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Objective: To report previously unreported etiologies of PRES including methadone and bath salt use, resulting in near fatal complications. Background Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized by headache, variable mental status, seizure, visual disturbances, and typical transient changes in the posterior cerebral perfusion. Its pathophysiology remains controversial, however it may be secondary to toxin induce endothelial dysfunction or relative hypertension causing imbalanced Starlin9s forces. The advent of modern brain imaging has afforded an improved understanding with well defined etiologies and presentations, but many atypical presentations exist. While typically associated with a benign prognosis, we present two patients with near fatal PRES related to the street drugs bath salt and methadone. Design/Methods: Case report from a tertiary medical center. Results: Patient 1: 26 year old male presented with acute altered mental status secondary to methadone overdose. Six days after admission patient noted to have new onset seizure, worsening mental status and imaging consistent with PRES. He was treated with anti-epileptics and supportive care. Two days later patient developed signs of brain stem herniation and further imaging revealed uncal and tonsillar herniation with Duvet9s haemorrhages. Patient 2: 51 year old male presented comatose after use of “Bath Salts” a legal drug of abuse with mixed hallucinogenic, agitative and sympathomimetic properties. Imaging confirmed PRES and course was complicated by hydrocephalus requiring extra ventricular drain placement and aggressive ICP management Conclusions: PRES is generally thought to be a benign, transient manifestation of encephalopathy resulting from reversible insult to the blood brain barrier in the setting of toxin, systemic illness, or hypertension with well defined etiologies. However, the cases presented here highlight atypical etiologies, methadone and bath salt use, resulting in near fatal complications. Disclosure: Dr. Pandya has nothing to disclose. Dr. Malaiyandi has nothing to disclose. Dr. Asi has nothing to disclose. Dr. Helms has nothing to disclose. Dr. Lynch has nothing to disclose.
May 6, 2019April 9, 2019Free AccessYou Never Forget Your First? Impact of Interview Timing on Final Rank Order (P2.9-042)Fallon Schloemer, Ann Helms, and Chad CarlsonAuthors Info & AffiliationsApril 9, 2019 issue92 (15_supplement)https://doi.org/10.1212/WNL.92.15_supplement.P2.9-042 Letters to the Editor
Abstract Objective To analyze the impact of interview date on the applicant rank for Neurology residencies in the United States. Methods A multi‐institutional retrospective review of interview dates and applicant rank list data for the National Resident Matching Program (NRMP) was conducted for five Neurology programs, totaling 1932 interviewed applicants over a combined total of 31 interview years. For each candidate, the interview date and applicant rank were abstracted along with the total number of interviews for that season. Statistical analyses were completed on the cumulative institution data set as well for each individual institution to assess for a possible relationship between interview date and applicant rank. Results The cumulative institutional analysis showed that the mean applicant rank decreased as the interview season progressed. Applicants who interviewed on the first day of the interview season were ranked 11.4% higher than those who interviewed on the last interview day. Additionally, applicants interviewed on the first interview day more likely to be ranked higher when compared to all other interview dates. Independent analysis of each program's data identified comparable, statistically significant, differences in mean applicant rank and interview position at three out of the five institutions. Conclusions This study evaluated the impact of interview order on the ranking of applicants by Neurology residency programs, noting a temporal relationship with applicant rank and interview date. The primacy bias appreciated in our data merits further evaluation in other medical specialties. Strategies to minimize the impact of this bias should be employed by residency programs who use medical matching services.
Importance Atrial cardiopathy is associated with stroke in the absence of clinically apparent atrial fibrillation. It is unknown whether anticoagulation, which has proven benefit in atrial fibrillation, prevents stroke in patients with atrial cardiopathy and no atrial fibrillation. Objective To compare anticoagulation vs antiplatelet therapy for secondary stroke prevention in patients with cryptogenic stroke and evidence of atrial cardiopathy. Design, Setting, and Participants Multicenter, double-blind, phase 3 randomized clinical trial of 1015 participants with cryptogenic stroke and evidence of atrial cardiopathy, defined as P-wave terminal force greater than 5000 μV × ms in electrocardiogram lead V 1 , serum N-terminal pro-B-type natriuretic peptide level greater than 250 pg/mL, or left atrial diameter index of 3 cm/m 2 or greater on echocardiogram. Participants had no evidence of atrial fibrillation at the time of randomization. Enrollment and follow-up occurred from February 1, 2018, through February 28, 2023, at 185 sites in the National Institutes of Health StrokeNet and the Canadian Stroke Consortium. Interventions Apixaban, 5 mg or 2.5 mg, twice daily (n = 507) vs aspirin, 81 mg, once daily (n = 508). Main Outcomes and Measures The primary efficacy outcome in a time-to-event analysis was recurrent stroke. All participants, including those diagnosed with atrial fibrillation after randomization, were analyzed according to the groups to which they were randomized. The primary safety outcomes were symptomatic intracranial hemorrhage and other major hemorrhage. Results With 1015 of the target 1100 participants enrolled and mean follow-up of 1.8 years, the trial was stopped for futility after a planned interim analysis. The mean (SD) age of participants was 68.0 (11.0) years, 54.3% were female, and 87.5% completed the full duration of follow-up. Recurrent stroke occurred in 40 patients in the apixaban group (annualized rate, 4.4%) and 40 patients in the aspirin group (annualized rate, 4.4%) (hazard ratio, 1.00 [95% CI, 0.64-1.55]). Symptomatic intracranial hemorrhage occurred in 0 patients taking apixaban and 7 patients taking aspirin (annualized rate, 1.1%). Other major hemorrhages occurred in 5 patients taking apixaban (annualized rate, 0.7%) and 5 patients taking aspirin (annualized rate, 0.8%) (hazard ratio, 1.02 [95% CI, 0.29-3.52]). Conclusions and Relevance In patients with cryptogenic stroke and evidence of atrial cardiopathy without atrial fibrillation, apixaban did not significantly reduce recurrent stroke risk compared with aspirin. Trial Registration ClinicalTrials.gov Identifier: NCT03192215
