Person: Rosenthal, Eric
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Rosenthal
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Eric
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Rosenthal, Eric
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Publication The standardization debate: A conflation trap in critical care electroencephalography(Elsevier BV, 2015) Ng, Marcus C.; Gaspard, Nicolas; Cole, Andrew; Hoch, Daniel; Cash, Sydney; Bianchi, Matt Travis; O’Rourke, Deirdre A.; Rosenthal, Eric; Chu, Catherine; Westover, MichaelPurpose: Persistent uncertainty over the clinical significance of various pathological continuous electroencephalography (cEEG) findings in the intensive care unit (ICU) has prompted efforts to standardize ICU cEEG terminology and an ensuing debate. We set out to understand the reasons for, and a satisfactory resolution to, this debate. Method: We review the positions for and against standardization, and examine their deeper philosophical basis. Results: We find that the positions for and against standardization are not fundamentally irreconcilable. Rather, both positions stem from conflating the three cardinal steps in the classic approach to EEG, which we term “description”, “interpretation”, and “prescription”. Using real-world examples we show how this conflation yields muddled clinical reasoning and unproductive debate among electroencephalographers that is translated into confusion among treating clinicians. We propose a middle way that judiciously uses both standardized terminology and clinical reasoning to disentangle these critical steps and apply them in proper sequence. Conclusion: The systematic approach to ICU cEEG findings presented herein not only resolves the standardization debate but also clarifies clinical reasoning by helping electroencephalographers assign appropriate weights to cEEG findings in the face of uncertainty.Publication First‐in‐man allopregnanolone use in super‐refractory status epilepticus(John Wiley and Sons Inc., 2017) Vaitkevicius, Henrikas; Husain, Aatif M.; Rosenthal, Eric; Rosand, Jonathan; Bobb, Wendell; Reddy, Kiran; Rogawski, Michael A.; Cole, AndrewAbstract Super‐refractory status epilepticus (SRSE) is associated with high morbidity and mortality. Treatment of SRSE is complicated by progressive cortical hyperexcitability believed to result in part from synaptic GABA receptor internalization and desensitization. Allopregnanolone, a neurosteroid that positively modulates synaptic and extrasynaptic GABAA receptors, has been proposed as a novel treatment. We describe the first two patients with SRSE who were each successfully treated with a 120‐h continuous infusion of allopregnanolone. Both patients recovered from prolonged SRSE with good cognitive outcomes.Publication Phylogenetic and epidemiologic evidence of multiyear incubation in human rabies(Wiley-Blackwell, 2014) Boland, Torrey A.; McGuone, Declan; Jindal, Jenelle; Rocha, Marcelo; Cumming, Melissa; Rupprecht, Charles E.; Barbosa, Taciana Fernandes Souza; de Novaes Oliveira, Rafael; Chu, Catherine; Cole, Andrew; Kotait, Ivanete; Kuzmina, Natalia A.; Yager, Pamela A.; Kuzmin, Ivan V.; Hedley-Whyte, E.; Brown, Catherine M.; Rosenthal, EricEight years after emigrating from Brazil, an otherwise healthy man developed rabies. An exposure prior to immigration was reported. Genetic analysis revealed a canine rabies virus variant found only in the patient’s home country, and the patient had not traveled internationally since immigrating to the United States. We describe how epidemiological, phylogenetic, and viral sequencing data provided confirmation that rabies encephalomyelitis may present after a long, multiyear incubation period, a consideration that previously has been hypothesized without the ability to exclude a more recent exposure. Accordingly, rabies should be considered in the diagnosis of any acute encephalitis, myelitis, or encephalomyelitis.Publication The probability of seizures during EEG monitoring in critically ill adults(Elsevier BV, 2015) Westover, Michael; Shafi, Mouhsin; Bianchi, Matt Travis; Moura, Lidia M.V.R.; O’Rourke, Deirdre; Rosenthal, Eric; Chu, Catherine; Donovan, Samantha; Hoch, Daniel; Kilbride, Ronan D.; Cole, Andrew; Cash, SydneyObjective: To characterize the risk for seizures over time in relation to EEG findings in hospitalized adults undergoing continuous EEG monitoring (cEEG). Methods: Retrospective analysis of cEEG data and medical records from 625 consecutive adult inpatients monitored at a tertiary medical center. Using survival analysis methods, we estimated the time-dependent probability that a seizure will occur within the next 72-h, if no seizure has occurred yet, as a function of EEG abnormalities detected so far. Results: Seizures occurred in 27% (168/625). The first seizure occurred early (<30 min of monitoring) in 58% (98/168). In 527 patients without early seizures, 159 (30%) had early epileptiform abnormalities, versus 368 (70%) without. Seizures were eventually detected in 25% of patients with early epileptiform discharges, versus 8% without early discharges. The 72-h risk of seizures declined below 5% if no epileptiform abnormalities were present in the first two hours, whereas 16 h of monitoring were required when epileptiform discharges were present. 20% (74/388) of patients without early epileptiform abnormalities later developed them; 23% (17/74) of these ultimately had seizures. Only 4% (12/294) experienced a seizure without preceding epileptiform abnormalities. Conclusions: Seizure risk in acute neurological illness decays rapidly, at a rate dependent on abnormalities detected early during monitoring. This study demonstrates that substantial risk stratification is possible based on early EEG abnormalities. Significance: These findings have implications for patient-specific determination of the required duration of cEEG monitoring in hospitalized patients.Publication Real-Time Automated Surveillance for Ventilator Associated Events Using Streaming Electronic Health Data(Oxford University Press, 2017) Seiguer Shenoy, Erica; Rosenthal, Eric; Biswal, Siddharth; Ghanta, Manohar; Ryan, Erin E; Shao, Yu-Ping; Suslak, Dolores; Swanson, Nancy; Valdery, Moura Junior; Hooper, David; Westover, M BrandonAbstract Background: Criteria defining Ventilator Associated Events (VAEs) are objective and often available in the electronic health record (EHR) data. The use of ventilation data extracted directly from the patient’s bedside monitor to allow for real-time surveillance, however, has not been previously incorporated into electronic surveillance approaches. Here we describe validation of a system that can detect and report on VAEs hospital-wide autonomously and in real-time. Methods: We developed a secure informatics hardware and software platform to identify VAEs autonomously using streaming data. The automated process included 1) archiving and analysis of bedside physiologic monitor data to detect increases in positive end-expiratory pressure (PEEP) or FiO2 settings; 2) real-time querying of EHR data for leukopenia or leukocytosis and concurrent antibiotic initiation; and 3) retrieval and interpretation of microbiology reports for the presence of respiratory pathogens. The algorithm was validated on two 3-month periods in 2015 and 2016 as follows: 1) autonomous surveillance (AS) generated detections of three VAE subclasses: VAC, IVAC, and PVAP; 2) manual surveillance (MS) by Infection Control (IC) staff independently performed standard surveillance based on chart review, 3) senior IC staff adjudicated the gold standard for cases of AS-MS discordance. The sensitivity (Se), specificity (Sp), and positive predictive value (PPV) of the algorithm are reported. Results: The number of ventilated patients, ventilator days, and events were: 1,591/9,407/3,014. In cases with complete data, AS detected 66 VAE events identified by MS; AS detected 32 VAEs missed by MS; no MS-identified events were missed by AS. The Se, Sp, and PPV of AS and MS were: 91%/100%/100%, and 61%/100%/83%, respectively. Clinical surveillance case reports generated by AS enabled visual interpretation (figure). Conclusion: We developed a surveillance tool directly streaming bedside physiologic monitor and EHR data including ventilator settings, laboratory results, and microbiology reports, to apply the CDC’s VAE definitions on source data. This resulted in an accurate, objective, and efficient method for real-time hospital-wide surveillance. Disclosures All authors: No reported disclosures.