors respectively was 0.661 (p = 0.002) and 0.829 (p = 0.001).ConclusionsHigh IL-6 concentration at baseline is a strong predictor for ACS development in COVID-19 patients. Also, elderly and concurrent CVD are significantly associated with ACS development.