Determining Intravenous rt-PA Eligibility in the Emergency Department

Introduction  

The purpose of this study was to assess the agreement of Emergency Department (ED) attendings, ED residents, and neurology residents compared with stroke neurologists in the assessment of intravenous rt-PA eligibility.     

Acute stroke imaging research roadmap

The recent "Advanced Neuroimaging for Acute Stroke Treatment" meeting on September 7 and 8, 2007 in Washington DC, brought together stroke neurologists, neuroradiologists, emergency physicians, neuroimaging research scientists, members of the National Institute of Neurological Disorders and Stroke (NINDS), the National Institute of Biomedical Imaging and Bioengineering (NIBIB), industry representatives, and members of the US Food and Drug Administration (FDA) to discuss the role of advanced neuroimaging in acute stroke treatment. The goals of the meeting were to assess state-of-the-art practice in terms of acute stroke imaging research and to propose specific recommendations regarding: (1) the standardization of perfusion and penumbral imaging techniques, (2) the validation of the accuracy and clinical utility of imaging markers of the ischemic penumbra, (3) the validation of imaging biomarkers relevant to clinical outcomes, and (4) the creation of a central repository to achieve these goals. The present article summarizes these recommendations and examines practical steps to achieve them.     

Empirical hospital and professional charges for patient care associated with out of hospital cardiac arrest before and after implementation of therapeutic hypothermia for comatose survivors

Objective

The objectives of this study are to characterize the total hospital and professional charges for patients with out of hospital cardiac arrest both with and without therapeutic hypothermia treatment.

Methods

Retrospective cohort study of all adult patients with non-traumatic out of hospital cardiac arrest brought to the ED of a single tertiary care hospital over 20 months preceding and 20 months following implementation of therapeutic hypothermia for comatose survivors. Billing and clinical data were obtained from administrative databases and the electronic medical record using explicit audited abstraction. Demographic, payer characteristics, median charges and reimbursements with interquartile ranges are described before and after implementation, stratified by patient outcome.

Results

Two hundred and twenty-three patients met study criteria. The median charge was $3,112 among the 135 patients (60.5%) that did not survive to admission and $94,916 among the 88 (39.5%) that did. Median charges before and after implementation of therapeutic hypothermia were $6,324 and $15,537 respectively. Medicare was the most frequent payer. Good neurological outcome occurred in 11/115 patients (9.6%) prior to implementation and 22/108 patients (20.4%) after. Among 23 patients treated with hypothermia, good neurological outcome occurred in 11 patients (47.8%). Good neurological outcome and treatment with hypothermia were associated with increased procedure utilization and higher charges.

Conclusion

Empirical patient level data confirm that charges for patients with out of hospital cardiac arrest are substantial, even among patients that do not survive to hospital admission. Treatment with therapeutic hypothermia is associated with better outcomes, more procedures, and higher charges.     

The utilization of a morcellator during laparoscopic sleeve gastrectomy.

Obesity continues to plague much of the western world. With the novel approach of laparoscopic sleeve gastrectomy (LSG), there are exciting results being reported in weight loss. One key problem in this patient population is hernia occurrences, particularly at the largest site where the specimen was retrieved. Using an interdisciplinary research design, a new technological breakthrough was proposed. A morcellator was introduced through the existing 15 millimeter (mm) incision to retrieve the resected portion of the stomach. This technology utilized widely by the obstetricians and gynecologists has been proven to retrieve specimens through smaller incisions fostering less pain, greater mobility, earlier discharge from hospitals--ultimately greater patient care. When applied to general bariatric surgery this technology is human centered, is exceedingly affordable, practical yet very forward looking. The morcellator's role in bariatric surgery is drawn from interdisciplinary communication regarding human technology, however the use of this innovative device has the potential to revolutionize the removal of resected specimens. The application of the morcellator in this regards has never been utilized to our knowledge.     

Viral myocarditis presenting with seizure and electrocardiographic findings of acute myocardial infarction in a 14-month-old child

Acute viral myocarditis is an uncommon but potentially fatal illness in children. Patients with myocarditis may present with nonspecific symptoms or atypical findings that make diagnosis in the emergency department difficult. We describe a previously healthy 14-month-old child with difficulty breathing and a tonic-clonic seizure who was subsequently found to have ECG changes and cardiac marker elevation consistent with acute myocardial infarction. The patient was immediately transferred from our community hospital ED to our tertiary care children's hospital. Shortly after admission, the patient developed intractable nonperfusing ventricular arrhythmias necessitating extracorporeal membrane oxygenation. Cardiac function did not recover, and the patient required heart transplantation before cessation of bypass. Serology and anatomic pathology confirmed coxsackievirus B myocarditis. This case illustrates (1) the nonspecific presentation of myocarditis as dyspnea and seizure, (2) the manner in which myocarditis can mimic myocardial infarction, and (3) the importance of early diagnosis in the ED and transfer to a tertiary care facility.     

Accelerated intracranial occlusive disease, oral contraceptives, and cigarette use.

We report clinical and angiographic features of accelerated intracranial occlusive disease resembling moyamoya vasculopathy in five young women who used oral contraceptives (OCs) and smoked cigarettes, but generally had no other obvious risk factors for cerebrovascular disease. Three women had been on OCs for at least 4 years, one woman each had been on OCs for 3 months and for 2 weeks. All five women had smoked cigarettes for at least eight pack-years. Intermittent and progressive multifocal cognitive, visual, motor, or sensory hemispheric symptoms and signs developed in all. All patients developed strokes, four preceded by transient ischemic attacks. Cerebral angiography demonstrated bilateral supraclinoid internal carotid artery stenosis in four patients and proximal posterior cerebral artery stenosis in one. Additional features included rete mirabile, telangiectasias, prominent lenticulostriate collaterals, and multifocal distal cerebral branch occlusions. Three had mild abnormalities of serum fibrinogen, antinuclear antibody, erythrocyte sedimentation rate, or CSF IgG. After discontinuing OCs and reducing cigarette use, four women have not had further strokes over a mean follow-up of approximately 5 years. In certain young women, clinical and angiographic features resembling moyamoya may develop with the use of OCs and cigarettes. We speculate that an immunologically mediated vasculopathy may explain, in part, this unusual cerebrovascular syndrome in otherwise healthy young women.