Faculty Bibliography

AIM/OBJECTIVE:To examine gender differences among cardiac arrest (CA) survivors' cognitive, functional, and psychiatric outcomes at discharge. METHODS:This is a prospective, observational cohort of 187 CA patients admitted to Columbia University Medical Center, considered for Targeted Temperature Management (TTM), and survived to hospital discharge between September 2015 and July 2017. Patients with sufficient mental status at hospital discharge to engage in the Repeatable Battery for Neuropsychological Status (RBANS), Modified Lawton Physical Self-Maintenance Scale (M-PSMS), Cerebral Performance Category Scale (CPC), Center for Epidemiological Studies Depression Scale (CES-D), and Post-Traumatic Stress Disorder Checklist - Civilian Version (PCL-C) were included. Fisher's exact, Wilcoxon Rank Sum, and regression analysis were utilized. RESULTS:80 patients (38% women, 44% white, mean age 53 ± 17 years) were included. No significant gender differences were found for age, race, Charlson Comorbidity Index, premorbid CPC or psychiatric diagnoses, arrest related variables, discharge CPC, or PCL-C scores. Women had significantly worse RBANS (64.9 vs 74.8, p = .01), M-PSMS (13.6 vs 10.6, p = .02), and CES-D (22.8 vs 14.3, p = .02) scores. These significant differences were maintained in multivariate models after adjusting for age, initial rhythm, time to return of spontaneous circulation, and TTM. CONCLUSIONS:Women have worse cognitive, functional, and psychiatric outcomes at hospital discharge after cardiac arrest than men. Identifying factors contributing to these differences is of great importance in cardiac arrest outcomes research.

OBJECTIVE:Selective laser amygdalohippocampotomy (SLAH) using magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is emerging as a treatment option for drug-resistant mesial temporal lobe epilepsy (MTLE). SLAH is less invasive than open resection, but there are limited series reporting its safety and efficacy, particularly in patients without clear evidence of mesial temporal sclerosis (MTS). METHODS:We report seizure outcomes and complications in our first 30 patients who underwent SLAH for drug-resistant MTLE between January 2013 and December 2016. We compare patients who required stereoelectroencephalography (SEEG) to confirm mesial temporal onset with those treated based on imaging evidence of MTS. RESULTS:Twelve patients with SEEG-confirmed, non-MTS MTLE and 18 patients with MRI-confirmed MTS underwent SLAH. MTS patients were older (median age 50 vs 30 years) and had longer standing epilepsy (median 40.5 vs 5.5 years) than non-MTS patients. Engel class I seizure freedom was achieved in 7 of 12 non-MTS patients (58%, 95% confidence interval [CI] 30%-86%) and 10 of 18 MTS patients (56%, 95% CI 33%-79%), with no significant difference between groups (odds ratio [OR] 1.12, 95% CI 0.26-4.91, P = .88). Length of stay was 1 day for most patients (range 0-3 days). Procedural complications were rare and without long-term sequelae. SIGNIFICANCE/CONCLUSIONS:We report similar rates of seizure freedom following SLAH in patients with MTS and SEEG-confirmed, non-MTS MTLE. Consistent with early literature, these rates are slightly lower than typically observed with surgical resection (60%-80%). However, SLAH is less invasive than open surgery, with shorter hospital stays and recovery, and severe procedural complications are rare. SLAH may be a reasonable first-line surgical option for patients with both MTS and SEEG confirmed, non-MTS MTLE.

BACKGROUND: There is a paucity of literature regarding the effect of antipsychotics on absolute neutrophil count (ANC) of patients with benign neutropenia (BN). We evaluated the change in ANC after atypical antipsychotic prescription (excluding clozapine) in a retrospective cohort of 22 patients with BN. METHODS/PROCEDURES: Records of all patients with BN who were prescribed antipsychotics and who had ANC measured before and during antipsychotic treatment were obtained from Bronx VA Medical Center between 2005 and 2015 (inclusive). Twenty-two patients met criteria for inclusion. Individual and group mean ANC were calculated before treatment and during treatment. A paired, two-tailed t test was performed on the group ANC means. RESULTS: The group mean pretreatment ANC was 1.24 +/- 0.220 K/cmm, and the mean ANC during the time of antipsychotic prescription increased to 1.40 +/- 0.230 K/cmm, with a P value of 0.0045, t value of 3.18, degrees of freedom equal to 21, and 95% confidence interval of 1.30 to 1.49 K/cmm. CONCLUSIONS: There was a statistically significant increase in ANC among our cohort during the time of antipsychotic prescription. All BN patients who were prescribed antipsychotics maintained a stable neutrophil count, with none of the 22 patients with BN in this study developing agranulocytosis during treatment. Although this study is limited by a low patient count as well as other demographic factors, these findings provide initial evidence regarding the safety of prescribing atypical antipsychotics to BN patients. Further studies are needed to replicate these findings and assess for effects of individual medications.

OBJECTIVES: Not all patients referred for evaluation of multiple sclerosis (MS) meet criteria required for MS or related entities. Identification of markers to exclude demyelinating disease may help detect patients whose presenting symptoms are inconsistent with MS. In this study, we evaluate whether patients who present a self-prepared list of symptoms during an initial visit are less likely to have demyelinating disease and whether this action, which we term the "list sign," may help exclude demyelinating disease. METHODS: Using chart review, 300 consecutive new patients who presented for evaluation to a neurologist at a tertiary MS referral center were identified retrospectively. Patients were defined as having demyelinating disease if diagnosed with MS or a related demyelinating condition. RESULTS: Of the 233 enrolled subjects, 157 were diagnosed with demyelinating disease and 74 did not meet criteria for demyelinating disease. Fifteen (8.4%) subjects had a positive list sign, of which 1 patient had demyelinating disease. The 15 subjects described a mean of 12.07 symptoms, and 8 of these patients met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for somatic symptom disorder. The specificity and positive predictive value of the list sign for non-demyelinating disease were 0.99 (95% confidence interval (CI) 0.96-0.99) and 0.93 (95% CI 0.66-0.99), respectively. CONCLUSION: A positive list sign may be useful to exclude demyelinating disease and to guide diagnostic evaluations for other conditions. Patients with a positive list sign also have a high incidence of somatic symptom disorder.

We discuss the case of a patient with Progressive Multifocal Leukoencephalopathy (PML), developed after treatment with Natalizumab for 42 months for relapsing remitting multiple sclerosis (RRMS). Imaging was consistent with wide-spread PML with features that portended a high risk of development of Immune Reconstitution Inflammatory Syndrome (IRIS). After completion of plasmapheresis, she was started on oral maraviroc, chemokine receptor 5 antagonists. Our patient did not develop radiological signs or symptoms of clinical IRIS and tolerated maraviroc without adverse side-effects. We propose that maraviroc merits further examination as an agent that may prevent IRIS in patients with natalizumab-associated PML

We discuss the case of a patient with a known history of relapsing-remitting multiple sclerosis (MS) who presented with the isolated complaint of altered visual perception in the absence of abnormalities on ophthalmological examination. To the best of the authors' knowledge, this is the first documented case of both facial metamorphopsia and palinopsia occurring as the symptoms of demyelinating brain lesions consistent with an acute MS exacerbation. These symptoms appear to be related to active demyelination that either involved the optic radiations in the visual pathway or the visual association area in the temporo-occipital region of the left hemisphere.

OBJECTIVE: The authors surveyed Psychiatry Residency Training Directors' (RTDs') attitudes about the role and feasibility of international rotations during residency training. METHOD: A 21-question survey was electronically distributed that explored RTDs' beliefs about the value, use, and availability of international clinical and research experiences during residency. RESULTS: Of 171 RTDs, 59 (34.5%) completed the survey; 83% of respondents rated the importance of global mental health education as 3-or-above on a scale of 1 (least important) to 5 (most important), but only 42% indicated that such opportunities were made available. The value of such opportunities was thought to lie primarily in professional development and cultural exposure, less so for enhancing core knowledge competencies. Obstacles to such opportunities included lack of accreditation, financial resources, and faculty/administrative support and supervision. CONCLUSION: RTD respondents endorsed the value of international experiences during residency, but their availability and educational impact are not fully supported.