BackgroundEarly recognition and treatment of autoimmune encephalitis (AE) has become an essential issue in clinical practice. However, little is known about patients with deteriorating conditions and the need for intensive care treatment. Here, we aimed to characterize underlying aetiologies, clinical symptoms, reasons for intensive care admission, and mortality of critically ill patients with AE.MethodsWe conducted a retrospective chart review of all patients with “definite” or “probable” diagnoses of AE treated at our neurological intensive care unit between 2002 and 2015. We collected and analyzed clinical, paraclinical, laboratory findings and assessed the mortality at last follow-up based on patient records.ResultsTwenty-seven patients [median age 55 years (range 25–87), male = 16] were included. Thirteen (48%) had “definite” AE. The most common reasons for admission were status epilepticus (7/27, 26%) and delirium (4/27, 15%). One-year survival was 82%, all five deceased were male, and 3 (60%) of them had “probable” disease. The non-survivors (median follow-up 1 year) were more likely to have underlying cancer and higher need for respiratory support compared to the survivors (p < 0.041, and p = 0.004, respectively).ConclusionsClinical presentations and outcomes in critically ill patients with AE are diverse, and the most common leading cause for intensive care unit admission was status epilepticus. The association of comorbid malignancy and the need for mechanical ventilation with mortality deserves further attention.Electronic supplementary materialThe online version of this article (doi:10.1007/s12028-016-0370-7) contains supplementary material, which is available to authorized users.
Therapeutic plasma exchange (TPE) is a well-established method of treatment for steroid-refractory relapses in multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Little is known about indications and clinical responses to TPE in autoimmune encephalitis and other immune-mediated disorders of the central nervous system (CNS). We performed a retrospective chart review of patients with immune-mediated disorders of the CNS undergoing TPE at our tertiary care center between 2003 and 2015. The response to TPE within a 3- to 6-month follow-up was scored with an established rating system. We identified 40 patients including 21 patients with multiple sclerosis (MS, 52.5%), 12 with autoimmune encephalitis (AE, 30%), and 7 with other immune-mediated CNS disorders (17.5%). Among patients with AE, eight patients had definite AE (Immunolobulin G for N-methyl-D-aspartate receptor n = 4, Leucine-rich, glioma inactivated 1 n = 2, Ma 2 n = 1, and Alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic Acid n = 1). Intravenous immunoglobulins had been given prior to TPE in all but one patient with AE, and indications were dominated by acute psychosis and epileptic seizures. While TPE has a distinct place in the treatment sequence of different immune-mediated CNS disorders, we found consistent efficacy and safety. Further research should be directed toward alternative management strategies in non-responders.
BackgroundOver the course of multiple sclerosis (MS) several conditions may arise that require critical care. We aimed to study the reasons for admission and outcome in patients with MS admitted to a neuro-intensive care unit (NICU).MethodsWe retrospectively searched the electronic charts of a 9-bedded NICU in a tertiary hospital for patients with a diagnosis of multiple sclerosis (MS) from 1993–2015, and matched them to NICU controls without MS based on age and gender. Conditional logistic regression was used to compare admission causes, Charlson’s Comorbidity Index, indicators of disease severity, and survival between MS and non-MS patients.ResultsWe identified 61 MS patients and 181 non-MS controls. Respiratory dysfunction was the most frequent reason for NICU admission among MS patients (34.4%), having infectious context as a rule. In a matched analysis, after adjusting for co-morbidities and immunosuppressive medications, patients with MS were more likely to be admitted to the NICU because of respiratory dysfunction (OR = 7.86, 95% CI 3.02–20.42, p<0.001), non-respiratory infections (OR = 3.71, 95% CI 1.29–10.68, p = 0.02), had a higher rate of multiple NICU admissions (OR = 2.53, 95% CI 1.05–6.05, p = 0.04) than non-MS patients. Mortality after NICU admission at a median follow-up time of 1 year was higher in MS than control patients (adjusted OR = 4.21, 95% CI 1.49–11.85, p = 0.04).ConclusionThe most common reason for NICU admission in MS patients was respiratory dysfunction due to infection. Compared to non-MS patients, critically ill MS patients had a higher NICU re-admission rate, and a higher mortality.
Mortality in critically ill MS patients is largely driven by respiratory complications. Sporadic disparities between clinical and pathological findings can be expected.
Journal Club: Effect of comorbidity on mortality in multiple sclerosisMultiple sclerosis (MS) is a chronic demyelinating disease of the CNS estimated to reduce life expectancy by 7-14 years compared to demographically similar groups in the general population.1 While several disease complications pose a potential risk for mortality, results from large observational studies suggest that comorbidities substantially influence survival in MS. 2,3 In a recent Neurology ® article, Marrie et al. 4 applied an effective methodologic approach to assess the contribution of comorbidity to excess mortality in the MS population. Besides its considerable epidemiologic merit, the study has important implications for the management of patients with MS, particularly if closer surveillance and targeted interventions may reduce the burden of comorbidity among them and improve survival. performed a retrospective matched cohort study using population-based administrative data. The authors stratified cohorts by birth year in order to study temporal changes in survival, hypothesizing that the latter improves in the MS population over time. They also hypothesized that comorbidity shortens the survival of persons with MS. Cox regression analysis employed for statistical analysis provides us with a thorough insight into the effect of multiple covariates on the time to death, whereas some other studies traditionally use logistic regression, which estimates the probability of binary survival response (died vs alive) over the period of observation. An alternative method with time-to-event outcome is the log-rank test, which does not allow adjustment for confounding factors. 5METHODS The authors combined data extracted from 2 data sources. The first was administrative (health) data from the province of Manitoba, Canada, covering 98% of the population. The second data source was the Manitoba Vital Statistics Death Database, encompassing information on all deaths in Manitoba, including date and cause of death classified according to ICD-9 or ICD-10, depending on the time period. Using a validated administrative case definition, the authors identified all MS cases and up to 5 controls for each case, matched on sex, exact year of birth, and region of residence, from April 1, 1984, to March 31, 2012 To analyze the survival in both populations, the authors used univariate Cox regression with age as the time scale. Unlike the standard approach of using time on study as the time scale in a Cox regression (which means estimating time from entry into the study until the event of interest, typically death), and adjusting the model for age, this alternative approach to use age as the time scale allows a straightforward adjustment for multiple effects of aging process, and is recommended for analyzing epidemiologic cohort data. 6 On the other hand, the authors addressed a common source of bias in applications of survival analysis known as left truncation, which occurs when the individuals who have already passed the event of interest prior to study...
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