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Background In the United States, nearly 25,000 patients annually undergo percutaneous ventriculostomy for the management of increased intracranial pressure with little consensus on extraventricular drain management. To characterize relationships between external ventricular drain management, permanent ventriculoperitoneal shunt placement, and hospital disposition, we hypothesized that patients requiring extended drainage would have greater association with ventriculoperitoneal shunt placement and unfavorable disposition. Methods Adult patients admitted to the Duke University Hospital Neuroscience Intensive Care Unit between 2008 and 2010 with extraventricular drains were analyzed. A total of 115 patient encounters were assessed to determine relative impact of age, sex, days of extraventricular placement, weaning attempts, cerebrospinal fluid drainage volumes, Glasgow Coma Scale, and physician’s experience on disposition at discharge and ventriculoperitoneal shunt placement. Univariate logistic regression was first used to test the effect of each variable on the outcome, followed by backward selection to determine a final multivariable logistic regression. Variables in the final model meeting p < 0.05 were declared as significant factors for the outcome. Results Increased extraventricular drain duration (odds ratio [OR] = 1.17, confidence interval [CI] = 1.05–1.30, p = 0.0049) was associated with ventriculoperitoneal shunt placement, while older age (OR = 1.05, CI = 1.02–1.08, p = 0.0027) and less physician extraventricular drain management experience (OR = 4.04, CI = 1.67–9.79, p = 0.0020) were associated with unfavorable disposition. Conclusion In a small cohort, exploratory analyses demonstrate potentially modifiable factors are associated with important clinical outcomes. These findings warrant further study to refine how such factors affect patient outcomes.

Background and Purpose Genes associated with the inflammatory response and cytostructural integrity may influence recovery following a brain injury. To examine this in the setting of spontaneous intracerebral hemorrhage (ICH), selected single nucleotide polymorphisms (SNPs) were assessed for associations with patient outcome. Methods A cohort of 54 patients with supratentorial ICH were enrolled. Based on known involvement with neuroinflammation and cytostructural integrity, 10 preselected SNPs from 6 candidate genes were tested for associations with 6-month functional outcome (modified Rankin Scale [mRS] ≥ 3), mortality, and in-hospital deterioration (Glasgow Coma Scale decrease by >2 within 7 days of admission) following ICH. Fisher's exact test and logistic regression with adjustment for race and ICH score were performed. Results SNP rs10940495 (gp130 G/A) within the gp130 gene was the only SNP significantly associated with lower odds of an unfavorable 6-month functional outcome (odds ratio = .16 for mRS ≥ 3; 95% confidence interval, .03-.87, P = .03). Compared with major allele (A) homozygotes, minor allele (G) carriers in the IL6 signal transducer gene (gp130) locus were 84% less likely to have a poor outcome (mRS ≥ 3) at 6 months following spontaneous ICH. The SNP rs10940495 (gp130 G/A) and SNP rs3219119 (PARP-1 A/T) were associated with 6-month mortality (P = .02 and .04, respectively) only on univariate analysis. None of the SNPs examined were associated with in-hospital deterioration. Conclusion In this exploratory study, SNP rs10940495 in the gp130 locus was associated with functional outcome at 6 months following spontaneous ICH. These findings, which should be validated through a larger study, suggest that inflammation plays an important role in mediating outcomes after ICH.

Parents with advanced cancer are faced with difficult decision-making about communication about their illness with their children. The objectives of this study were to describe how parents communicated with their children about advanced cancer and to explore associations between communication and parental depression and anxiety. This was a cross-sectional, mixed-methods study of 42 patients with stage IV solid tumor malignancies who had at least one child less than 18 years of age. Participants completed a semi-structured interview and the Hospital Anxiety and Depression Scale (HADS). We used multiple linear regression to evaluate the association between extent of communication and HADS Anxiety and Depression scores. Interview data were analyzed using standard qualitative content and thematic techniques and triangulated with survey data. Higher HADS Anxiety scores, but not HADS Depression scores, were cross-sectionally associated with greater extent of parental communication (p = 0.003), even when controlling for performance status and children’s ages. In qualitative analyses, parents who acknowledged the terminal nature of their illness or experienced higher symptom burden were more likely to report that they also communicated more extensively with children. A third of parents (n = 14, 33%) described difficulty with illness-related communication with their children. In this pilot study, parents with advanced cancer who reported more illness-related communication with their children also reported more symptoms of general anxiety. Future interventions should address psychological distress relevant to parenting and further assess how parental communication may be linked to parental mood symptoms.

Decisions to limit care, including use of a do-not-resuscitate (DNR) order, are associated with increased risk of death after intracerebral hemorrhage (ICH). Given the value that patient surrogates place on the physician's perception of prognosis, understanding prognostic indicators that influence clinical judgment of outcomes is critical.The purpose of this study was to understand the patient variables and comorbid illnesses associated with DNR orders placed on patients within 72 hours after ICH.Single-center, retrospective review of medical records of 198 consecutive patients with an admission diagnosis of primary supratentorial ICH between July 2007 and December 2010.Patients who did not experience a DNR order placement during their primary admission for ICH (non-DNR group) were compared to patients who received a new DNR order in the first 72 hours of admission (DNR group).Patient characteristics obtained include demographic data, past medical history, clinical data pertaining to the admission for the ICH, and radiographic images. Demographic, medical, and ICH injury data during the first three days of admission were collected.Multiple differences in patient and hospital factors were found between patients receiving a new, early DNR order and those who did not receive a DNR order after ICH. In regression modeling, Caucasian race, direct admission, and higher ICH score were associated with placement of a new DNR order early in the course of injury.Race, transfer procedures, and injury severity may be important factors associated with placement of new, early DNR orders in patients after ICH.

Background Individuals with cystic fibrosis (CF) face the challenges of managing a chronic, progressive disease. While palliative care is a standard of care in serious illnesses, there are no guidelines for its incorporation into CF care. Patients with CF, caregivers, and CF care providers may lack knowledge about palliative care and perceive barriers to integrated care. Objectives To: 1) explore knowledge and perceptions of palliative care among patients with CF, caregivers, and CF care providers; 2) solicit opinions about incorporating palliative care into routine CF care; and 3) solicit recommendations for CF-specific palliative care education for patients and caregivers. Methods We conducted semi-structured interviews with adult patients with CF, parents of adolescents with CF, and CF care providers to assess knowledge and perceptions of palliative care. Discussion included suggestions for palliative care education and integration into CF care. The sample was characterized using summary statistics. Key themes were identified using qualitative content analysis. Results Ten patients with CF, ten parents, and eight CF care providers participated. Many had minimal knowledge of palliative care and endorsed the association with end of life as a barrier to palliative care, but after learning more about palliative care, thought it could be helpful, and should be introduced earlier. Conclusions In this single center study, many patients with CF, caregivers, and providers lacked knowledge about palliative care. These findings warrant replication in a larger, multisite study to inform palliative care educational interventions as a step toward consistent integration of palliative care into routine CF care.

Background Health centers in low-income countries often depend on donations to provide appropriate diagnostic equipment. However, donations are sometimes made without an understanding of the recipient's needs, practical constraints or sustainability of supplies. Methods We donated a set of physical diagnostic equipment, non-invasive instrument tests and laboratory supplies to a rural health center in the Democratic Republic of Congo. We collected information on the usage and durability of equipment and supplies for each patient encounter over a 1-year period. Results We recorded 913 patient encounters. The most commonly used physical diagnostic equipment were the stethoscope (98.9%; 903/913), thermometer (81.7%; 746/913), adult scale (81.4%; 744/913), stop watch (62.6%; 572/913), adult sphygmomanometer (55.8%; 510/913), infant scale (24.9%; 228/913), measuring tape (24.3%; 222/913) and fetoscope (23.8%; 218/913). The most commonly used laboratory tests were the blood smear for malaria (53.7%; 491/913), hematocrit (23.5%; 215/913), urinalysis (20.1%; 184/913) and sputum stain for TB (13.3%; 122/913). With the exception of a penlight and solar lantern, all equipment remained functional. Conclusions This study adds valuable information about the utility and durability of equipment supplied to a health center in the Democratic Republic of Congo. Our results might aid in determining the appropriateness of donated medical equipment in similar settings. The selection of donated goods should be made with knowledge of the context in which it will be used, and utilization should be monitored.

91 Background: Patients with advanced cancer who have minor children face unique challenges when coping with their life-limiting illness and the impact of their illness on their families. The goal of this study was to examine whether psychosocial functioning, treatment preferences, and treatment decisions in advanced cancer differ by parental status. Methods: A cohort of 60 parents with metastatic solid tumors age-matched with 60 non-parents (N = 120) participated in three structured interviews assessing treatment preferences and decisions over six months with complementary medical record review. Participants also completed validated measures of psychosocial functioning. Results: Seventy percent (n = 85) of the sample completed all study assessments. Mean age (45 years, SD 8), mean performance status score (ECOG = 1.2, SD 0.9), median duration of metastatic illness (19 months, range 1-115), gender ratio (66% female), and dropout rates were similar between groups. Parents and non-parents reported similar overall health-related quality of life, but parents were more likely to report poorer emotional well-being (p = 0.006) and more symptoms of depression (p = 0.04) and anxiety (p = 0.04) than non-parents. Parents and non-parents were equally likely to describe life-extension as their primary goal of anti-neoplastic treatment. Parents reported greater willingness to live in pain (48% “very willing” vs 27%, p = 0.007) and accept intubation/ventilation (40% vs 20%, p = 0.01) for life-extension. Compared to non-parents, parents were more likely to report their family members as the most influential factor in their decision-making (44% vs 12%) and less likely to cite their oncologist’s recommendation (25% vs 41%). There were no significant differences between groups for completion of a health care power of attorney or living will. Conclusions: Compared to similarly aged adults with metastatic cancer, parents experience greater psychological distress, are more willing to live in pain for life extension, and place greater importance on family-related factors in their cancer treatment decision-making.

Background: Oculomotor nerve palsy (OMNP) is a well-recognized complication of posterior communicating artery (PCOM) aneurysms. Only a few comparative studies have assessed the effect of clipping versus coiling on recovery from OMNP in PCOM aneurysms. A retrospective review and meta-analysis was conducted to assess the relationship between PCOM aneurysm treatment and OMNP. Materials and Methods: Medical records of all patients presenting between January 2000 and February 2013 with intracranial aneurysm were searched. All patients with OMNP secondary to PCOM aneurysm were included for analysis. Patients undergoing surgical clipping or endovascular coiling were compared with respect to complete resolution of OMNP after aneurysm surgery (i.e., primary outcome). A meta-analysis of published studies of OMNP associated with PCOM aneurysm was performed after a MEDLINE search. Results: Seventeen patients with OMNP secondary to PCOM aneurysms met the inclusion criteria. Surgical clipping (seven of eight patients, or 87.5%) resulted in greater complete resolution of OMNP compared with endovascular coiling (four of nine patients, or 44.4%), P = 0.13. A meta-analysis of similar studies revealed that complete resolution of OMNP was more commonly associated with surgical clipping (36 of 43 patients, or 83.7%) than with endovascular coiling (29 of 55 patients, or 52.7%), yielding an adjusted odds ratio (OR) of 6.04 [confidence interval (CI) =1.88-19.45, P = 0.003]. Multivariate analysis found that the degree of pre-operative OMNP (OR = 0.07, CI = 0.02-0.28, P = 0.001) and surgical clipping (OR = 6.37, CI = 1.73-23.42, P = 0.005) were significant factors that affected the complete recovery of OMNP. Conclusion: Complete recovery of OMNP with PCOM aneurysms is more commonly associated with surgical clipping than with endovascular coiling. Also, the degree of pre-operative OMNP and the treatment modality are significant factors that affect the complete recovery of OMNP.

Although intracerebral hemorrhage (ICH) is a common form of cerebrovascular disease, little is known about factors leading to neurological deterioration occurring beyond 48 h after hematoma formation. The purpose of this study was to characterize the incidence, consequences, and associative factors of late neurological deterioration (LND) in patients with spontaneous ICH.Using the Duke University Hospital Neuroscience Intensive Care Unit database from July 2007 to June 2012, a cohort of 149 consecutive patients with spontaneous supratentorial ICH met criteria for analysis. LND was defined as a decrease of two or more points in Glasgow Coma Scale score or death during the period from 48 h to 1 week after ICH symptom onset. Unfavorable outcome was defined as a modified Rankin Scale score of2 at discharge.Forty-three subjects (28.9 %) developed LND. Logistic regression models revealed hematoma volume (OR = 1.017, 95 % CI 1.003-1.032, p = 0.019), intraventricular hemorrhage (OR = 2.519, 95 % CI 1.142-5.554, p = 0.022) and serum glucose on admission (OR = 2.614, 95 % CI 1.146-5.965, p = 0.022) as independent predictors of LND. After adjusting for ICH score, LND was independently associated with unfavorable outcome (OR = 4.000, 95 % CI 1.280-12.500, p = 0.017). In 65 subjects with follow-up computed tomography images, an increase in midline shift, as a surrogate for cerebral edema, was independently associated with LND (OR = 3.822, 95 % CI 1.157-12.622, p = 0.028).LND is a common phenomenon in patients with ICH; further, LND appears to affect outcome. Independent predictors of LND include hematoma volume, intraventricular hemorrhage, and blood glucose on admission. Progression of perihematomal edema may be one mechanism for LND.

241 Background: Parents with advanced or incurable cancer may struggle when communicating with their children about their illness. Most literature on family communication about cancer reflects the opinions of parents with early-stage cancer or the experiences of children. The life-limiting nature of incurable illness distinguishes the experiences of parents with advanced cancer. Therefore, the aim of this study was to describe how parents with advanced cancer communicated about their illness with their dependent children. Methods: We conducted semi-structured interviews with 46 patients with stage IV solid tumor malignancies who had at least one child under 18 years of age. Interviews addressed illness-related communication with children as well as other topics related to the experience of parenting with advanced cancer. Data were analyzed using thematic content analysis. Results: Parents usually sought to protect their children by limiting details about their illness or framing discussions in an optimistic manner. Age and developmental stage of children greatly influenced how parents communicated and what information was divulged. Disclosure about the life-limiting nature of their illness varied significantly. Parents identified several barriers to communication including children’s avoidance of discussion, personal difficulty accepting the terminal nature of their illness, uncertainty about prognosis, and concerns about how to communicate with their children. Despite these barriers, many parents had not received professional guidance to facilitate their communication. Conclusions: Parents with advanced cancer reported a wide diversity in motivations and techniques in discussing their illness with their children. Despite the availability of child-focused communication resources, parents identified several barriers to illness-related communication with their children. Results from this study can provide guidance for clinicians to help patients overcome these challenges and to assist parents with the difficult task of communicating with children about their illness. Future research interventions to address communication barriers may lead to improved outcomes for patients and their families.

Background Intracerebral hemorrhage (ICH) is a common and devastating form of cerebrovascular disease. In ICH, gender differences in outcomes remain relatively understudied but have been examined in other neurological emergencies. Further, a potential effect of age and gender on outcomes after ICH has not been explored. This study was designed to test the hypothesis that age and gender interact to modify neurological outcomes after ICH. Methods Adult patients admitted with spontaneous primary supratentorial ICH from July 2007 through April 2010 were assessed via retrospective analysis of an existing stroke database at Duke University. Univariate analysis of collected variables was used to compare gender and outcome. Unfavorable outcome was defined as discharge to hospice or death. Using multivariate regression, the combined effect of age and gender on outcome after ICH was analyzed. Results In this study population, women were younger (61.1+14.5 versus 65.8+17.3 years, p=0.03) and more likely to have a history of substance abuse (35% versus 8.9%, p