Neurohospitalist最新文献

{"title":"Late-Onset Multiple Acyl-CoA Dehydrogenase Deficiency Presenting as Hyperammonemia and Encephalopathy: Case Series.","authors":"Cristina Viguera Altolaguirre, Andrew B Stergachis, David A Sweetser, Nina B Gold","doi":"10.1177/19418744251324959","DOIUrl":"10.1177/19418744251324959","url":null,"abstract":"<p><p><b>Background:</b> Multiple acyl-CoA dehydrogenase deficiency (MADD) is an inherited metabolic disorder (IMD) that affects the electron transfer chain and fatty acid oxidation. The late-onset form of MADD has a heterogenous clinical presentation that typically results in episodic lethargy, hypoglycemia, acidosis, and rhabdomyolysis during metabolic decompensations. <b>Purpose:</b> In this case report series we describe three cases of late-onset MADD presenting with hyperammonemia and encephalopathy, a less frequent but severe complication. <b>Methods:</b> the medical records of three patients with MADD and hyperammonemia were retrospectively analyzed for details surrounding their presentation and workup. <b>Results:</b> One patient had hyperammonemia to 445 μmol/L, obtundation, and seizures, requiring venovenous hemodialysis. Two patients had abnormal brain imaging findings. Two of the cases were initially diagnosed as hepatic encephalopathy, but treatment for this did not reverse the hyperammonemia. Workup for IMDs revealed biochemical profiles consistent with MADD, with non-diagnostic genetic testing. MADD-directed therapy led to a reversal of hyperammonemia and return to neurologic baseline of all patients. <b>Conclusion:</b> This series highlights hyperammonemia as a presentation of late-onset MADD, a potentially lethal but treatable disorder.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251324959"},"PeriodicalIF":0.9,"publicationDate":"2025-03-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11881097/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143574338","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictors of Skilled Nursing Facility Length of Stay and Discharge After Aneurysmal Subarachnoid Hemorrhage.","authors":"Carl M Porto, Dylan N Wolman, Joshua R Feler, Carlin C Chuck, Gnaneswari Karayi, Radmehr Torabi, Krisztina Moldovan, Karen L Furie, Ali Mahta","doi":"10.1177/19418744251323639","DOIUrl":"10.1177/19418744251323639","url":null,"abstract":"<p><strong>Background and purpose: </strong>Aneurysmal subarachnoid hemorrhage (aSAH) carries high morbidity and mortality with survivors often requiring extended care at skilled nursing facilities (SNF). Predictors of SNF discharge to home (SNFdcH) remain unclear.</p><p><strong>Methods: </strong>Retrospective review of a single-center prospectively maintained aSAH database from June 2016-March 2024 was conducted. Patients discharged to SNF were grouped by subsequent discharge to home. Predictors of discharge to home and facility length of stay (LOS) were determined using t-tests, Fisher analyses, and cumulative link modeling.</p><p><strong>Results: </strong>Of 450 aSAH patients, 61 (13.5%) were discharged to SNFs. 49 (80.3%) returned home, with 61% achieving mRS <3 at discharge. Discharged patients were younger (mean 63.3 ± 11.5 vs 70.2 ± 9.3 years, <i>P</i> = .040) with lower median modified Fisher scores (3 [IQR 3-4] vs 4 [4-4], <i>P</i> = .046). Tracheostomy (OR = .14, 95% CI [.02, .75], <i>P</i> = .023) and gastrostomy tube (PEG) placement (OR = .13, 95% CI: .03-.51, <i>P</i> = .003) decreased the odds of SNFdcH. Discharged patients had shorter hospital LOS (26 ± 10 vs 39 ± 15 days, <i>P</i> < .001) and lower median modified Rankin scores (mRS) at hospital discharge (4 [4-5] vs 5 [4-5], <i>P</i> = .028) and at 90 days post-discharge (4 [3-5] vs 6 [5-6], <i>P</i> = .001). Multivariable regression identified age, PEG, and hospital LOS as predictors of SNFdcH. Tracheostomy and PEG predicted SNF LOS.</p><p><strong>Conclusions: </strong>Most aSAH patients discharged from SNFs returned home, with 61% achieving mRS <3. Patients not discharged were medically complex with neurological deficits. These findings may guide care discussions and highlight the role of SNFs in bridging hospitalization and independence.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251323639"},"PeriodicalIF":0.9,"publicationDate":"2025-02-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11863197/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143524541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Problem Solving: A 67-year-old Man With Painful Leg Weakness and Difficulty Walking.","authors":"Ryan Verity, Elizabeth Raynor, Jonah Zuflacht","doi":"10.1177/19418744251324078","DOIUrl":"10.1177/19418744251324078","url":null,"abstract":"<p><p>Rapidly progressive neurologic symptoms can be alarming to both the patient and the clinician, given the concern for serious pathologies. In this case, a 67-year-old patient presents with painful sensorimotor symptoms that progress rapidly within days of onset. Proper localization and consideration of medical co-morbidities is essential for accurate diagnosis. This case highlights the importance of a detailed neurologic examination to aid in the localization and differential diagnosis. The case will take readers through a stepwise approach to this complex neurologic presentation, work-up and management.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251324078"},"PeriodicalIF":0.9,"publicationDate":"2025-02-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11851592/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143515731","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Satisfaction With Teleneurology in Low Resource Setting: A Cross-Sectional Study Among Patients and Healthcare Providers.","authors":"Mohammed Farhan Ansari, Deepak Menon, Milu Anna Ittycheria, Sarath Govindaraj, Rehan Shahed, Deenadayalan Boopalan, Rajani Parthasarathy, Girish N Rao, Faheem Arshad, Suvarna Alladi","doi":"10.1177/19418744251321552","DOIUrl":"10.1177/19418744251321552","url":null,"abstract":"<p><strong>Background and objectives: </strong>Teleneurology has become instrumental in extending neurologic care in remote and underserved areas, enhancing access, and potentially improving patient outcomes while reducing costs. This study evaluates the satisfaction of both patients and healthcare providers with teleneurology services for common neurological disorders.</p><p><strong>Methods: </strong>In this single-center, prospective observational study, 58 patients suffering from headache, epilepsy, stroke, or dementia were recruited through the \"Karnataka Brain Health Initiative.\" Teleconsultations were facilitated via Zoom, incorporating brief neurological examinations. Satisfaction levels were gauged using the Telemedicine Satisfaction Questionnaire (TSQ) for patients and the Patient and Physician Satisfaction with Monitoring Questionnaire (PPSM) for healthcare providers.</p><p><strong>Results: </strong>Of the 58 patients enrolled, 18 had headache, 12 epilepsy, 13 stroke, and 15 dementia, with a mean age of 43.7 years. All completed the TSQ, yielding a mean score of 4.47 ± 0.41. The average teleconsultation lasted 21.21 minutes. The PPSM questionnaire, completed by neurologists for all patients, resulted in a mean score of 4.33 ± 0.44. Of these, 36 consultations initiated by primary care physicians had a PPSM mean score of 4.47 ± 0.51. Agreement on quality of care was 60%, time-saving benefit 98%, and willingness for future use 95%.</p><p><strong>Discussion: </strong>The findings indicate high satisfaction among both patients and providers, underscoring the effectiveness of teleneurology in delivering quality care comparable to in-person consultations. The positive feedback from primary care physicians highlights teleneurology's potential as an integral component of healthcare delivery in low-resource settings.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251321552"},"PeriodicalIF":0.9,"publicationDate":"2025-02-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11843563/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143484186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Navigating the Shift: Comparing Safety and Cost of Tenecteplase versus Alteplase in Acute Ischemic Stroke.","authors":"Carina Cassano, Daryl Schiller, Magda Fulman","doi":"10.1177/19418744251321530","DOIUrl":"10.1177/19418744251321530","url":null,"abstract":"<p><strong>Background and purpose: </strong>Recently, institutions have been transitioning to tenecteplase (TNK) as the primary agent for stroke management instead of alteplase (tPA) due to its comparable safety and cost-effectiveness. Despite TNK's potential cost benefits, there's limited literature on how wasted doses impact the overall cost. This study aimed to compare the safety and cost of TNK to tPA following the transition to TNK as the primary agent for acute ischemic stroke (AIS) management at a community hospital.</p><p><strong>Methods: </strong>This retrospective study compared patients treated with tPA or TNK for AIS. The primary outcome was a composite of intracranial hemorrhage, any other bleed, and death from any cause. Secondary outcomes included the individual components of the primary outcome, length of hospitalization, time from administration decision to medication administration, readmission rate, medication costs, and wasted doses.</p><p><strong>Results: </strong>48 AIS patients who received either tPA or TNK between November 2021 and February 2024 were included. TNK didn't result in more occurrences of the primary outcome compared to tPA (OR 1.00, 95% CI 0.25 to 4.03). The TNK group had a shorter median length of hospitalization and decreased elapsed time from administration decision to administration. The cost difference between a 50 mg kit of TNK and a 100 mg vial of tPA is about $1100. The total number of wasted doses was 10 for tPA and 12 for TNK.</p><p><strong>Conclusions: </strong>There was no difference in safety between TNK and tPA. While TNK offers cost savings, poor waste management could undermine its overall cost-effectiveness.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251321530"},"PeriodicalIF":0.9,"publicationDate":"2025-02-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11830155/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143442420","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Case of Extended Duration Triple Antithrombotic Therapy in a Patient With an Intracranial Stent and Atrial Fibrillation.","authors":"Samuel C Greer, Drew A Wells, Ehizele Osehobo, Kerri Jones","doi":"10.1177/19418744251321547","DOIUrl":"10.1177/19418744251321547","url":null,"abstract":"<p><p>Our case report presents the clinical management of a 77-year-old female with recurrent acute ischemic stroke (AIS) due to severe intracranial large artery atherosclerosis (LAA), requiring intracranial stenting complicated by new-onset atrial fibrillation (AF). This clinical scenario necessitated the use of triple antithrombotic therapy (TAT) with aspirin, ticagrelor, and apixaban. While guidelines recommend minimizing the duration of TAT or favoring alternative regimens due to bleeding risks, this case highlights the safe application of an extended duration TAT course in a high-risk patient. The patient initially presented with recurrent AIS despite dual antiplatelet therapy (DAPT). Subsequent intracranial stenting and AF diagnosis posed challenges in balancing ischemic and bleeding risks. Multidisciplinary, shared decision-making guided the initiation of TAT. Despite a history of early recurrent strokes and high-risk stenting, no major, life-threatening, or minor bleeding complications were observed during the extended duration of TAT. This case underscores the need for tailored antithrombotic regimens in neurovascular patients with AF and high ischemic risk.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251321547"},"PeriodicalIF":0.9,"publicationDate":"2025-02-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11829274/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434268","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Successful Treatment of Cerebral Gnathostomiasis With Solely Steroid Administration: A Case Report.","authors":"Witoon Mitarnun, Lisa Kongngern","doi":"10.1177/19418744251321884","DOIUrl":"10.1177/19418744251321884","url":null,"abstract":"","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251321884"},"PeriodicalIF":0.9,"publicationDate":"2025-02-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11829273/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434270","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Housing Status and Healthcare Utilization in People Presenting With Seizure.","authors":"Sandeepa S Mullady, Andrew J Wood, Elan L Guterman, Nicole Rosendale","doi":"10.1177/19418744251321877","DOIUrl":"10.1177/19418744251321877","url":null,"abstract":"<p><strong>Objective: </strong>To examine the association between housing status and healthcare utilization in individuals presenting with seizure.</p><p><strong>Methods: </strong>We performed a retrospective cross-sectional analysis of all adults (age >18) presenting to a public hospital emergency department with seizures, defined by ICD-9/10 codes, between 1/1/2016 and 8/03/2019. They were categorized by housing status (people experiencing homelessness [PEH], people with housing). Healthcare utilization outcomes were 30-day re-visit to acute care, discharge disposition, and hospital length of stay for those admitted. We used multivariable linear and logistic regression models adjusting for age, comorbidities, and insurance status.</p><p><strong>Results: </strong>There were 6483 individuals (2092 [32.3%] PEH). Compared to people with housing, PEH were younger (48.2 vs 50.9, <i>P</i> < .0001), more likely to be a person of color (80.9 vs 75.1%, <i>P</i> < .0001), and have Medicaid (51.4% vs 42.9%, <i>P</i> < .0001). People with housing had a higher prevalence of admission to the intensive care unit (3.6% vs 1.8%, <i>P</i> < .0001). After adjustment, admitted PEH had higher odds of 30-day re-visit (adjusted odds ratio [aOR] 1.87, 95% confidence interval [CI] 1.58, 2.21), shorter length of stay (coef Β-12.87, 95% CI: -22.62, -3.11), and lower odds of being discharged to a facility (aOR 0.37, 95% CI: .26, .55) compared to people with housing.</p><p><strong>Conclusion and relevance: </strong>PEH with seizures had increased healthcare utilization. Further analysis, including imaging findings, anti-seizure medications prescribed, and presumed etiology, is needed to understand the drivers of healthcare utilization and identify appropriate interventions.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251321877"},"PeriodicalIF":0.9,"publicationDate":"2025-02-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11826817/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143434269","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond Septic Encephalopathy: A Case Report of Severe RCVS and PRES in a Patient With HLH due to Appendicitis.","authors":"Kathryn Swider, Aleksey Tadevosyan, Mara M Kunst, Joseph D Burns","doi":"10.1177/19418744251319057","DOIUrl":"10.1177/19418744251319057","url":null,"abstract":"<p><p><b>Background and Objectives</b>: We report a rare case of severe posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) in an adult patient with hemophagocytic lymphohistiocytosis (HLH), and speculate that these three diagnoses are related by similar mechanisms of vascular endothelial dysfunction. <b>Methods</b>: Informed consent for this case report was obtained from the patient's legally authorized surrogate decision maker. <b>Discussion and Practical Implications</b>: Our patient initially presented with HLH secondary to intra-abdominal sepsis, and was later found to have severe PRES and RCVS resulting in extensive border-zone cortex infarction. Improvement of the severe systemic inflammatory syndrome characteristic of HLH and arrest of PRES and RCVS progression occurred only after HLH-specific treatment was initiated. In addition to illustrating the potential of HLH to manifest as PRES and RCVS, this case emphasizes the importance of prompt recognition and treatment of HLH and the role the neurologist can play in this process. This case also sheds light on the pathophysiological links between PRES, RCVS, and HLH. These three diagnoses may be related by similar mechanisms of vascular endothelial dysfunction caused by uncontrolled and severe systemic inflammation.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251319057"},"PeriodicalIF":0.9,"publicationDate":"2025-02-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11806449/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143383627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Inpatient Implementation of Portable Ocular Fundus Photography Among Neurology Residents.","authors":"Nicholas U Schwartz, Andrew Silverman, Shannon Beres, Heather E Moss, Kathryn Kvam, Kristin Galetta","doi":"10.1177/19418744251317260","DOIUrl":"10.1177/19418744251317260","url":null,"abstract":"<p><p><b>Background:</b> Nonmydriatic ocular fundus photography has been studied with demonstrated benefit in the evaluation of emergency department neurological complaints, particularly in triaging headache and focal neurological deficits. Likewise, portable fundus camera usage may be practical for inpatients with neurological complaints, although feasibility has not been studied in a neurology teaching service. <b>Purpose:</b> The objective of this study is to determine if a portable, nonmydriatic fundus camera could be integrated into routine clinical care by neurology inpatient housestaff at a tertiary medical center. <b>Research Design:</b> Housestaff were asked to obtain fundus photographs for patients with specific indications for fundoscopy. <b>Study Sample:</b> During a 1-month pilot period, housestaff were successfully able to upload images from 21 patients, which were reviewed by a neuro-ophthalmology attending, with input from on-call ophthalmology if desired. <b>Results:</b> Surveys of housestaff before (n = 13) and after (n = 12) implementation demonstrated increased confidence in camera operation and in ocular structure identification, description, and interpretation. Thematic analysis on qualitative feedback suggested benefits in clinical (improving fundus visualization, aiding in triage, sharing images with offsite staff), health systems (reducing length of stay, reducing ophthalmology consultations, reduced unnecessary testing), and educational domains (facilitating group discussions of images, sharing photographs with patients). <b>Conclusions:</b> Overall, inpatient portable fundus photography was shown to be feasible and effective for rapid fundus visualization for neurological inpatients, enhancing the ability to share, document, and compare examinations among neurology housestaff. Further work is needed to confirm clinical and educational benefits of portable fundus photography usage by neurology residents, as suggested by this healthcare quality improvement pilot study.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251317260"},"PeriodicalIF":0.9,"publicationDate":"2025-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11780609/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143081413","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}