S Andrew Josephson

University of California, San Francisco, San Francisco, California, United States

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Publications (98)558.46 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Dementia is an important risk factor for delirium, but the optimal strategy for incorporating cognitive impairment into delirium risk assessment at the time of hospital admission is unknown. We compared 2 informant-based screening tools for dementia and mild cognitive impairment [AD8 and D=(MC)] to the Mini Mental State Examination (MMSE) and Mini-cog in predicting hospital-acquired delirium. This prospective cohort study at an academic medical center consisted of 162 medical inpatients over age 50 years without delirium upon admission. Each participant was evaluated using the MMSE, Mini-cog, AD8, and D=(MC) upon admission and was assessed daily for delirium. An MMSE≤24 carried a 5.5 [95% confidence intervals (CI), 2.7-11.1] relative risk for delirium, whereas cognitive impairment detected by the Mini-cog, D=(MC), or AD8 carried a 2-fold risk. Adding the D=(MC) to the MMSE increased the sensitivity for predicting delirium from 52% (range, 32% to 73%) for the MMSE alone to 65% (range, 46% to 85%) if either test was positive. If both were positive, specificity was maximized at 97% (range, 94% to 100%), but sensitivity was 17% (range, 2% to 33%). The MMSE and Mini-cog identify a large proportion of patients at risk for hospital-acquired delirium, but the combination of performance-based and an informant-based screens may maximize specificity and sensitivity.
    Alzheimer disease and associated disorders. 10/2014;
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    ABSTRACT: Objective: Some have argued that physicians should not presume to make thrombolysis decisions for incapacitated patients with acute ischemic stroke because the risks and benefits of thrombolysis involve deeply personal values. We evaluated the influence of the inability to consent and of personal health-related values on older adults' emergency treatment preferences for both ischemic stroke and cardiac arrest.Methods: 2,154 U.S. adults age 50 and older read vignettes in which they had either suffered an acute ischemic stroke and could be treated with thrombolysis, or had suffered a sudden cardiac arrest and could be treated with cardiopulmonary resuscitation. Participants were then asked (1) whether they would want the intervention, or (2) whether they would want to be given the intervention even if their informed consent could not be obtained. We elicited health-related values as predictors of these judgments.Results: Older adults were as likely to want stroke thrombolysis when unable to consent (78.1%) as when asked directly (76.2%), while older adults were more likely to want CPR when unable to consent (83.6% compared to 75.9%). Greater confidence in the medical system and reliance on statistical information in decision-making were both associated with desiring thrombolysis.Interpretation: Older adults regard thrombolysis no less favorably when considering a situation in which they are unable to consent. These findings provide empirical support for recent professional society recommendations to treat ischemic stroke with thrombolysis in appropriate emergency circumstances under a presumption of consent. ANN NEUROL 2014. © 2014 American Neurological Association
    Annals of Neurology 07/2014; · 11.19 Impact Factor
  • Neel S. Singhal, S. Andrew Josephson
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    ABSTRACT: Delirium and neurologic impairment are extremely common in the intensive care setting, and their delayed identification are important contributors to patient morbidity. Even in comatose patients, the clinical neurologic examination remains the most accurate and effective tool in assessing nervous system function. Rapid identification of neurologic deficits with a practical and easily reproducible neurologic examination is a core skill for effectively caring for critically ill patients. The purpose of this tutorial is to discuss techniques of neurologic examination and localization with an emphasis on comatose patients. Commonly encountered cases of encephalopathy and coma along with clinical pearls are presented.
    Journal of critical care 01/2014; · 2.13 Impact Factor
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    ABSTRACT: Object Intraoperative rerupture during open surgical clipping of cerebral aneurysms in subarachnoid hemorrhage (SAH) is a relatively frequent and potentially catastrophic occurrence. Patients who suffer rerupture have been shown to have worse outcomes at discharge compared with those who do not have rerupture. Perioperative injury likely plays a large part in the clinical worsening of these patients. However, due to the increased vessel manipulation and repeat exposure to acute hemorrhage, it is possible that secondary injury from increased incidence of vasospasm also contributes. Identifying an increased rate of vasospasm in these patients would justify early aggressive treatment with measures to prevent delayed cerebral ischemia. The authors investigated whether patients who suffer intraoperative rerupture during surgical treatment of ruptured cerebral aneurysms are at increased risk of developing vasospasm. Methods Five hundred consecutive patients treated with open surgical clipping for SAH were reviewed, and clinical and imaging data were collected. Angiographic vasospasm was defined as vessel narrowing believed to be consistent with vasospasm on angiography. Symptomatic vasospasm was defined as angiographic vasospasm in the setting of a clinical change attributable to vasospasm. Rates of angiographic and symptomatic vasospasm among patients with and without intraoperative rerupture were compared. Results There were no significant differences between the groups with and without rupture with respect to age, sex, modified Fisher grade, history of hypertension, or smoking. The group with intraoperative rupture had more patients with Hunt and Hess Grade I. Angiographic vasospasm was noted in 279 (66%) of the 425 patients without rerupture compared with 49 (65%) of the 75 patients with rerupture (p = 1.0, Fisher's exact test). Symptomatic vasospasm was noted in 154 (36%) of the 425 patients without rerupture, compared with 31 (41%) of the 75 patients with rerupture (p = 0.44, Fisher's exact test). In multivariate analysis, higher modified Fisher grade was significantly predictive of vasospasm, whereas older age and male sex were protective. Conclusions This study found no significant influence of intraoperative rerupture during open surgical clipping on the rate of angiographic or symptomatic vasospasm. Brief exposure to acute hemorrhage and vessel manipulation associated with rerupture events did not affect the rate of vasospasm. Risk of vasospasm was related to increased modified Fisher grade, and inversely related to age and male sex. These results do not justify early, targeted vasospasm therapy in patients with intraoperative rerupture.
    Journal of Neurosurgery 12/2013; · 3.15 Impact Factor
  • Annals of Neurology 12/2013; 74(6):A5-7. · 11.19 Impact Factor
  • Annals of Neurology 11/2013; 74(5):A7-9. · 11.19 Impact Factor
  • Stephen L Hauser, S Andrew Josephson, S Claiborne Johnston
    Annals of Neurology 10/2013; 74(4):A5-A25. · 11.19 Impact Factor
  • Yana L Kriseman, Han Lee, Sharon Chung, S Andrew Josephson
    The Neurohospitalist. 10/2013; 3(4):221-227.
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    S Andrew Josephson, S Claiborne Johnston, Stephen L Hauser
    Annals of Neurology 09/2013; 74(3):A7-A8. · 11.19 Impact Factor
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    ABSTRACT: Risk factors for delirium are well-described, yet there is no widely used tool to predict the development of delirium upon admission in hospitalized medical patients. To develop and validate a tool to predict the likelihood of developing delirium during hospitalization. Prospective cohort study with derivation (May 2010-November 2010) and validation (October 2011-March 2012) cohorts. Two academic medical centers and 1 Veterans Affairs medical center. Consecutive medical inpatients (209 in the derivation and 165 in the validation cohort) over age 50 years without delirium at the time of admission. Delirium assessed daily for up to 6 days using the Confusion Assessment Method. The AWOL prediction rule was derived by assigning 1 point to each of 4 items assessed upon enrollment that were independently associated with the development of delirium (Age ≥ 80 years, failure to spell "World" backward, disOrientation to place, and higher nurse-rated iLlness severity). Higher scores were associated with higher rates of delirium in the derivation and validation cohorts (P for trend < 0.001 and 0.025, respectively). Rates of delirium according to score in the combined population were: 0(1/50, 2%), 1(5/141, 4%), 2(15/107, 14%), 3(10/50, 20%), and 4(7/11, 64%) (P for trend < 0.001). Area under the receiver operating characteristic curve for the derivation and validation cohorts was 0.81 (0.73-0.90) and 0.69 (0.54-0.83) respectively. The AWOL prediction rule characterizes medical patients' risk for delirium at the time of hospital admission and could be used for clinical stratification and in trials of delirium prevention. Journal of Hospital Medicine 2013. © 2013 Society of Hospital Medicine.
    Journal of Hospital Medicine 08/2013; · 1.40 Impact Factor
  • S Andrew Josephson, S Claiborne Johnston, Stephen L Hauser
    Annals of Neurology 05/2013; 73(5):A5-6. · 11.19 Impact Factor
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    ABSTRACT: Key points CXCL13 and CXCL12 mediate chemotaxis of CNS lymphoma cells and CXCL13 concentration in CSF is prognosticCXCL13 plus IL-10 are highly specific for the diagnosis of CNS lymphoma.
    Blood 04/2013; · 9.78 Impact Factor
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    ABSTRACT: To determine the frequency and clinical predictors of seizures and markers of epileptiform activity in a non-critically ill general inpatient population. We performed a retrospective cohort study of patients 18 years and older who underwent inpatient electroencephalography (EEG) between January 1, 2005, and December 31, 2010, for an indication of spells or altered mental status. The EEGs and reports were reviewed for ictal activity, interictal epileptiform abnormalities, and nonepileptiform abnormalities. Demographic and clinical data were gathered from the electronic medical record to determine seizure predictors. Of 2235 patients screened, 1048 met the inclusion criteria, of which 825 (78.7%) had an abnormal EEG finding. Seizures occurred in 78 of 1048 patients (7.4%), and interictal epileptiform discharges were noted in 194 of 1048 patients (18.5%). An intracranial mass and spells as the indication for the EEG were independently associated with the group of patients experiencing seizures in a multivariate logistic regression model (adjusted for age, sex, EEG indication, intracranial mass, stroke, and history of epilepsy). Ninety-seven percent of patients (69 of 71) experienced their first seizure within 24 hours of monitoring, and the presence of seizures was associated with a lower likelihood of being discharged (odds ratio, 0.45; 95% CI, 0.27-0.76). Seizures occurred at a high frequency in hospitalized patients with spells and altered mental status. The EEG may be an underused investigative tool in the hospital with the potential to identify treatable causes of these common disorders.
    Mayo Clinic Proceedings 04/2013; 88(4):326-31. · 5.79 Impact Factor
  • Stephen L Hauser, S Andrew Josephson, S Claiborne Johnston
    Annals of Neurology 03/2013; 73(3):A5-6. · 11.19 Impact Factor
  • S Claiborne Johnston, S Andrew Josephson, Stephen L Hauser
    Annals of Neurology 02/2013; 73(2):A5-6. · 11.19 Impact Factor
  • Kendall B Nash, S Andrew Josephson, Karen Sun, Donna M Ferriero
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    ABSTRACT: Hospitalist medicine has gown rapidly over the past decade in response to increasing complexity of hospitalized patients, financial pressures, and a national call for improved quality and safety outcomes. An adult neurohospitalist model of care has recently emerged to address these factors and the need for inpatient neurologists who offer expertise and immediate availability for emergent neurologic conditions such as acute stroke and status epilepticus. Similarly, hospitalized children with acute neurologic disorders require a uniquely high level of care, which increasingly cannot be delivered by pediatric neurologists with busy outpatient practices or by pediatric hospitalists without specialized training. This perspective explores the concept of a pediatric neurohospitalist model of care, including the potential impact on quality of care, hospitalization costs, and education.
    Neurology 01/2013; · 8.30 Impact Factor
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    ABSTRACT: Central nervous system (CNS) lymphoma can present a diagnostic challenge. Currently, there is no consensus regarding what presurgical evaluation is warranted or how to proceed when lesions are not surgically accessible. We conducted a review of the literature on CNS lymphoma diagnosis (1966 to October 2011) to determine whether a common diagnostic algorithm can be generated. We extracted data regarding the usefulness of brain and body imaging, serum and cerebrospinal fluid (CSF) studies, ophthalmologic examination, and tissue biopsy in the diagnosis of CNS lymphoma. Contrast enhancement on imaging is highly sensitive at the time of diagnosis: 98.9% in immunocompetent lymphoma and 96.1% in human immunodeficiency virus-related CNS lymphoma. The sensitivity of CSF cytology is low (2%-32%) but increases when combined with flow cytometry. Cerebrospinal fluid lactate dehydrogenase isozyme 5, β2-microglobulin, and immunoglobulin heavy chain rearrangement studies have improved sensitivity over CSF cytology (58%-85%) but have only moderate specificity (85%). New techniques of proteomics and microRNA analysis have more than 95% specificity in the diagnosis of CNS lymphoma. Positive CSF cytology, vitreous biopsy, or brain/leptomeningeal biopsy remain the current standard for diagnosis. A combined stepwise systematic approach outlined here may facilitate an expeditious, comprehensive presurgical evaluation for cases of suspected CNS lymphoma.
    JAMA neurology. 01/2013;
  • Karen G Hirsch, S Andrew Josephson
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    ABSTRACT: Patients with kidney disease have increased rates of neurologic illness such as intracerebral hemorrhage and ischemic stroke. The acute care of patients with critical neurologic illness and concomitant kidney disease requires unique management considerations including attention to hyponatremia, renal replacement modalities in the setting of high intracranial pressure, reversal of coagulopathy, and seizure management to achieve good neurologic outcomes.
    Advances in chronic kidney disease 01/2013; 20(1):39-44. · 2.42 Impact Factor
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    Michel Shamy, Karl Meisel, S. Andrew Josephson
    01/2013: chapter In-hospital management of stroke;
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    ABSTRACT: Dizziness is a frequent reason for neuroimaging and neurological consultation, but little is known about the utility of either practice. We sought to characterize the patterns and yield of neuroimaging and neurological consultation for dizziness in the emergency department (ED). We retrospectively identified consecutive adults presenting to an academic ED from 2007 to 2009, with a primary complaint of dizziness, vertigo, or imbalance. Neurologists reviewed medical records to determine clinical characteristics, whether a neuroimaging study (head computed tomography [CT] or brain magnetic resonance imaging [MRI]) or neurology consultation was obtained in the ED, and to identify relevant findings on neuroimaging studies. Two neurologists assigned a final diagnosis for the cause of dizziness. Logistic regression was used to evaluate bivariate and multivariate predictors of neuroimaging and consultation. Of 907 dizzy patients (mean age 59 years; 58% women), 321 (35%) had a neuroimaging study (28% CT, 11% MRI, and 4% both) and 180 (20%) had neurological consultation. Serious neurological disease was ultimately diagnosed in 13% of patients with neuroimaging and 21% of patients with neurological consultation, compared to 5% of the overall cohort. Headache and focal neurological deficits were associated with both neuroimaging and neurological consultation, while age ≥60 years and prior stroke predicted neuroimaging but not consultation, and positional symptoms predicted consultation but not neuroimaging. In a tertiary care ED, neuroimaging and neurological consultation were frequently utilized to evaluate dizzy patients, and their diagnostic yield was substantial.
    The Neurohospitalist. 01/2013; 3(1):7-14.

Publication Stats

749 Citations
558.46 Total Impact Points


  • 2003–2014
    • University of California, San Francisco
      • Department of Neurology
      San Francisco, California, United States
  • 2012–2013
    • Weill Cornell Medical College
      • Department of Neurology and Neuroscience
      New York City, NY, United States
    • Cornell University
      • Department of Neurology and Neuroscience
      Ithaca, NY, United States