Faculty Bibliography

Background/UNASSIGNED:We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. Methods/UNASSIGNED:We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Results/UNASSIGNED:.06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Conclusions/UNASSIGNED:Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.

BACKGROUND:Headache mobile health (mHealth) applications (apps) have gained popularity in use but there is little research into what people with migraine find important to track. This information is important for helping with adherence and determining meaningful data to patients. We conducted several clinical trials using a headache research app (RELAXaHEAD). The app contains a "notes" feature (a free-text input section) where patients could record notes related to their headache. OBJECTIVE:To identify what patients view as important when tracking migraine/headaches within a headache tracking mHealth app. METHODS:This was a retrospective study where smartphone diary notes inputted by people with migraine were qualitatively analyzed; notes were extracted, a preliminary codebook was developed and used to code each note. Using grounded theory, themes and subthemes emerged. RESULTS:About 288 subjects in the trials used the notes function. There were 5364 total notes with an average of 18.6 ± 39.2 notes/user. The qualitative analysis yielded 759 unique codes and the emergence of 4 major themes. The first theme was "Utility in free-text tracking of headache characteristics, medications, and sleep" which emerged as a space for users to elaborate on data that could have been inputted into other sections of the app. The second theme was "Monitoring coexisting conditions both related to and distinct from headache." The third theme was "Personal records of behavioral therapy adherence," which included a range of concepts from behavioral therapy session frequency/adherence to subjects' thoughts or emotions regarding the behavioral therapy. The fourth theme was "Migraine trigger, prevention, and relief patterns deciphered through consistent data tracking." CONCLUSION/CONCLUSIONS:We found that the majority of patients choose to expand on information beyond what can be inputted into specific icons in a headache app. Moreover, they want to be able to monitor not only headache-related symptoms but symptoms they experience from other conditions. In addition to tracking their pharmacologic treatment, they may choose to track their nonpharmacologic, that is, behavioral therapy use, and they also use a smartphone diary app to assess what triggers versus relieves a migraine. While the RELAXaHEAD app was designed with features to extract data that would be useful to physicians and patients in treating migraine, our study results indicated that users also prefer a range of tracking capabilities that may or may not be useful to physicians but may be important for headache smartphone user engagement.

INTRODUCTION:Embedded performance validity tests (PVTs) allow for continuous and economical validity assessment during neuropsychological evaluations; however, similar to their freestanding counterparts, a limitation of well-validated embedded PVTs is that the majority are memory-based. This study cross-validated several previously identified non-memory-based PVTs derived from language, processing speed, and executive functioning tests within a single mixed clinical neuropsychiatric sample with and without cognitive impairment. METHOD:This cross-sectional study included data from 124 clinical patients who underwent outpatient neuropsychological evaluation. Validity groups were determined by four independent criterion PVTs (failing ≤1 or ≥2), resulting in 98 valid (68% cognitively impaired) and 26 invalid performances. In total, 23 previously identified embedded PVTs derived from Verbal Fluency (VF), Trail Making Test (TMT), Stroop (SCWT), and Wisconsin Card Sorting Test (WCST) were examined. RESULTS:=.05-.22) with areas under the curve (AUCs) of.65-.81 and 19-54% sensitivity (≥89% specificity) at optimal cut-scores. When subdivided by impairment status, all PVTs except for WCST Failures to Maintain Set were significant (AUCs =.75-94) with 33-85% sensitivity (≥90% specificity) in the cognitively unimpaired group. Among the cognitively impaired group, most VF, TMT, and SCWT PVTs remained significant, albeit with decreased accuracy (AUCs =.65-.76) and sensitivities (19-54%) at optimal cut-scores, whereas all WCST PVTs were nonsignificant. Across groups, SCWT embedded PVTs evidenced the strongest psychometric properties. CONCLUSION:VF, TMT, and SCWT embedded PVTs generally demonstrated moderate accuracy for identifying invalid neuropsychological performance. However, performance on these non-memory-based PVTs from processing speed and executive functioning tests are not immune to the effects of cognitive impairment, such that alternate cut-scores (with reduced sensitivity if adequate specificity is maintained) are indicated in cases where the clinical history is consistent with cognitive impairment. In contrast, WCST indices generally had poor accuracy.

Early-phase clinical trials using oral inhibitors of MEK, the mitogen-activated protein kinase kinase, have demonstrated benefit for patients with neurofibromatosis type 1 (NF1)-associated tumors, particularly progressive low-grade gliomas and plexiform neurofibromas. Given this potential of MEK inhibition as an effective medical therapy, the use of targeted agents in the NF1 population is likely to increase substantially. For clinicians with limited experience prescribing MEK inhibitors, concern about managing these treatments may be a barrier to use. In this manuscript, the Clinical Care Advisory Board of the Children's Tumor Foundation reviews the published experience with MEK inhibitors in NF1 and outlines recommendations for side-effect management, as well as monitoring guidelines. These recommendations can serve as a beginning framework for NF providers seeking to provide the most effective treatments for their patients. IMPLICATIONS FOR PRACTICE: Neurofibromatosis type 1 (NF1) clinical care is on the cusp of a transformative shift. With the success of recent clinical trials using MEK inhibitors, an increasing number of NF1 patients are being treated with MEK inhibitors for both plexiform neurofibromas and low-grade gliomas. The use of MEK inhibitors is likely to increase substantially with the expected upcoming approval of selumetinib for a specific indication for treatment of plexiform neurofibromas in NF1. Given these changes, the Clinical Care Advisory Board of the Children's Tumor Foundation has identified a need within the NF1 clinical community for guidance for the safe and effective use of MEK inhibitors for NF1-related tumors. This article provides a review of the published experience of MEK inhibitors in NF1 and provides recommendations for monitoring and management of side effects.

BACKGROUND AND PURPOSE/OBJECTIVE:In patients with symptomatic vertebrobasilar intracranial atherosclerotic disease (ICAD), impaired distal flow predicts recurrent stroke, but limited data exist on the association between perfusion status and recurrent stroke in anterior circulation ICAD. METHODS:This is a retrospective study of patients hospitalized for symptomatic ICAD with 50-99% stenosis of the intracranial carotid or middle cerebral artery. The primary outcome is recurrent symptomatic ischemic stroke in the territory of the artery with ≥50% stenosis within 90 days. The primary predictor is distal hypoperfusion on magnetic resonance (MR) or computed tomography (CT) perfusion, defined as a ≥15 mL volume of territory of the symptomatic artery with Tmax >6 seconds. RESULTS:Fifty patients met inclusion criteria, including 15 (30%) with recurrent stroke and 15 (30%) with distal hypoperfusion. Distal hypoperfusion was present in 10 of 15 (66.7%) with recurrent stroke versus 5 of 35 (14.3%) without recurrent stroke (P < .001). The hazard ratio for recurrent stroke in patients with distal hypoperfusion was 6.80 (95% confidence interval [CI] 2.31-20.0). CONCLUSION/CONCLUSIONS:Distal hypoperfusion in acutely symptomatic ICAD with 50-99% stenosis is associated with stroke recurrence. Distal hypoperfusion could be used to enrich future trials of secondary stroke prevention in ICAD patients.

This systematic review and meta-analysis addresses the efficacy and safety of nonopioid adjunctive analgesics for patients in the ICU.

Background/UNASSIGNED:Few data exist regarding the rate of inferior vena cava (IVC) filter retrieval among brain-injured patients. Methods/UNASSIGNED:codes to ascertain venous thromboembolism (VTE) diagnoses. We used standard descriptive statistics to calculate the crude rate of filter placement. We used Cox proportional hazards analysis to examine the association between IVC filter placement and mortality and the occurrence of PE after adjustment for demographics, comorbidities, and mechanical ventilation. We used Kaplan-Meier survival statistics to calculate cumulative rates of retrieval 12 months after filter placement. Results/UNASSIGNED:Among 44 641 Medicare beneficiaries, 1068 (2.4%; 95% confidence interval [CI], 2.3%-2.5) received an IVC filter, of whom 452 (42.3%; 95% CI, 39.3%-45.3) had a diagnosis of VTE. After adjusting for demographics, comorbidities, and mechanical ventilation, filter placement was not associated with a reduced risk of mortality (hazard ratio [HR], 1.0; 95% CI, 0.8-1.3) regardless of documented VTE. The occurrence of pulmonary embolism at 12 months was associated with IVC filter placement (HR, 3.19; 95% CI, 1.3-3.3) in the most adjusted model. The cumulative rate of filter retrieval at 12 months was 4.4% (95% CI, 3.1%-6.1%); there was no significant difference in retrieval rates between those with and without VTE. Conclusions/UNASSIGNED:In a large cohort of Medicare beneficiaries hospitalized with acute brain injury, IVC filter placement was uncommon, but once placed, very few filters were removed. IVC filter placement was not associated with a reduced risk of mortality and did not prevent future PE.