Koenig M.A.,Punchbowl |
Kaplan P.W.,Johns Hopkins Bayview Medical Center
Seminars in Neurology | Year: 2013
Over the last decade, significant improvements have been made in understanding and categorizing coma and disorders of consciousness. Although imaging techniques have been paramount in exploring disorders of consciousness, electrophysiologic techniques continue to be important for studying brain function in behaviorally unresponsive patients. In acute coma, electroencephalogram and evoked potentials have important roles in excluding nonconvulsive seizures, determining prognosis, monitoring for signs of improvement or worsening, and examining for markers of conscious response to external stimuli. Absence of cortical SSEPs is the most specific marker of poor prognosis after cardiac arrest. Recognition of stimulus-induced epileptiform discharges and clinical seizures has further blurred the lines along the ictal-interictal spectrum in coma. For chronic disorders of consciousness, more experimental techniques, such as cognitive event-related potentials and long-latency evoked potentials, have demonstrated an expanded role in determining prognosis and examining for indicators of consciousness. Like functional magnetic resonance imaging, these specialized techniques have demonstrated signs of preserved cognition in patients who otherwise appear unconscious. Future directions for clinical electrophysiologic testing in disorders of consciousness are likely to include automated and quantitative signal processing techniques and better standardization of cognitive event-related potentials. © 2013 Georg Thieme Verlag KG Stuttgart New York.
CONTINUUM Lifelong Learning in Neurology | Year: 2012
Purpose of Review: The purpose of this article is to describe the modern management of delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (SAH). SAH causes an inflammatory reaction to blood products in the basal cisterns of the brain, which may produce cerebral ischemia and strokes through progressive narrowing of the cerebral artery lumen. This process, known as cerebral vasospasm, is the most common cause of DCI after SAH. Untreated DCI may result in strokes, which account for a significant portion of the death and long-term disability after SAH.Recent Findings: A number of publications, including two recent consensus statements, have clarified many best practices for defining, diagnosing, monitoring, preventing, and treating DCI. DCI is best defined as new onset of focal or global neurologic deficits or strokes not attributable to another cause. In addition to the clinical examination, radiographic studies such as transcranial Doppler ultrasonography, CT angiography, and CT perfusion may have a role in determining which patients are at high risk for developing DCI. The mainstay of prevention and treatment of DCI is maintenance of euvolemia, which can be a difficult therapeutic target to measure. Hemodynamic augmentation with induced hypertension with or without inotropic support has become the first-line treatment of DCI. The ideal method of measuring hemodynamic values and volume status in patients with DCI remains elusive. In patients who do not adequately respond to or cannot tolerate hemodynamic augmentation, endovascular therapy (intraarterial vasodilators and balloon angioplasty) is a complementary strategy. Optimal triggers for escalation and de-escalation of therapies for DCI have not been well defined.Summary: Recent guidelines and consensus statements have clarified many aspects of prevention, monitoring, and treatment of DCI after SAH. Controversies continue regarding the optimal methods for measurement of volume status, the role of invasive neuromonitoring, and the targets for hemodynamic augmentation therapy. © 2012 American Academy of Neurology.
Parikh N.I.,Punchbowl |
Cnattingius S.,Karolinska University Hospital |
Mittleman M.A.,Harvard University |
Ludvigsson J.F.,Orebro University |
Ingelsson E.,Karolinska Institutet
Human Reproduction | Year: 2012
BACKGROUND: Subfertility shares common pathways with cardiovascular disease (CVD), including polycystic ovarian syndrome, obesity and thyroid disorders. Women with prior 0-1 pregnancies are at an increased risk of incident CVD when compared with women with two pregnancies. It is uncertain whether history of subfertility among women eventually giving birth is a risk factor for CVD. METHODS: Among Swedish women with self-reported data on subfertility in the Swedish Medical Birth Register (n = 863 324), we used Cox proportional hazards models to relate a history of subfertility to CVD risk after adjustment for age, birth year, highest income, education, birth country, hypertension, diabetes, preterm birth, small for gestational age (SGA), smoking and for BMI in separate models. In additional analyses, we excluded women with: (i) pregnancy-related or non-pregnancy-related hypertension and/or diabetes; and (ii) preterm births and/or SGA babies. RESULTS: Among nulliparous women eventually having a childbirth (between 1983 and 2005, the median follow-up time 11.9; 0-23 years and 9 906 621 person-years of follow-up), there was an increased risk of CVD among women reporting ≥5 years of subfertility versus 0 years (hazard ratio 1.19, 95% confidence interval 1.02-1.39). There were not significantly elevated CVD risks for women with 1-2 or 3-4 years of subfertility versus 0 years. Accounting for BMI did not change results. Excluding women with hypertension and/or diabetes attenuated associations, whereas exclusion of women with preterm and/or SGA births did not change findings. CONCLUSIONS: Subfertility among women eventually having a childbirth is a risk factor for CVD even upon accounting for cardiovascular risk factors and adverse pregnancy outcomes. Future studies should explore the mechanisms underlying this association. © The Author 2011. Published by Oxford University Press. All rights reserved.
Critical Care Clinics | Year: 2014
Brain injury represents the major cause of long-term disability and mortality among patients resuscitated from cardiac arrest. Brain-directed therapies include maintenance of normal oxygenation, hemodynamic support to optimize cerebral perfusion, glycemic control, and targeted temperature management. Pertinent guidelines and recommendations are reviewed for brain-directed treatment. The latest clinical trial data regarding targeted temperature management are also reviewed. Contemporary prognostication among initially comatose cardiac arrest survivors uses a combination of clinical and electrophysiologic tests. The most recent guidelines for prognostication after cardiac arrest are reviewed. Ongoing research regarding the effects of induced hypothermia on prognostic algorithms is also reviewed. © 2014 Elsevier Inc.
News Article | October 20, 2014
Party planning resource and digital invitations provider Punchbowl is coming out swinging against rival Evite today with a full-page ad in the L.A. Times designed to kick off a marketing campaign aimed at encouraging users to ditch the older service. The move comes at a time when Punchbowl has just snagged a large handful of new brand partnerships from major players, including Sesame Street, Sanrio (Hello Kitty), Hasbro (My Little Pony, Transformers), Star Wars Rebels, Chuck E. Cheese, and more, and has rolled out a redesigned website. The company had already swung an exclusive partnership with Disney at the beginning of the year – which yes, means that Punchbowl has the much sought-after “Frozen” invitations. But its new deals will also impact Punchbowl’s bottom line, as they are multi-year, revenue sharing arrangements that allow the site to offer some of the more popular kids’ character brands to the moms and dads planning their children’s parties and other events. Punchbowl doesn’t talk a lot about where it is, financially, as a private company. CEO Matt Douglas would say only that its user base is in the millions – though smaller than Evite’s – and that it’s in a position now to be profitable if it wanted to flip that proverbial switch. But Punchbowl is currently invested in growing the business, he notes, and it’s doing so without plans to raise any more cash from investors at this point. “Right now we’re in a period of expansion…from a fundraising and cash standpoint we’re in excellent shape,” he says. The CEO cites “very strong” growth that has been aided by the Disney deal, but also attributes much of what makes the business work to the sophisticated technology running on Punchbowl’s backend. The company engages in what’s known as multivariate testing, which is similar to A/B testing except it involves more experiments running simultaneously. Punchbowl may have up to eight different tests running on its site at any time, testing everything from different price points to different feature sets and consumer experiences. This is how the service is able to better monetize its new customers and party hosts, converting them into subscribers who pay either monthly or annually for access to more designs and features, like polling, recurring events, adding co-hosts, and a larger number of guests. Punchbowl also makes a portion of its revenue from the sales of party supplies, but the focus for the near future is on the invites side of its business. A “good chunk” of hosts become subscribers, Douglas says, declining to provide specific metrics, citing competitive reasons. Plus, the company has learned from its back-end analytics how to makeover the site for its relaunch today, he says. The new site is designed to work even better on a tablet or a smartphone. (The company also offers native apps, but many still come to Punchbowl via the web). “We’ve redesigned everything about the site,” says Douglas, “which is hard to do when you have a big, existing user base.” The updated website is menu-driven, allowing party planners to quickly drill down into the category of invitation they want and begin building – before they’re asked to create an account. “We’ve taken a 10-step process down to 3 steps,” Douglas explains. “In the past, we had a lot of party-planning features in the workflow. This time, we’ve focused just on the online invitations feature.” With the new partnerships now out in the open and the updated site going live, Douglas wants to establish Punchbowl as a legitimate – and known – rival to Evite, whose longtime web presence has made it a brand users remember and return to for their party planning needs. Change, of course, can be hard to affect. “It’s like AOL email and Internet Explorer 6 – who’s using this stuff anymore? It’s the same people who are using Evite,” jokes Douglas. That’s not necessarily true, though – I’ve received a couple of Evites in the past few weeks alone, and not necessarily from people who are behind the times. It’s just that the product works well enough, so people return. That means Punchbowl has its work cut out for it in this marketing blitz, but scoring the new brand deals will help. After all, Chuck E. Cheese alone has 575 locations across the U.S. where parents regularly host kids’ birthdays – and that business is now advertising for Punchbowl on the Chuck E. Cheese party-planning website.