Background Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known. Methods We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter and maintenance of glucose at a level between 180 and 200 mg per deciliter). Results At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The ...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa011300

Intensive Insulin Therapy in Critically Ill Patients

Retrospective study: The diagnostic accuracy of conventional forceps biopsy of gastric epithelial compared to endoscopic submucosal dissection (STROBE compliant).

Thank you for downloading an introduction to the event related potential technique. Maybe you have knowledge that, people have look hundreds times for their favorite readings like this an introduction to the event related potential technique, but end up in malicious downloads. Rather than reading a good book with a cup of tea in the afternoon, instead they are facing with some malicious bugs inside their laptop.

An Introduction To The Event Related Potential Technique

http://web.mit.edu/~ppurdon/www/source-imaging.pdf

EEG source imaging

Purpose Focal cortical dysplasias (FCD) are localized regions of malformed cerebral cortex and are very frequently associated with epilepsy in both children and adults. A broad spectrum of histopathology has been included in the diagnosis of FCD. An ILAE task force proposes an international consensus classification system to better characterize specific clinicopathological FCD entities. Methods Thirty-two Task Force members have reevaluated available data on electroclinical presentation, imaging, neuropathological examination of surgical specimens as well as postsurgical outcome. Key findings The ILAE Task Force proposes a three-tiered classification system. FCD Type I refers to isolated lesions, which present either as radial (FCD Type Ia) or tangential (FCD Type Ib) dyslamination of the neocortex, microscopically identified in one or multiple lobes. FCD Type II is an isolated lesion characterized by cortical dyslamination and dysmorphic neurons without (Type IIa) or with balloon cells (Type IIb). Hence, the major change since a prior classification represents the introduction of FCD Type III, which occurs in combination with hippocampal sclerosis (FCD Type IIIa), or with epilepsy-associated tumors (FCD Type IIIb). FCD Type IIIc is found adjacent to vascular malformations, whereas FCD Type IIId can be diagnosed in association with epileptogenic lesions acquired in early life (i.e., traumatic injury, ischemic injury or encephalitis). Significance This three-tiered classification system will be an important basis to evaluate imaging, electroclinical features, and postsurgical seizure control as well as to explore underlying molecular pathomechanisms in FCD.

/pdf/the-clinicopathologic-spectrum-of-focal-cortical-dysplasias-9ml6bps7xb.pdf

The clinicopathologic spectrum of focal cortical dysplasias: A consensus classification proposed by an ad hoc Task Force of the ILAE Diagnostic Methods Commission

The discovery that electroencephalography (EEG) contains useful information at frequencies above the traditional 80Hz limit has had a profound impact on our understanding of brain function. In epilepsy, high-frequency oscillations (HFOs, >80Hz) have proven particularly important and useful. This literature review describes the morphology, clinical meaning, and pathophysiology of epileptic HFOs. To record HFOs, the intracranial EEG needs to be sampled at least at 2,000Hz. The oscillatory events can be visualized by applying a high-pass filter and increasing the time and amplitude scales, or EEG time-frequency maps can show the amount of high-frequency activity. HFOs appear excellent markers for the epileptogenic zone. In patients with focal epilepsy who can benefit from surgery, invasive EEG is often required to identify the epileptic cortex, but current information is sometimes inadequate. Removal of brain tissue generating HFOs has been related to better postsurgical outcome than removing the seizure onset zone, indicating that HFOs may mark cortex that needs to be removed to achieve seizure control. The pathophysiology of epileptic HFOs is challenging, probably involving populations of neurons firing asynchronously. They differ from physiological HFOs in not being paced by rhythmic inhibitory activity and in their possible origin from population spikes. Their link to the epileptogenic zone argues that their study will teach us much about the pathophysiology of epileptogenesis and ictogenesis. HFOs show promise for improving surgical outcome and accelerating intracranial EEG investigations. Their potential needs to be assessed by future research.

/pdf/high-frequency-oscillations-as-a-new-biomarker-in-epilepsy-3wwzb8vo3r.pdf

High-frequency oscillations as a new biomarker in epilepsy.

Objective. —To test the hypothesis that prolonged motor recovery after long-term ventilation may be due to polyneuropathy and can be foreseen at an early stage by electromyography (EMG). Design. —Cohort study with an entry period of 18 months. Polyneuropathy was identified by EMG studies in the intensive care unit (ICU). During a 1-year follow-up, amount of time was recorded to reach a rehabilitation end point. Setting. —The general ICU of a community hospital. Patients. —Fifty patients younger than 75 years who were receiving mechanical ventilation for more than 7 days. Main Outcome Measures. —A rehabilitation end point was defined as return of normal muscle strength and ability to walk 50 m independently. Results. —In 29 of 50 patients, an EMG diagnosis of polyneuropathy was made in the ICU. Patients with polyneuropathy had a higher mortality in the ICU (14 vs 4;P=.03), probably related to multiple organ failure (22 vs 11;P=.08) or aminoglycoside treatment of suspected gram-negative sepsis (17 vs 4;P=.05). Rehabilitation was more prolonged in 12 patients with polyneuropathy than in 12 without polyneuropathy (P=.001). Of nine patients with delays beyond 4 weeks, eight had polyneuropathy, five of whom had persistent motor handicap after 1 year. In particular, axonal polyneuropathy with conduction slowing on EMG indicated a poor prognosis. Conclusions. —Polyneuropathy in the critically ill is related to multiple organ failure and gram-negative sepsis, is associated with higher mortality, and causes important rehabilitation problems. EMG recordings in the ICU can identify patients at risk. (JAMA. 1995;274:1221-1225)

https://jamanetwork.com/journals/jama/articlepdf/389826/jama_274_15_032.pdf

The role of polyneuropathy in motor convalescence after prolonged mechanical ventilation

The standardized EEG electrode array of the IFCN

Epilepsy surgery requires precise localization of the epileptic source. EEG-correlated functional MRI (EEG-fMRI) is a new technique showing the haemodynamic effects of interictal epileptiform activity. This study assesses its potential added value in the presurgical evaluation of patients with complex source localization. Adult surgical candidates considered ineligible because of an unclear focus and/or presumed multifocality on the basis of EEG underwent EEG-fMRI. Interictal epileptic discharges (IEDs) in the EEG during fMRI were identified by consensus between two observers. Topographically distinct IED sets were analysed separately. Only patients with significant, positive blood oxygen level-dependent (BOLD) responses that were topographically related to the EEG were re-evaluated for surgery. Forty-six IED sets from 29 patients were analysed. In eight patients, at least one BOLD response was significant, positive and topographically related to the IEDs.These patients were rejected for surgery because of an unclear focus (n = 3), presumed multifocality (n = 2) or a combination of both (n = 3). EEG-fMRI improved localization in four out of six unclear foci. In patients with presumed multifocality, EEG-fMRI advocated one of the foci in one patient and confirmed multifocality in four out of five patients. In four patients EEG-fMRI opened new prospects for surgery and in two of these patients intracranial EEG supported the EEG-fMRI results. In these complex cases, EEG-fMRI either improved source localization or corroborated a negative decision regarding surgical candidacy. It is thus a valuable tool in the presurgical evaluation of patients. Guidelines for the use of EEG-fMRI in clinical practice are proposed.

EEG-fMRI in the preoperative work-up for epilepsy surgery.

Acute axonal polyneuropathy has been found in patients with multiple organ dysfunction syndrome. This ‘critical illness polyneuropathy’ (CIP) has been associated with difficult weaning from the ventilator in retrospective studies. To test the hypothesis that CIP is related to the degree and number of organ dysfunctions, and to weaning problems. Prospective study of 18 months. A multidisciplinary intensive care unit in a general hospital. Thirty-eight patients under 75 years of age who had been mechanically ventialted for more than 7 days, without previous signs of or risk factors for polyneuropathy. Organ dysfunctions were quantified using a dynamic scoring system (0–12 points). Electromyography studies were performed during mechanical ventilation to identify patients with and without CIP. CIP was present in 18 out of 38 patients and associated with an increased organ dysfunction score (5.3±1.8 vs. 3.6±1.5;p=0.003) and number of organs involved [median (range): 4 (3–5) vs. 2 (1–4);p=0.009], in particular cardiovascular (p=0.003), renal (p=0.04), and hematopoietic failure (p=0.04). Patients with polyneuropathy were ventilated longer, but this was not clearly due to more difficult weaning [median: 16.5 (1–48) vs. 9.5 (1–38) days;p=0.26]. Polyneuropathy was present in 2 of 4 patients with normal weaning. Axonal polyneuropathy is related to the severity of multiple-organ-dysfunction syndrome. Its presence does not necessarily implicate difficult weaning from artificial ventilation.

/pdf/critical-illness-polyneuropathy-in-multiple-organ-4kqhf5sv67.pdf

Frans S. S. Leijten

Papers

High-frequency oscillations as a new biomarker in epilepsy.

The role of polyneuropathy in motor convalescence after prolonged mechanical ventilation

The standardized EEG electrode array of the IFCN

EEG-fMRI in the preoperative work-up for epilepsy surgery.

Critical illness polyneuropathy in multiple organ dysfunction syndrome and weaning from the ventilator