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Bedside optic nerve ultrasound holds promise for diagnosing increased intracranial pressure in child

Embargoed news from Annals of Internal Medicine

American College of Physicians

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Bedside optic nerve ultrasound holds promise for diagnosing increased intracranial pressure in children and adults

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Bedside optic nerve ultrasound holds promise for diagnosing increased intracranial pressure in children and adults. Findings from a systematic review and meta-analysis are published in Annals of Internal Medicine.

Increased intracranial pressure can be caused by multiple conditions including traumatic brain injury and brain tumors, which may lead to brain herniation or death. Traditional diagnostic tests such as CT scan, lumbar puncture, and intracranial drains are limited by invasiveness, contraindications, radiation exposure, availability, and need for patient transportation. Bedside optic nerve ultrasound is a noninvasive, quick, and easy-to-use test for diagnosing this critical condition. It involves applying a layer of gel to the closed eyelid with the patient in the supine position. It is hypothesized that the intracranial pressure transmits into the intraorbital space which allows an ultrasound of the eye to reflect the pressure inside the brain. However, surveys indicate that optic nerve ultrasound is not routinely used in clinical practice.

Researchers from McMaster University analyzed 71 studies involving 4,551 patients to examine the accuracy of optic nerve ultrasound for diagnosing increased intracranial pressure. They found an excellent accuracy of optic nerve ultrasound in detecting increased intracranial pressure among children and adults, patients suffering from traumatic and non-traumatic causes of intracranial pressure (brain bleeds and tumors), and whether the specialist performing the ultrasound was a neurosurgeon, radiologist, emergency medicine clinician, neurologist, or critical care specialist. The authors recommend adding this useful tool in clinical practice to standard tests in diagnosing patients with suspected increased intracranial pressure.

The authors of an accompanying editorial suggest that these results should be considered with caution because measurement of the optic nerve sheath diameter is riddled with greater challenges than other bedside ultrasonography clinical applications. They recommend future research to establish a standardized protocol for using optic nerve ultrasound and anticipate tele-ultrasound practice to be increasingly available.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at To reach the lead author, Saleh A. Almenawer, MD, please contact Veronica McGuire at

2. Many nonpharmaceutical interventions show effectiveness for improving poststroke physical and mental wellbeing
Work Group provides a synopsis of VA guidelines for the rehabilitation care of patients after stroke

Review abstract:
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Cardiorespiratory training, repetitive task training, and transcranial direct current stimulation (tDCS) may improve activities of daily living in adults with stroke. Cognitive behavioral therapy, exercise, and selective serotonin reuptake inhibitors (SSRIs) may reduce symptoms of poststroke depression, but use of SSRIs to prevent depression or improve motor function was not supported. Findings from systematic review for the 2019 U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense Guidelines (DoD) for Stroke Rehabilitation are published in Annals of Internal Medicine.

Stroke is the fifth most common cause of death and a leading cause of long-term disability in the United States. Approximately 44 percent of younger individuals, aged 18 to 50 years, who have had a stroke experience moderate disability, and require some assistance with activities of daily living or mobility. Early rehabilitation after stroke is essential to help reduce disability severity and to address depression, which can often occur as a result of stroke.

Researchers from ECRI Institute reviewed 19 systematic reviews and 37 randomized, controlled trials addressing pharmacologic and nonpharmacologic therapies for motor deficits or mood disorders in adults with stroke to inform updated recommendations from the VA and DoD. The quality of evidence was low to very low for assessing most interventions for improving poststroke motor deficits. Moderate-quality evidence supported using cardiorespiratory training to improve maximum walking speed and using repetitive task training or tDCS to improve functional movement. Low-quality evidence showed a positive effect of SSRIs or serotonin-norepinephrine reuptake Inhibitors (SNRIs) in reducing symptoms of poststroke depression. Nonpharmacologic approaches, such as cognitive behavior therapy, exercise, and mind-body approaches also seemed to safely reduce symptoms of depression and anxiety.

In a synopsis of the 2019 guidelines, members of the VA and DoD Work Group summarized the resulting recommendations in 6 areas: timing and approach; motor therapy; dysphagia; cognitive, speech, and sensory therapy; mental health therapy; and other functions, such as returning to work and driving.

Notes and media contacts: For embargoed PDFs please contact Lauren Evans at To speak with Kristen E. D'Anci, PhD from ECRI Institute, please contact Laurie Menyo at

3. Identifying a novel homozygous mutation in the lipoprotein lipase gene definitively confirmed the diagnosis of familial chylomicronemia syndrome

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A case of three siblings diagnosed with a homozygous lipoprotein lipase mutation for the diagnosis of familial chylomicronemia syndrome (FCS) in their 50s highlights the importance of delineating a rare condition, such as FCS, at any age to optimize the clinical outcome. Until they were definitively diagnosed, the siblings received inappropriate therapy, and suffered from unremitting hypertriglyceridemia and recurrent pancreatitis. Their case reports are described in Annals of Internal Medicine.

FCS with severe hypertriglyceridemia is a very rare and underdiagnosed monogenic disorder characterized by varying degrees of abdominal pain caused by acute pancreatitis, and less threatening clinical findings on the skin and eyes. Fasting chylomicronemic plasma appears milky and usually has a triglyceride level above 11.3 mmol/L. Current treatment for FCS is medical nutrition therapy with a fat-restricted diet.

The siblings, who included fraternal twins, were offspring of a first-cousin marriage in a Pennsylvania Dutch family. From an early age, the female twin suffered from recurrent stomach pains. All three siblings suffered multiple pancreatitis episodes in their 30s and 40's. A carbohydrate-restricted diet provided no relief, which prompted them to seek a second opinion for their treatments. Clinicians from the University of Pennsylvania and their colleagues used next-generation sequencing with the LipidSeq panel targeting the FCS-causal genes identified a novel LPL homozygous variant which has never been reported, and definitively confirmed the diagnosis of FCS. The finding prompted the clinicians to prescribe a fat-restricted diet, the most appropriate treatment for FCS, that stabilized the siblings' triglyceride levels and curtailed pancreatitis episodes.

Notes and media contacts: For embargoed PDFs please contact Lauren Evans at To speak with the lead author, Masako Ueda, MD, please contact her directly at

Also new in this issue:

Presenting Risks and Benefits: Helping the Data Monitoring Committee Do Its Job
Scott R. Evans, PhD; Robert Bigelow, PhD; Christy Chuang-Stein, PhD; Susan S. Ellenberg, PhD; Paul Gallo, PhD; Weili He, PhD; Qi Jiang, PhD; and Frank Rockhold, PhD

Research and Reporting Methods

A Process for Assessing Products for Infection Prevention in Health Care Settings: A Framework From the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention
Vineet Chopra, MD, MSc; Hillary M. Babcock, MD, MPH; Lynn Janssen, MS, CIC, CPHQ; Kristina Bryant, MD; Loretta Fauerbach, MS, CIC; and Thomas R. Talbot III, MD, MPH

Special Article


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