Oxygen care and treatment of retinopathy of prematurity in ocular and neurological prognosis

This retrospective cohort study aimed to investigate the effects of neonatal oxygen care and retinopathy of prematurity (ROP) treatment on ROP-related ocular and neurological prognoses. We included premature infants treated for ROP at a tertiary referral center between January 2006 and December 2019. Demographic and clinical data were collected from electronic medical records. Odds ratios (ORs) of oxygen care- and ROP treatment-related factors were calculated for ocular and neurological comorbidities 3 years after ROP treatment, after adjusting for potential confounders. ROP requiring treatment was detected in 171 eyes (88 infants). Laser treatment for ROP (OR = 4.73, 95% confidence interval [CI] 1.64–13.63) and duration of invasive ventilation (OR = 1.02, 95% CI 1.00–1.03) were associated with an increase in ocular comorbidities, along with a history of neonatal seizure (OR = 28.29, 95% CI 5.80–137.95) and chorioamnionitis (OR = 32.13, 95% CI 5.47–188.74). No oxygen care- or ROP treatment-related factors showed significant odds for neurological comorbidities. Shorter duration of invasive oxygen supply during neonatal care (less than 49 days) and anti-vascular endothelial growth factor injection as the primary treatment for ROP are less likely to cause ocular comorbidities. No association was identified between ROP treatment modalities and the risk of neurological comorbidities.

High Flow Nasal Cannula Decreased Pulmonary Complications in Neurologically Critically Ill Patients

Objective: Pulmonary complications could badly affect the recovery of neurological function and neurological prognosis of neurological critically ill patients. This study evaluated the effect of high-flow nasal cannula (HFNC) therapy on decreasing pulmonary complications in neurologically critically ill patients.Patients and Methods: The patients admitted to the intensive care unit (ICU) with serious neurological disease and receiving oxygen therapy were retrospectively reviewed (Ethical No. IRB2021-YX-001). Patients were divided into the HFNC group and the conventional oxygen therapy (COT) group. We analyzed the data within these two groups, including patients’ baseline data, short-term outcomes of respiratory complications, general outcomes including hospital stay, ICU stay and mortality, and neurological functions. To analyze the relevant factors, we performed multivariable logistic regression analysis.Results: A total of 283 patients met the criteria, including 164 cases in the HFNC group and 119 cases in the COT group. The HFNC group had remarkably less mechanical ventilation requirement with lower phlegm viscosity. Even more, ICU stay and total hospital stay were significantly shortened in the HNFC group.Conclusion: HFNC decreased pulmonary complications in neurologically critically ill patients and improved recovery of neurological function and neurological prognosis.

Eleven-year Retrospective Study Characterizing Patients With Severe Brain Damage and Poor Neurological Prognosis -Role of Physicians’ Attitude Toward Life-Sustaining Treatment

BackgroundSevere brain hemorrhage/infarction and cardiac arrest constitute the most critical situations leading to poor neurological prognosis. Characterization of these patients is required to offer successful end-of-life care, but actual practice is affected by multiple confounding factors, including ethicolegal issues, particular in Japan and Asia. The aim of this study is to evaluate the clinical courses of patients with severe brain damage and to assess the preference of end-of-life care for these patients in Japanese hospitals.MethodsA retrospective observational study was conducted between 2008 and 2018. All intracranial hemorrhage/infarction and cardiac arrest out-patients (n=510) who were admitted to our two affiliated hospitals and survived but with poor neurologic outcomes were included. Demographic characteristics as well as prognosis and treatment policies were also assessed. Results Patients were divided into two categories; cases with absent brainstem reflex (BSR) (BSR[-]) and those with preserved BSR (BSR[+]). The survival rate was higher and the length of hospitalization was longer in patients with BSR[+] than in those with BSR[-]. Among three life-sustaining policies (i.e., aggressive treatment, withdrawal of treatment, and withholding of treatment), withholding of treatment was adopted to most patients. In BSR[-], the proportion of three treatment policies performed at the final decision did not differ from that at the initial diagnosis on neurological status (p=0.432). In contrast, this proportion tended to be altered in BSR[+] (p=0.072), with a decreasing tendency of aggressive treatment and a modest increasing tendency of withdrawal of treatment. Furthermore, the requests from patients’ families to withdraw life-sustaining treatment, including discontinuation of mechanical ventilation, increased, but actual implementation of withdrawal by physicians was less than half of the requests. ConclusionsBSR constitutes a crucial determinant of mortality and length of hospitalization in comatose patients with severe brain damage. Although the number of withdrawal of life-sustaining treatment tends to increase over time in BSR[+] patients, there are many more requests from patients’ families for withdrawal. Since physicians has a tendency to desist from withdrawing life-sustaining treatment, more in-depth communication between medical staff and patients’ families will facilitate mutual understanding over ethicolegal and religious issues and may thus improve end-of-life care.

Verbal and memory deficits caused by aphasic status epilepticus after resection of a left temporal lobe glioma

Background: Nonconvulsive status epilepticus (NCSE) is induced by common neurosurgical conditions, for example, trauma, stroke, tumors, and surgical interventions in the brain. The aggressiveness of the treatment for NCSE depends on its neurological prognosis. Aphasic status epilepticus (ASE) is a subtype of focal NCSE without consciousness impairment. The impact of ASE on neurological prognosis is poorly documented. We describe a case of postoperative ASE resulting in verbal and memory deficits. Case Description: A 54-year-old, right-handed man with focal impaired awareness seizures underwent partial resection for a left temporal lobe tumor. No neurological deficits were observed immediately after surgery. Three days later, however, a focal to bilateral tonic-clonic seizure (FBTCS) occurred, followed by aphasia. Electroencephalography revealed 1.5 Hz left-sided periodic discharges. He was diagnosed with ASE. Multiple anti-seizure drugs were ineffective for the resolution of the patient’s verbal disturbance. Nine days after the FBTCS, deep sedation with intravenous anesthetics was performed and the ASE stopped. Thereafter, his symptoms gradually improved. However, the prolonged ASE resulted in verbal and memory deficits. Automated hippocampal volumetry revealed an approximate decrease of 20% on the diseased side on magnetic resonance imaging 3 months after surgery. Conclusion: Prolonged ASE can induce verbal and memory deficits. Early intervention with intravenous anesthetics is required to obtain a favorable neurological prognosis.

Prediction of delayed neuropsychiatric sequelae after carbon monoxide poisoning via serial determination of serum neuron-specific enolase levels

Background Neuron-specific enolase (NSE) is released into serum when nerve cells are damaged, and the levels thereof are used to determine neurological prognosis in patients who have suffered cardiac arrest or stroke. Delayed neuropsychiatric sequelae (DNS), a major complication of carbon monoxide poisoning (COP), can be caused by inflammatory response which is a mechanism of neuronal injury in cardiac arrest and stroke. NSE is known as a predictor of neurological prognosis in ischemic brain injury after cardiac arrest, and it is also reported as a predictor of DNS in acute COP. When serum NSE is measured serially in cardiac arrest patients, the best time to predict neurological prognosis is known at 48–72 h, but there are no studies analyzing serial serum NSE in acute COP. Thus, we explored whether serum NSE levels measured three times at 24 h intervals after COP predicted the development of DNS. Methods This prospective observational study was conducted on patients treated for COP from May 2018 to April 2020 in a tertiary care hospital in Korea. Neuron-specific enolase levels were assessed 24, 48, and 72 h after presentation at hospital. We used logistic regression to explore the association between NSE levels and DNS development. Results The NSE level was highest at 48 h, and the difference between the DNS group and the non-DNS group was greatest on the same time point. On multivariable logistic regression analysis, the NSE level at 48 h of >20.98 ng/mL (odds ratio [OR], 3.570; 95% confidence interval [CI], 1.412–9.026; P = .007) and the initial Glasgow Coma Scale (GCS) score of <9 (OR, 4.559; 95% CI, 1.658–0.12.540; P = .003) was statistically significant for DNS development. Conclusion Early identification of those who will experience DNS in acute COP patients is clinically important for deciding treatment. In this study, we revealed that NSE level of >20.98 ng/mL at 48 h time point can be used as an independent predictor of DNS (OR, 3.570; 95% CI, 1.412–9.026; P = .007; AUC, 0.648).

Is Early Surgical Intervention Effective for Traumatic Severe Cervical Spinal Cord Injury? A Retrospective Study

Background: Although early surgery is known to be effective for the treatment of traumatic cervical spinal cord injury (CSCI), whether it is equally effective in severe CSCI cases remains undetermined. This study aimed to determine whether surgery within 24 h improves the neurological prognosis and reduces the complications associated with surgery for traumatic severe CSCI.Methods: The data of 42 patients with traumatic severe CSCI with American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades A–B who underwent surgery between December 2007 and May 2018 were retrospectively reviewed. The participants were classified into early surgery (<24 h) and late surgery (>24 h) groups. Using the inverse probability of treatment weighting (IPTW) with propensity score adjustment for confounding factors, the AIS grades before and 1 month following surgical treatment, which were considered the primary outcomes, were compared. The secondary outcomes were the intensive care unit length of stay (ICU-LOS) and occurrence of respiratory complications and cardiac arrest.Results: In the early surgery group (n = 32, 76%), the average time to surgery was 10.25 h (4–23 h). The IPTW analysis indicated significant differences in the neurological improvement according to the AIS grade at 1 month following surgery (odds ratio [OR]: 17.1, 95% confidence interval [Cl]: 1.9–156.7, p = 0.012), the ICU-LOS >7 days (OR: 0.14, 95% Cl: 0.02–0.90, p = 0.04), and the occurrence of respiratory complications (OR: 0.08, 95% Cl: 0.01–0.73, p = 0.03) and cardiac arrest (OR: 0.13, 95% Cl: 0.02–0.85, p = 0.03).Conclusions: Early surgery (within 24 h) for traumatic severe CSCI may improve the neurological prognosis and prevent a long ICU-LOS and postoperative complications.

Early aggressive nutrition at 22–23 weeks gestational age improves weight gain and does not worsen neurological prognosis

The effect of early aggressive nutrition (EAN) on extremely low birth weight (ELBW) infants is unknown. The purpose of this study was to investigate the effect of EAN on ELBW infants, especially premature neonates of 22–23 weeks gestational age (GA22–23-week). Twenty-eight preterm infants of less than 26 weeks were divided into two groups (GA22–23-week group, 10 infants; GA24–25-week group, 18 infants) and compared. Each preterm infant received more than 3.0 g/kg/day of amino acids in the first day after birth and 1.0 g/kg/day of lipid emulsion from the next day. The GA22–23-week group had significantly smaller head circumference (20.4 ± 1.0 cm vs. 22.2 ± 1.4 cm, P = 0.002) and body weight at birth (539 ± 68 g vs. 697 ± 155 g, P = 0.003), but there were no differences in early postnatal weight loss (10.4% ± 6.3% vs. 8.1% ± 6.3%, P = 0.37), and body weight at 37 weeks postmenstrual age (1906 ± 321 g vs. 2081 ± 379 g, P = 0.17). Blood urea nitrogen levels were higher in the GA22–23-week group (59.7 ± 16.6 mg/dl vs. 45.0 ± 10.8 mg/dl, P = 0.004), but there were no differences in direct-bilirubin, bile acids, and ammonia levels. After discharge, there was no significant difference in developmental quotient at 2 years of age (71.3 ± 15.1 vs. 78.1 ± 22.6, P = 0.20) between the two groups. Conclusion: We suggest that EAN reduces the rate of early postnatal weight loss in ELBW infants and contributes to weight gain until full term age.