Faculty Bibliography

BACKGROUND AND PURPOSE/OBJECTIVE:The relationship between in-hospital hyperglycemia and neurological outcome after intracerebral hemorrhage (ICH) is not well studied. METHODS:We analyzed the relationships between pre-hospital and hospital variables including highest in-hospital glucose (HIHGLC) and discharge Glasgow Coma Scale (GCS), discharge Modified Rankin Scale (MRS) and 3-month MRS using a single-institution cohort of ICH patients between 2013 and 2015. RESULTS:There were 106 patients in our sample. Mean HIHGLC was 154 ± 58mg/dL for patients with discharge GCS of 15 and 180 ± 57mg/dL for patients with GCS < 15; 146 ± 55mg/dL for patients with discharge MRS 0-3 and 175 ± 58mg/dL for patients with discharge MRS 4-6; and 149 ± 52mg/dL for patients with 3-month MRS of 0-3 and 166 ± 61mg/dL for patients with 3-month MRS of 4-6. On univariate analysis, discharge GCS was associated with HIHGLC (P = .01), age (P = .006), ICH volume (P = .008), and length of stay (LOS) (P = .01); discharge MRS was associated with HIHGLC (P < .001), age (P < .001), premorbid MRS (P = .046), ICH volume (P < .001), and LOS (P < .001); and 3-month MRS was associated with HIHGLC (P = .006), discharge MRS (P < .001), age (P = .001), sex (P = .002), ICH volume (P = .03), and length of stay (P = .004). On multivariate analysis, discharge GCS only had a significant relationship with ICH volume (odds ratio [OR] .949, .927-.971); discharge MRS had a significant relationship with age (OR 1.043, 1.009-1.079), premorbid MRS (OR 2.622, 1.144-6.011), and ICH volume (OR 1.047, 1.003-1.093); and 3-month MRS only had a significant relationship with age (OR 1.039, 1.010-1.069). CONCLUSIONS:The relationship between in-hospital hyperglycemia and neurological outcomes in ICH patients was meaningful on univariate, but not multivariate, analysis. Glucose control after ICH is important.

Depot medications have been used for long-term treatment of many different medical conditions (schizophrenia, opioid addiction) and for prevention of pregnancy (birth control). In addition, proposals for depot medication for antidepressants have been made as a possible treatment for chronic depression. For the treatment of chronic epilepsy, there are currently no depot antiepileptic drugs (AEDs). However, there may be a role for them. Depot AEDs could improve medication adherence rates, thereby reducing the morbidity and mortality that are associated with ongoing seizures. This could help to reduce hospital costs for people with epilepsy. Potential patient populations that could benefit from a depot AED include patients with forgetfulness, socioeconomic barriers to access of daily oral medications, impaired gastric absorption or dysphagia, comorbid epilepsy and psychiatric disease, and personal preference to avoid the inconvenience of taking a medication daily or even multiple times per day. In this article, we review reasons to create a depot AED and the outcomes of doing so in the context of the pillars of bioethics: beneficence (to act in a patient's best interest), autonomy (to respect a patient as an individual and honor their preferences), nonmaleficence (to do no harm), and justice (to treat all persons fairly and equally).

Background/UNASSIGNED:Numerous medical society guidelines recommend discontinuation of antibiotics at a maximum of 24 hours after noninstrumented spinal surgery, even when a drain is left in place. As a result of these recommendations, our institution's Neurosurgery Quality Improvement Committee decided to stop administering prolonged prophylactic systemic antibiotics (PPSAs) to patients with drains after noninstrumented spinal surgery. Methods/UNASSIGNED:We retrospectively reviewed data for patients who had noninstrumented spinal surgery performed by a neurosurgeon at our institution between December 2012 and July 2014 (PPSA period) and December 2014 and July 2016 (non-PPSA period) and had a drain left in place postoperatively. In the PPSA period, patients received antibiotics until drain removal. In the non-PPSA period, patients received antibiotics for a maximum of 24 hours. Results/UNASSIGNED:= .24). Conclusion/UNASSIGNED:After discontinuing PPSAs for patients with noninstrumented spinal procedures, as is recommended for quality improvement, we saw a nonsignificant increase in our rate of SSIs. Further monitoring of this population is warranted.

Recently, there have been a number of lawsuits in the United States in which families objected to performance of apnoea testing for determination of brain death. The courts reached conflicting determinations in these cases. We discuss the medicolegal complications associated with apnoea testing that are highlighted by these cases and our position that the decision to perform apnoea testing should be made by clinicians, not families, judges, or juries.

BACKGROUND:The case of Jahi McMath has captured the attention of the public, healthcare professionals, and ethicists. Jahi was declared brain dead in late 2013, but her family transferred her to New Jersey to continue organ support. A lengthy legal battle has been ongoing since then. Jahi's family and two neurologists, Drs. Calixto Machado and Alan Shewmon, believe that she is not brain dead. Her family and Dr. Shewmon think that she is capable of following commands, thus making her minimally conscious. METHODS:Review of case materials. RESULTS AND CONCLUSION/CONCLUSIONS:Because brain death is an irreversible coma, one of three conclusions must be drawn: 1) Jahi was never dead; 2) Jahi met the criteria for brain death, but she isn't dead now; or 3) Jahi's movements are not purposeful responses, and she has been brain dead since 2013. The possibility that a person who was declared brain dead is now following commands threatens to erode the notion that brain death should be considered legal death. The discordant ideas that Jahi is brain dead and is following commands can only be reconciled if a formal evaluation for determination of death is repeated by reputable examiners.

The case of Charlie Gard, an infant who was hospitalized in England due to a mitochondrial DNA depletion syndrome that led to an epileptic encephalomyopathy, was highly publicized. Though Charlie's parents lobbied for him to receive experimental nucleoside replacement therapy as a desperate effort to save him, this request was denied, and after a lengthy legal battle, he died in late July 2017. We discuss the ethical considerations and consequences of this case.

OBJECTIVE The objective of this study was to determine the effects of a quality improvement initiative in which daily antibiotics and daily sampling of cerebrospinal fluid (CSF) were discontinued for patients with lumbar drains. METHODS The frequency of surgical site infections (SSIs), antibiotic-related complications (development of Clostridium difficile infection [CDI] and growth of resistant bacteria), and cost for patients with lumbar drains were compared during 3 periods: 1) prolonged prophylactic systemic antibiotics (PPSA) until the time of drain removal and daily CSF sampling (September 2013-2014), 2) PPSA and CSF sampling once after placement then as needed (January 2015-2016), and 3) antibiotics only during placement of the lumbar drain and CSF sampling once after placement then as needed (April 2016-2017). RESULTS Thirty-nine patients were identified in period 1, 53 patients in period 2, and 39 patients in period 3. There was no change in the frequency of SSI after discontinuation of routine CSF testing or PPSA (0% in period 1, 2% in period 2, and 0% in period 3). In periods 1 and 2, 3 patients developed infections due to resistant organisms and 2 patients had CDI. In period 3, 1 patient had an infection due to a resistant organism. The median cost of CSF tests per patient was $100.68 (interquartile range [IQR] $100.68-$134.24) for patients in period 1 and $33.56 (IQR $33.56-$33.56) in periods 2 and 3 (p < 0.001). The median cost of antibiotics per patient was $26.32 (IQR $26.32-$30.65) in periods 1 and 2 and $3.29 ($3.29-$3.29) in period 3 (p < 0.001). The cost associated with growth of resistant bacteria and CDI was $91,291 in periods 1 and 2 and $25,573 in period 3. CONCLUSIONS After discontinuing daily antibiotics and daily CSF sampling for patients with lumbar drains, the frequency of SSI was unchanged and the frequency of antibiotic-related complications decreased.

OBJECTIVE:Medical student knowledge about brain death determination is limited. We describe an educational initiative to improve medical student awareness about brain death and assess the impact of this initiative. SUBJECTS AND METHODS/METHODS:Beginning in July 2016, students at our medical school were required to attend a 90-min brain death didactic and simulation session during their neurology clerkship. Students completed a test immediately before and after participating in the initiative. RESULTS:Of the 145 students who participated in this educational initiative between July 2016 and June 2017, 124 (86%) consented to have their data used for research purposes as part of a medical education registry. Students correctly answered a median of 53% of questions (IQR 47-58%) on the pretest and 86% of questions (IQR 78-89%) on the posttest (p < .001). Comfort with both performing a brain death evaluation and talking to a family about brain death improved significantly after this initiative (18% of students were comfortable performing a brain death evaluation before the initiative and 86% were comfortable doing so after the initiative, p < .001; 18% were comfortable talking to a family about brain death before the initiative and 76% were comfortable doing so after the initiative, p < .001). CONCLUSIONS:Incorporation of simulation in undergraduate medical education is high-yield. At our medical school, knowledge about brain death and comfort performing a brain death exam or talking to a family about brain death was limited prior to development of this initiative, but awareness and comfort dealing with brain death improved significantly after this initiative.

In response to a number of recent lawsuits related to brain death determination, the American Academy of Neurology Ethics, Law, and Humanities Committee convened a multisociety quality improvement summit in October 2016 to address, and potentially correct, aspects of brain death determination within the purview of medical practice that may have contributed to these lawsuits. This article, which has been endorsed by multiple societies that are stakeholders in brain death determination, summarizes the discussion at this summit, wherein we (1) reaffirmed the validity of determination of death by neurologic criteria and the use of the American Academy of Neurology practice guideline to determine brain death in adults; (2) discussed the development of systems to ensure that brain death determination is consistent and accurate; (3) reviewed strategies to respond to objections to determination of death by neurologic criteria; and (4) outlined goals to improve public trust in brain death determination.