Objective: This study compares 2 treatment protocols allowing low vs high continuous IV midazolam (cIV-MDZ) doses. Methods:We compared adults with refractory status epilepticus treated with a protocol allowing for high-dose cIV-MDZ (n 5 100; 2002-2011) with those treated with the previous lower-dose cIV-MDZ (n 5 29; 1996-2000. We collected data on baseline characteristics, cIV-MDZ doses, seizure control, hospital course, and outcome.Results: Median maximum cIV-MDZ dose was 0.4 mg/kg/h (interquartile range [IQR] 0.2, 1.0) for the high-dose group and 0.2 mg/kg/h (IQR 0.1, 0.3) for the low-dose group (p , 0.001) with similar duration of infusion. Median time from status epilepticus onset to cIV-MDZ start was 1 day (IQR 1, 3) for the high-dose group and 2 days (IQR 1, 5) for the low-dose group (p 5 0.016). "Withdrawal seizures" (occurring within 48 hours of discontinuation of cIV-MDZ) were less frequent in the high-dose group (15% vs 64%, odds ratio 0.10, 95% confidence interval 0.03-0.27). "Ultimate cIV-MDZ failure" (patients requiring change to a different cIV antiepileptic medication) and hospital complications were not different between groups. Hypotension was more frequent with higher cIV-MDZ doses but was not associated with worse outcome. Discharge mortality was lower in the high-dose group (40% vs 62%, odds ratio 0.34, 95% confidence interval 0.13-0.92 in multivariate analysis).Conclusions: High-dose cIV-MDZ treatment of refractory status epilepticus can be performed safely, is associated with a lower seizure rate after cIV-MDZ discontinuation, and may be associated with lower mortality than traditional lower-dose protocols. Classification of evidence:This study provides Class III evidence that midazolam at higher infusion rates is associated with a reduction in seizure recurrence within 48 hours after discontinuation and may be associated with lower mortality. Neurology ® 2014;82:359-365 GLOSSARY AED 5 antiepileptic drug; cEEG 5 continuous EEG; CI 5 confidence interval; cIV 5 continuous IV; ICU 5 intensive care unit; IQR 5 interquartile range; MDZ 5 midazolam; OR 5 odds ratio; RSE 5 refractory status epilepticus; SE 5 status epilepticus.Status epilepticus (SE) is a neurologic emergency that requires prompt management.1-3 SE that does not respond to standard treatment regimens is labeled as refractory SE (RSE).2,4 Recent guidelines recommend anesthetic doses of midazolam for these patients, 2 but so far no adequately powered randomized controlled trial has compared different treatment strategies for RSE. 2,5,6 The difficulty of conducting such a study has been recently highlighted by the early termination of a prospective trial comparing propofol and barbiturates for patients with RSE. Thus, the best currently available options for guiding therapy of these very sick patients are careful investigation of the underlying pathophysiology as well as comprehensive observational studies.We previously reported our initial experience with the use of midazolam infusions for the treatment of RSE, 8 after which ...
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Previous proteomic evidence revealed that the content of certain peptide fragments including Vgf-derived peptide aa 398-411 (Vgf398-411) of the precursor Vgf protein in the cerebral spinal fluid (CSF) correctly identified patients with ALS from normal and disease controls. Using quantitative ELISA immunoassay we found that the CSF levels of Vgf decreases with muscle weakness in patients with ALS. In SOD1 G93A transgenic mice, loss of full-length Vgf content in CSF, serum and in SMI-32 immunopositive spinal cord motor neurons is noted in asymptomatic animals (approximately 75 days old) and continues to show a progressive decline as animals weaken. In vitro studies show that viral-mediated exogenous Vgf expression in primary mixed spinal cord neuron cultures attenuates excitotoxic injury. Thus, while Vgf may be a reliable biomarker of progression of muscle weakness in patients with ALS, restoration of Vgf expression in spinal cord motor neurons may therapeutically rescue spinal cord motorneurons against excitotoxic injury.
BACKGROUND:Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized.OBJECTIVE:To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort.METHODS:We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention.RESULTS:A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between 2007 and 2017, the prevalence of frailty grew from 7.9% to 21.7%. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < .001) and decreased odds of favorable discharge disposition (OR = 0.72, P < .001). Frail patients exhibited an elevated rate of complications (OR = 1.06, P < .001), including unplanned return to the ICU (OR = 1.55, P < .001) and operating room (OR = 1.17, P = .003). Finally, frail patients experienced increased ventilator days (+12%, P < .001), ICU LOS (+11%, P < .001), and total LOS (+13%, P < .001). All associations with death and disposition remained significant after stratification for age, trauma severity, and neurosurgical intervention.CONCLUSION:For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.
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