Current neurology and neuroscience reports
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Curr Neurol Neurosci Rep · Oct 2019
ReviewNew Insights Into Cryptococcus Spp. Biology and Cryptococcal Meningitis.
Defective cell-mediated immunity is a major risk factor for cryptococcosis, a fatal disease if untreated. Cryptococcal meningitis (CM), the main presentation of disseminated disease, occurs through hematogenous spread to the brain from primary pulmonary foci, facilitated by yeast virulence factors. We revisit remarkable recent improvements in the prevention, diagnosis and management of CM. ⋯ Cryptococcal antigen (CrAg), main capsular polysaccharide of Cryptococcus spp. is detectable in blood and cerebrospinal fluid of infected patients with point of care lateral flow assays. Recent World Health Organization guidelines recommend 7-day amphotericin B plus flucytosine, then 7-day high dose (1200 mg/day) fluconazole for induction treatment of HIV-associated CM. Management of raised intracranial pressure, a consequence of CM, should rely mainly on daily therapeutic lumbar punctures until normalisation. In HIV-associated CM, following introduction of antifungal therapy, (re)initiation of antiretroviral therapy should be delayed by 4-6 weeks to prevent immune reconstitution inflammatory syndrome, common in CM. CM is a fatal disease whose diagnosis has recently been simplified. Treatment should always include antifungal combination therapy and management of raised intracranial pressure. Screening for immune deficiency should be mandatory in all patients with cryptococcosis.
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Curr Neurol Neurosci Rep · Jun 2018
ReviewCannabinoids for Treatment of MS Symptoms: State of the Evidence.
Cannabis and cannabinoids have been used medically and recreationally for thousands of years and recently there has been a growing body of research in this area. With increased access now that medical marijuana is available in many jurisdictions, patients and providers want to know more about the evidence for benefits and risks of cannabinoid use. This paper provides an overview of the available cannabinoid-based formulations, a summary of the highest quality evidence for the use of cannabinoids for treating spasticity and pain associated with multiple sclerosis (MS), and a discussion of possible dosing regimens based on information from these studies. ⋯ Two recent high-quality systematic reviews concluded that the only strong evidence for medical marijuana in neurological disorders was for reducing the symptoms of patient-reported spasticity and central pain in MS and that the only complementary and alternative medicine (CAM) intervention in MS with strong supportive evidence was cannabinoids. Based on this review, they concluded that nabiximols (Sativex oral spray), oral cannabis extract (OCE), and synthetic tetrahydrocannabinol (THC) are probably effective at reducing patient-reported symptoms of spasticity in people with MS, but OCE and synthetic THC were not found to be effective for reducing physician-administered measures of spasticity. In addition, nabiximols, OCE, and synthetic THC are probably effective at reducing MS-related pain. Cannabinoids were generally well-tolerated. However, cannabis use has been associated with an increased risk of psychosis and schizophrenia in at-risk individuals, there is growing evidence that cannabis can increase the risk for cardiovascular diseases, including myocardial infarction (MI), hypertension, heart failure, and stroke, and a recently recognized adverse effect of cannabis is cannabinoid hyperemesis syndrome. The medical use of cannabinoids remains controversial. While cannabinoids have been studied for a variety of neurologic disorders, there is strongest evidence to indicate benefits in treatment of spasticity and neuropathic pain in multiple sclerosis. Although the best dose for an individual remains uncertain, most participants in the studies discussed in this paper used between 20 and 40 mg of THC a day in divided doses. Adverse events in studies were generally more common in the groups using cannabinoid products but serious adverse events were rare and cannabis products were generally well-tolerated. Cannabis use does appear to be associated with increased risk of certain adverse events, including psychosis, cardiovascular diseases, and cannabinoid hyperemesis syndrome.
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Curr Neurol Neurosci Rep · Nov 2019
ReviewMachine Learning and Artificial Intelligence in Neurocritical Care: a Specialty-Wide Disruptive Transformation or a Strategy for Success.
Neurocritical care combines the complexity of both medical and surgical disease states with the inherent limitations of assessing patients with neurologic injury. Artificial intelligence (AI) has garnered interest in the basic management of these complicated patients as data collection becomes increasingly automated. ⋯ In this opinion article, we highlight the potential AI has in aiding the clinician in several aspects of neurocritical care, particularly in monitoring and managing intracranial pressure, seizures, hemodynamics, and ventilation. The model-based method and data-driven method are currently the two major AI methods for analyzing critical care data. Both are able to analyze the vast quantities of patient data that are accumulated in the neurocritical care unit. AI has the potential to reduce healthcare costs, minimize delays in patient management, and reduce medical errors. However, these systems are an aid to, not a replacement for, the clinician's judgment.
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Curr Neurol Neurosci Rep · Mar 2018
ReviewPrognostic Value of EEG in Patients after Cardiac Arrest-An Updated Review.
This paper aims to review and summarize the key contributions of EEG to prognostication after cardiac arrest (CA). ⋯ While there are more EEG patterns predicting poor than good outcome, even EEG patterns previously considered to be "very malignant" may result in survival with a meaningful neurological outcome depending on their underlying etiology as well as the continuity and reactivity of the EEG background. Regardless of the potentially confounding factors, EEG patterns are highly specific with a relatively low false-positive rate. The development of more complex and comprehensive approaches to quantitative EEG analysis could help improve the prognostic value of EEG, but this approach has its own limitations. Seizures and status epilepticus in the setting of CA predict poor outcomes, but it is not clear whether treating them prevents additional brain damage and results in improved outcome. Either continuous EEG or frequent intermittent EEGs should be obtained within the first 12-24 h of return of spontaneous circulation in order to capture highly dynamic and prognostic patterns. Even though EEG has high predictive value for outcomes after cardiac arrest, it should not be the only prognostic tool. Rather, to improve prognostication, EEG should be used in combination with the neurological examination and other ancillary tests.
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Curr Neurol Neurosci Rep · Nov 2018
ReviewPrognostic Factors in Pediatric Sport-Related Concussion.
Sport-related concussion (SRC) and mild traumatic brain injury (mTBI) have been thrust into the national spotlight, with youth athletes bearing the burden of this public health problem. The current review aims to provide a practical summary of pediatric SRC, including key terminology, return to play/school, and risk factors for post-concussion syndrome (PCS). ⋯ While the majority of youth athletes recover within 2 to 4 weeks, approximately 10% of athletes experience a protracted recovery with symptoms lasting months, impacting social, scholastic, and sporting activities. In the pediatric population, the strongest predictors of PCS are initial symptom burden and prior concussion, with mixed results behind the factors of gender, headaches, and learning disability. The role of psychiatric, family history, sports, and socioeconomic factors remain in their infancy.