Julio A Chalela

Medical University of South Carolina, Charleston, South Carolina, United States

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Publications (97)516.97 Total impact

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    ABSTRACT: Objective: To determine the prevalence, type, and significance of brain damage in critically ill patients with a primary non-neurological diagnosis developing acute brain dysfunction. Methods: This retrospective cohort study was performed at the Johns Hopkins University School of Medicine, an academic tertiary care hospital. Medical records were reviewed of 479 consecutive ICU patients who underwent brain MRI over a 2-year period. Patients were selected for analysis if MRI was obtained to evaluate an acute onset of brain dysfunction (altered mental status, seizures, and/or focal neurological deficit). Subjects with a history of a central nervous system disorder were excluded. The principal clinical endpoint was Glasgow Outcome Scale (GOS) assessed at discharge. MRI-defined brain abnormalities were classified according to type and location. Factors associated with MRI-defined abnormalities were assessed in uni- and multivariable models. Results: 146 patients met inclusion criteria (mean age 54±7years). Brain damage was detected in 130 patients (89%). The most prevalent lesions were white matter hyperintensities (104/146, 71%) and acute cerebral infarcts (59/146, 40%). In a multivariable model, lesions on brain MRI were independently associated with unfavorable outcome (GOS1-3 in 71% of patients with lesions vs. 44% in those without, p=0.007). No adverse events occurred in relation to transport and MRI scanning. Conclusions: In critically ill patients without known neurological disease who have brain dysfunction, MRI reveals an unexpectedly high burden of underlying brain damage, which is associated with unfavorable outcome. The results indicate that brain damage could be an important and under-recognized factor contributing to critical illness brain dysfunction.
    Full-text · Article · Oct 2015 · Neurocritical Care
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    ABSTRACT: Patients with acute brain injuries require strict physiologic control to minimize morbidity and mortality. This study aimed to assess in-hospital compliance to strict physiologic parameters (BP, HR, ICP, SpO2) in these populations. Patients with severe cerebrovascular events were admitted to the neurointensive care unit (NSICU) and were continuously monitored using the BedMasterEX (Excel Medical Electronics Inc, FL) system, which recorded hemodynamic data via an arterial catheter continuously in 5-s intervals. Furthermore, we investigated the impact of healthcare provider shift changes (6-8 a.m./p.m) and of day (6 a.m.-6 p.m.) versus night (6 p.m-6 a.m) shifts in hemodynamic control. Fifty patients admitted to the NSICU, 50 % male, mean age 59.7 ± 13.9 years with subarachnoid hemorrhage (23), ischemic stroke (8), subdural hematoma (4), intracerebral hemorrhage (3), intraventricular hemorrhage (2), and miscellaneous injuries (10) were enrolled. Data represented 2,337 total hours of continuous monitoring. Systolic BPs (SBP) were on average outside of recommended ranges 32.26 ± 30.46 % of the monitoring period. We subdivided adherence to ideal SBP range: optimal (≥99 % of time spent in NSICU within range) was achieved in 12 %, adequate (90 %) in 16 %, suboptimal (80 %) in 20 %, inadequate I (70 %) in 12 %, and inadequate II (<70 %) in 40 % of patients. Comparison of shift change %time and day versus night %time out of parameter yielded no statistically significant differences across SAH patients. Hemodynamic management of patients with cerebrovascular injuries, based on targeted thresholds in the NSICU, yielded optimal control of SBP in only 28 % of our patients (within parameters ≥90 % of time).
    No preview · Article · Apr 2015 · Neurocritical Care
  • Charles M. Andrews · Christine M. Martin · Julio A. Chalela
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    ABSTRACT: result of occupational exposure and as an unusual complication of parenteral nutrition seen usually in critically ill patients. Diagnosis requires a high indexof suspicion as the classic symptoms (parkinsonism) aredifficult to elicit in critically ill patients. Risk factors for manganese encephalopathy have been identified and clinicians should be mindful of them. There is a poor correlation between manganese levels and clinical findings and between response to therapy and residual imaging changes. Reliable biomarkers to determine manganese status and to detect Mn toxicity are not widely available. Treatment strategies include stopping the offending agent, using dopamine agonists, and possibly using chelating agents.
    No preview · Article · Jan 2015
  • Ron R. Neyens · Melissa L. Hill · Michelle R. Huber · Julio A. Chalela
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    ABSTRACT: Early and adequate enteral nutrition is associated with reduced morbidity and mortality in the critically ill patient, but due to high rates of enteral intolerance and concerns for aspiration and pneumonia, many patients do not receive it in a timely fashion. Although not definitively proven to reduce the rates of aspiration and pneumonia, prokinetic therapy has a modest benefit in improving enteral tolerance and delivery of enteral nutrition. Therapeutic selection is dependent upon the clinical scenario, patient’s comorbidities, drug-drug interactions, and end-organ function. Patients deemed to be at high risk of intolerance, prokinetic adverse events, or failed prokinetic therapy may benefit from placement of a post-pyloric tube.
    No preview · Article · Jan 2015
  • M.R. Huber · V.R. Vernacchio · R.R. Neyens · J.A. Chalela
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    ABSTRACT: Patients in the critical care unit often receive nutrition through enteral access. A common complication of enteral nutrition is the occlusion of the enteral tube. This complication occurs at a rate as high as 35 %. A clog that cannot be dissolved may require replacement of the enteral tube, which increases the risk of adverse outcomes and cost. To prevent this complication critical care practitioners should be diligent in recognizing risk factors and using best practice to help prevent an occlusion from forming. Some of the risk factors of enteral occlusion include contact of enteral nutrition with acidic fluid, intact protein and high-fiber formulations, improper administration of medications, and slowing or stopping the flow of enteral nutrition. Prevention is of utmost importance in maintaining enteral tube patency and includes proper tube feed flushing with sterile water. When treatment is required for an occluded tube, warmwater flushes are the first-line agent to restore patency. Second-line therapy includes activated pancreatic enzyme solution. When all treatment options have failed, replacement of the enteral tube is necessary.
    No preview · Article · Jan 2015
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    ABSTRACT: Introduction: The use of mechanical thrombectomy for the treatment of acute ischemic stroke has significantly advanced over the last 5 years. Few data are available comparing the cost and clinical and angiographic outcomes associated with available techniques. The aim of this study is to compare the cost and efficacy of current endovascular stroke therapies. Methods: A single-center retrospective review was performed of the medical record and hospital financial database of all ischemic stroke cases admitted from 2009 to 2013. Three discrete treatment methodologies used during this time were compared: traditional Penumbra System (PS), stent retriever with local aspiration (SRLA) and A Direct Aspiration first Pass Technique (ADAPT). Statistical analyses of clinical and angiographic outcomes and costs for each group were performed. Results: 222 patients (45% men) underwent mechanical thrombectomy. Successful revascularization was defined as Thrombolysis In Cerebral Infarction (TICI) 2b/3 flow, which was achieved in 79% of cases with PS, 83% of cases with SRLA, and 95% of cases with ADAPT. The average total cost of hospitalization for patients was $51 599 with PS, $54 700 with SRLA, and $33 611 with ADAPT (p<0.0001). Average times to recanalization were 88 min with PS, 47 min with SRLA, and 37 min with ADAPT (p<0.0001). Similar rates of good functional outcomes were seen in the three groups (PS 36% vs SRLA 43% vs ADAPT 47%; p=0.4). Conclusions: The ADAPT technique represents the most technically successful yet cost-effective approach to revascularization of large vessel intracranial occlusions.
    No preview · Article · Jul 2014 · Journal of Neurointerventional Surgery
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    ABSTRACT: Patients in the critical care unit often receive nutrition through enteral access. A common complication of enteral nutrition is the occlusion of the enteral tube. This complication occurs at a rate as high as 35 %. A clog that cannot be dissolved may require replacement of the enteral tube, which increases the risk of adverse outcomes and cost. To prevent this complication critical care practitioners should be diligent in recognizing risk factors and using best practice to help prevent an occlusion from forming. Some of the risk factors of enteral occlusion include contact of enteral nutrition with acidic fluid, intact protein and high-fiber formulations, improper administration of medications, and slowing or stopping the flow of enteral nutrition. Prevention is of utmost importance in maintaining enteral tube patency and includes proper tube feed flushing with sterile water. When treatment is required for an occluded tube, warmwater flushes are the first-line agent to restore patency. Second-line therapy includes activated pancreatic enzyme solution. When all treatment options have failed, replacement of the enteral tube is necessary.
    No preview · Chapter · Jan 2014
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    ABSTRACT: Novel oral anticoagulants present challenges and uncertainties in the management of hemorrhagic emergencies. An 84-year-old man taking dabigatran presented with a subdural hematoma requiring neurosurgical intervention. Routine coagulation assays were prolonged at admission and following administration of Factor VIII Inhibitor Bypassing Activity (FEIBA). Thromboelastography (TEG(®)) was utilized to assess clot dynamics prior to placement of a subdural drain, which was safely inserted despite a prolonged thrombin time (TT). Exclusive reliance on the TT may delay necessary interventions. TEG(®) may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.
    Full-text · Article · May 2013 · Journal of Thrombosis and Thrombolysis
  • Julio A Chalela · Julia Rothlisberger · Bryan West · Angela Hays
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    ABSTRACT: Background: The "white cerebellum" sign is a rare imaging finding described mainly in children with hypoxic brain injury. Materials and methods: Single case report and review of the literature. Findings: We describe a child with acute bacterial meningitis in whom plain CT and MRI showed the white cerebellum sign. The subtle imagings findings were not recognized and a lumbar puncture was performed. Markedly increased intracranial pressure was documented by lumbar puncture and by placement of an intraparenchymal monitor. Contrary to most prior descriptions the patient made a very good recovery. Conclusions: The white cerebellum sign is a subtle imaging finding seen in patients with diffuse cerebral edema, such finding may not be as ominous as previously thought.
    No preview · Article · Apr 2013 · Neurocritical Care
  • Jill Blandford · Julio A Chalela
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    ABSTRACT: Introduction: Perimesencephalic subarachnoid hemorrhage is a rare neurologic condition of unclear etiology. Multiple mechanisms have been postulated as potential triggers, but none are universally accepted. Methods: Single observational case report and review of the literature. Results: We describe a patient who developed perimesencephalic subarachnoid hemorrhage in the setting of "hypoxic training" (breath-holding while swimming). We describe the plausible pathophysiologic events that caused the hemorrhage. Conclusion: The occurrence of perimesencephalic subarachnoid hemorrhage during hypoxic training suggests that acute venous congestion may be a triggering factor. The increasing popularity of hypoxic training demands vigilance from health care providers.
    No preview · Article · Mar 2013 · Neurocritical Care
  • J Ivan Lopez · Ashley Holdridge · Julio Chalela
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    ABSTRACT: Although headaches are common in the general population and have many causes, headaches secondary to inflammatory processes in the blood vessels in the Central Nervous System (CNS) are not so common. The most common types of vasculitis that are associated with headaches include primary CNS vasculitis, systemic necrotizing arteritis, granulomatous vasculitis, and systemic collagen diseases. It is important to differentiate between "true" vasculitides and a condition known and reversible cerebral vasoconstriction syndrome (RCVS). While treatment for many of the vasculitides consists of anti-inflammatory medications, this approach may produce significant complications in RCVS. It is up to the clinician to judiciously use imaging and laboratory data to reach the proper diagnosis and therefore offer the correct treatment to these patients.
    No preview · Article · Mar 2013 · Current Pain and Headache Reports

  • No preview · Article · Feb 2013 · Journal of the South Carolina Medical Association (1975)
  • Julio A Chalela · J Ivan Lopez
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    ABSTRACT: Hunger strikes are not infrequent occurrences in military and civilian prisons. Although practicing clinicians are familiar with the management of patients who have limited oral intake, managing hunger strikers is unfamiliar to most. The psychological, physiological, and social events that surround hunger strikes are very complex and need to be understood by those caring for hunger strike patients. To provide adequate medical care to hunger strike patients, clinicians most understand the physiological events that ensue after prolonged starvation. Careful vigilance for development of refeeding syndrome is of key importance. A multidisciplinary approach to hunger strikes is of utmost importance, and involvement of a multidisciplinary clinical team as well as prison officials is essential.
    No preview · Article · Oct 2012 · Nutrition in Clinical Practice
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    ABSTRACT: Background: Patient selection for acute ischemic stroke has been largely driven by time-based criteria, although emerging data suggest that image-based criteria may be useful. The purpose of this study was to directly compare outcomes of patients treated within a traditional time window with those treated beyond this benchmark when CT perfusion (CTP) imaging was used as the primary selection tool. Methods: A prospectively collected database of all patients with acute ischemic stroke who received intra-arterial therapy at the Medical University of South Carolina was retrospectively analyzed, regardless of time from symptom onset. At presentation, CTP maps were qualitatively assessed. Selected patients underwent intra-arterial therapy. Functional outcome according to the modified Rankin scale (mRS) score at about 90 days was documented. Results: 140 patients were included in the study. The median time from symptom onset to groin access was 7.0 h. Overall, 28 patients (20%) had bleeding complications, but only 10 (7.1%) were symptomatic. The average National Institute of Health Stroke Scale (NIHSS) score for patients treated ≤ 7 h from symptom onset was 17.3 and 30.2% had a mRS score of 0-2 at 90 days. Patients treated >7 h from symptom onset had an average NIHSS score of 15.1 and 45.5% achieved a mRS score of 0-2 at 90 days (p=0.104). Patients in the two groups had similar rates of symptomatic intracerebral hemorrhage (8.5% and 5.8%, respectively; p=0.745). Conclusions: No difference was found in the rates of good functional outcome between patients treated ≤ 7 h and those treated >7 h from symptom onset. These data suggest that imaging-based patient selection is a safe and viable methodology.
    No preview · Article · Aug 2012 · Journal of Neurointerventional Surgery
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    Julio A Chalela · Thomas Burnett
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    ABSTRACT: The use of chemical agents for terrorist attacks or military warfare is a major concern at the present time. Chemical agents can cause significant morbidity, are relatively inexpensive, and are easy to store and use. Weaponization of chemical agents is only limited by the physicochemical properties of some agents. Recent incidents involving toxic industrial chemicals and chemical terrorist attacks indicate that critical care services are frequently utilized. For obvious reasons, the critical care literature on chemical terrorism is scarce. This article reviews the clinical aspects of diagnosing and treating victims of chemical terrorism while emphasizing the critical care management. The intensivist needs to be familiar with the chemical agents that could be used in a terrorist attack. The military classification divides agents into lung agents, blood agents, vesicants, and nerve agents. Supportive critical care is the cornerstone of treatment for most casualties, and dramatic recovery can occur in many cases. Specific antidotes are available for some agents, but even without the antidote, aggressive intensive care support can lead to favorable outcome in many cases. Critical care and emergency services can be overwhelmed by a terrorist attack as many exposed but not ill will seek care.
    Preview · Article · May 2012 · Military medicine
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    ABSTRACT: BACKGROUND: Recent evidence indicates that multidisciplinary care improves patient outcomes in cerebrovascular (CV) disease. A multidisciplinary integrated CV program was recently instituted at a high-volume tertiary referral center, providing the opportunity to evaluate patient outcomes before and after its introduction. OBJECTIVE: To evaluate outcomes after treatment of patients with intracranial aneurysm in relation to the introduction of a CV program at our institution. METHODOLOGY: A retrospective chart review was performed on all new patient encounters for a 6-month period each before and immediately after the introduction of the CV program, as well as at a more recent 6-month period to evaluate long-term results. Data were collected on demographic variables, rupture status, medical comorbidities, hospital complications, in-hospital procedures, hospital course and modified Rankin score at discharge and follow up. RESULTS: The total number of patients treated increased from 55 in the 6-month period before the introduction of the CV program to 112 in the most recent time period (p<0.05). Both the surgical clipping and endovascular coiling procedures increased (p<0.05). A significant increase occurred in patients with multiple comorbidities (30.5% vs 34.7%, p=0.035). The mean length of stay decreased from 12.22±13.26 days before the program to 9.23±12.04 days in the most current data (p<0.05). CONCLUSIONS: Creation of an integrated CV program at a large-volume tertiary referral center resulted in better outcomes for an increased number of more medically complicated patients with intracranial aneurysms. This study provides preliminary data for developing an integrated model of multidisciplinary care for the management of CV disease.
    No preview · Article · Apr 2012 · Journal of Neurointerventional Surgery
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    ABSTRACT: REACH Medical University of South Carolina (MUSC) provides stroke consults via the internet in South Carolina. From May 2008 to April 2011 231 patients were treated with intravenous (IV) thrombolysis and 369 were transferred to MUSC including 42 for intra-arterial revascularization [with or without IV tissue plasminogen activator (tPA)]. Medical outcomes and hemorrhage rates, reported elsewhere, were good (Lazaridis et al., 2011). Here we report operational features of REACH MUSC which covers 15 sites with 2,482 beds and 471,875 Emergency Department (ED) visits per year. Eight Academic Faculty from MUSC worked with 165 different physicians and 325 different nurses in the conduct of 1085 consults. For the 231 who received tPA, time milestones (in minutes) were: Onset to Door: 62 (mean), 50 (median); Door to REACH Consult: 43 and 33, Consult Request to Consult Start: was 9 and 7, Consult Start to tPA Decision: 31 and 25; Decision to Infusion: 20 and 14, and total Door to Needle: 98 and 87. The comparable times for the 854 not receiving tPA were: Onset to Door: 140 and 75; Door to REACH Consult: 61 and 41; Consult Request to Consult Start: 9 and 7, Consult Start to tPA Decision: 27 and 23. While the consultants respond to consult requests in <10, there is a long delay between arrival and Consult request. Tracking of operations indicates if we target shortening Door to Call time and time from tPA decision to start of drug infusion we may be able to improve Door to Needle times to target of <60. The large number of individuals involved in the care of these patients, most of whom had no training in REACH usage, will require novel approaches to staff education in ED based operations where turnover is high. Despite these challenges, this robust system delivered tPA safely and in a high fraction of patients evaluated using the REACH MUSC system.
    Full-text · Article · Mar 2012 · Frontiers in Neurology

  • No preview · Article · Mar 2012 · Clinical Neurology and Neurosurgery

  • No preview · Article · Mar 2012 · Clinical neurology and neurosurgery
  • Julio A Chalela · J Ivan Lopez

    No preview · Article · Jan 2012 · Neurology

Publication Stats

3k Citations
516.97 Total Impact Points

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Institutions

  • 2006-2015
    • Medical University of South Carolina
      • • Division of Neuroradiology
      • • Department of Neurosciences (College of Medicine)
      • • Department of Radiology
      Charleston, South Carolina, United States
  • 2004-2006
    • Johns Hopkins University
      • Department of Anesthesiology and Critical Care Medicine
      Baltimore, Maryland, United States
    • University of California, Los Angeles
      Los Ángeles, California, United States
    • Emory University
      Atlanta, Georgia, United States
  • 2005
    • University of Ulsan
      Urusan, Ulsan, South Korea
  • 2003-2005
    • National Institutes of Health
      • Branch of Stroke and Ischemia
      베서스다, Maryland, United States
  • 2001-2003
    • University of Pennsylvania
      • Department of Neurology
      Filadelfia, Pennsylvania, United States
    • National Institute of Neurological Disorders and Strokes
      Chicago, Illinois, United States
  • 1999
    • Hospital of the University of Pennsylvania
      • Department of Neurology
      Filadelfia, Pennsylvania, United States