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Introduction The surge of SARS-CoV-2-virus infected (COVID-19) patients presenting to New York City (NYC) hospitals quickly overwhelmed and outnumbered the available acute care and intensive care resources in NYC in early March 2020. Upon the arrival of military medical assets to the Javits Convention Center in NYC, the planned mission to care for non-SARS-CoV-2 patients was immediately changed to manage patients with (SARS-CoV-2)COVID-19 and their comorbid conditions. Healthcare professionals from every branch of the uniformed services, augmented by state and local resources, staffed the Javits New York Medical Station (JNYMS) from April 2020. Methods The data review reported aggregated summary statistics and participant observations collected by N.Y. State and U.S. military officials. Results During the 28 days of patient intake at the JNYMS, 1,095 SARS-CoV-2-positive patients were transferred from NYC hospitals to the JNYMS. At its peak, the JNYMS accepted 119 patients in a single day, had a maximum census of 453, and had a peak intensive care unit census of 35. The median length of stay was 4.6 days (interquartile range: 3.1-6.9 days). A total of 103 patients were transferred back to local hospitals, and there were 6 deaths, with an overall mortality rate of 0.6% (95% CI, 0.3-1.2). Discussion and Conclusions This is the first report of the care provided at the JNYMS. Within 2 weeks, this multi-agency effort was able to mobilize to care for over 1,000 SARS-CoV-2 patients with varying degrees of illness in a 1-month period. This was the largest field hospital mobilization in the U.S. medical history in response to a non-wartime pandemic. Its success with huge patient throughput including disposition and low mortality relieved critical overcrowding and supply deficiencies throughout NYC hospitals. The downstream impact likely saved additional hundreds of lives and reduced stress on the system during this healthcare crisis.

Concussions and chronic traumatic encephalopathy (CTE) related to professional football has received much attention within emergency care and sports medicine. Research suggests that some of this may be due to a greater likelihood of initial helmet contact (IHC), however this association has not been studied across all age groups. This study aims to investigate the association between player age and IHC in American football.Retrospective review of championship games between 2016 and 2018 at 6 levels of amateur tackle football as well as the National Football League (NFL). Trained raters classified plays as IHC using pre-specified criteria. A priori power analysis established the requisite impacts needed to establish non-inferiority of the incidence rate of IHC across the levels of play.Thirty-seven games representing 2912 hits were rated. The overall incidence of IHC was 16% across all groups, ranging from 12.6% to 18.9%. All but 2 of the non-NFL divisions had a statistically reduced risk of IHC when compared with the NFL, with relative risk ratios ranging from 0.55-0.92. IHC initiated by defensive participants were twice as high as offensive participants (RR 2.04, p0.01) while 6% [95% CI 5.4-7.2] of all hits were helmet-on-helmet contact.There is a high rate of IHC with a lower relative risk of IHC at most levels of play compared to the NFL. Further research is necessary to determine the impact of IHC; the high rates across all age groups suggests an important role for education and prevention.

Study objective People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States. Methods Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm. Results Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic. Conclusion Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.

Contains fulltext : 249977.pdf (Publisher’s version ) (Closed access) BACKGROUND: It is important to evaluate whether a new treatment for heart failure with reduced ejection fraction (HFrEF) provides additive benefit to background foundational treatments. As such, we aimed to evaluate the efficacy and safety of empagliflozin in patients with HFrEF in addition to baseline treatment with specific doses and combinations of disease-modifying therapies. METHODS: We performed a post-hoc analysis of the EMPEROR-Reduced randomised, double-blind, parallel-group trial, which took place in 520 centres (hospitals and medical clinics) in 20 countries in Asia, Australia, Europe, North America, and South America. Patients with New York Heart Association (NYHA) classification II-IV with an ejection fraction of 40% or less were randomly assigned (1:1) to receive the addition of either oral empagliflozin 10 mg per day or placebo to background therapy. The primary composite outcome was cardiovascular death and heart failure hospitalisation; the secondary outcome was total heart failure hospital admissions. An extended composite outcome consisted of inpatient and outpatient HFrEF events was also evaluated. Outcomes were analysed according to background use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) or angiotensin receptor neprilysin inhibitors (ARNIs), as well as β blockers and mineralocorticoid receptor antagonists (MRAs) at less than 50% or 50% or more of target doses and in various combinations. This study is registered with ClinicalTrials.gov, NCT03057977. FINDINGS: In this post-hoc analysis of 3730 patients (mean age 66·8 years [SD 11·0], 893 [23·9%] women; 1863 [49·9%] in the empagliflozin group, 1867 [50·1%] in the placebo group) assessed between March 6, 2017, and May 28, 2020, empagliflozin reduced the risk of the primary outcome (361 in 1863 participants in the empagliflozin group and 462 of 1867 in the placebo group; HR 0·75 [95% CI 0·65-0·86]) regardless of background therapy or its target doses for ACE inhibitors or ARBs at doses of less than 50% of the target dose (HR 0·85 [0·69-1·06]) and for doses of 50% or more of the target dose (HR 0·67 [0·52-0·88]; p(interaction)=0·18). A similar result was seen for β blockers at doses of less than 50% of the target dose (HR 0·66 [0·54-0·80]) and for doses of 50% or more of the target dose (HR 0·81 [0·66-1·00]; p(interaction)=0·15). Empagliflozin also reduced the risk of the primary outcome irrespective of background use of triple therapy with an ACE inhibitor, ARB, or ARNI plus β blocker plus MRA (given combination HR 0·73 [0·61-0·88]; not given combination HR 0·76 [0·62-0·94]; p(interaction)=0·77). Similar patterns of benefit were observed for the secondary and extended composite outcomes. Empagliflozin was well tolerated and rates of hypotension, symptomatic hypotension, and hyperkalaemia were similar across all subgroups. INTERPRETATION: Empagliflozin reduced serious heart failure outcomes across doses and combinations of disease-modifying therapies for HFrEF. Clinically, these data suggest that empagliflozin might be considered as a foundational therapy in patients with HFrEF regardless of their existing background therapy. FUNDING: Boehringer Ingelheim and Eli Lilly and Company.

Background and Aims Several chronic medical conditions appear to increase the risk of severe COVID-19. Chronic kidney disease (CKD) patients have a high risk of symptomatic infection and severe respiratory symptoms because of chronic inflammation, uremic toxins accumulation, endothelial dysfunction and an impaired immune response. Even though the presence of one or more comorbidities increases the risk of mortality, information of the outcome of COVID-19 in CKD patients is not yet available. The aim of the study is to present the incidence and outcome of COVID-19 in patients referring to our Nephrology Unit considering CKD patients, dialysis patients and kidney transplant recipients. MO520 Table 1. Demographic, clinical and radiological features. Variables Total (n=52) Survivors (n=39) Nonsurvivors(n=13) Age, yr 67.2± 13.8 65± 14 72± 12 Woman 21 (39%) 17 (44.7%) 5 (13%) Comorbidity CV disease 41 (78.8%) 30 (79%) 11(84.6%) DM 22 (42%) 14 (36.8%) 8 (61.5%) Cancer 18 (31%) 12 (31.6%) 6(46.1%) BMI>30 7 (3%) 4(10.5%) 2(15.4%) Dialysis 31(59.5%) 24 (63.1) 6 (46%) Kidney transplantation 16 (30.7%) 11 (29%) 2 (15%) CKD IV-V stage 4 (7%) 2 (5.2%) 1 (7.7%) Onset of Symptoms fever 29 (79%) 22(58%) 7 (13%) cough 3(6%) 2 (5.2%) 1 (7.7%) dyspnea 8 (15.4%) 4 (10.5%) 4 (30.8%) Symptomless 8 (15.4%) 6 (15.8%) 2 (15.4%) Admission HRCT Bilateral peripheral ground-gass opacity 39(81.2%) 31 (79.5%) 8(88.8%) Unilateral opacity 6 (12.5%) 5(12.8%) 1 (11.1) No opacity 3 (6.2%) 3 (7.7%) 0 PaO2/FiO2 ratio 330 ± 102. 376 ±93 286 ±86 Method This study is prospective single centre carried out considering patients referring to the Nephrology Unit of St. Orsola University Hospital in Bologna with COVID 19 diagnosis from 15THMarch to 30THMay 2020. Results Our cohort included 52 patients admitted to our Nephrology Unit because of Sars Cov2 infection confirmed by positive reverse transcriptase polymerase chain reaction on nasopharyngeal swab. The mean age was 67.2 ± 13.8 years (range, 33-88 years). Demographic, clinical and radiological features in Table 1. Forty-eight patients (92.3%) underwent chest TC. The main findings were: several bilateral interstitial pneumonia (39 patients, 81.2%), monolateral peripheral ground-glass opacities (6 patients, 12.5%), no signs of pneumonia (3 patients, 6.2 %). Clinical course is highly variable: 18 patients (34.6 %) were asymptomatic, 23 patients (44 %) had a mild course requiring low flux oxygen therapy and 11 patients (21%) presented severe pneumonia and respiratory distress that requires ventilatory support in intensive care unit. Forty patients (70%) had hydroxychloroquine-azithromycin dual therapy, 3 patients (6%) had antiviral therapy in addiction. Sixteen patients (31%) with P/F

Introduction The unfolding COVID-19 pandemic has predictably followed the familiar contours of well established socioeconomic health inequities, exposing and often amplifying preexisting disparities. People living in homeless shelters are at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared to the general population. The purpose of this study was to identify shelter characteristics that may be associated with higher transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods We conducted a cross-sectional assessment of five congregate shelters in Rhode Island. Shelter residents 18 years old and older were tested for SARS-CoV-2 from April 19-April 24, 2020. At time of testing, we collected participant characteristics, symptomatology, and vital signs. Shelter characteristics and infection control strategies were collected through a structured phone questionnaire with shelter administrators. Results A total of 299 shelter residents (99%, 299/302) participated. Thirty-five (11.7%) tested positive for SARS-CoV-2. Shelter-level prevalence ranged from zero to 35%. Symptom prevalence did not vary by test result. Shelters with positive cases of SARS-CoV-2 were in more densely populated areas, had more transient resident populations, and instituted fewer physical distancing practices compared to shelters with no cases. Conclusion SARS-CoV-2 prevalence varies with shelter characteristics but not individual symptoms. Policies that promote resident stability and physical distancing may help reduce SARS-CoV-2 transmission. Symptom screening alone is insufficient to prevent SARS-CoV-2 transmission. Frequent universal testing and congregate housing alternatives that promote stability may help reduce spread of infection.

BackgroundIndividuals experiencing homelessness residing in congregate shelters have increased risk for SARS-CoV-2 infection. Prevalence of asymptomatic SARS-CoV-2 in congregate shelters is high, but shelter characteristics associated with SARS-CoV-2 transmission are currently unknown.MethodsWe conducted a cross-sectional, multicenter cohort study across five congregate shelters in Rhode Island. We tested people 18 years of age and older staying in Rhode Island congregate shelters in April 2020 during the COVID-19 pandemic. A survey instrument was designed and implemented based on an a priori sample size. All consented participants reported basic demographics, recent travel, duration of time at the shelter, any symptomatology, and had their temperature and pulse oximetry measured. Each participant was tested for COVID-19 using nasopharyngeal swabbing. Shelter characteristics about location, occupancy, resident length of stay, and COVID-19 mitigation strategies were collected through structured phone questionnaire with shelter staff.ResultsA total of 302 individuals were screened and 299 participated across five homeless shelters. The median age was 47.9 (range 18-85) and 20% were female. Of the 299 participants, 35 (11.7%) were positive for SARS-CoV-2; rates varied among shelters, ranging from 0% to 35%. Among the participants in the study, 5% had a new cough, 4% shortness of breath, and 3% reported loss of taste or smell. Symptom prevalence did not vary significantly between positive and negative SARS-CoV-2 groups. Regular symptom screening was not associated with lower infection rates. Shelters with higher rates of positivity were in more densely populated areas, cared for a more transient populations, and instituted fewer social distancing practices for sleeping arrangements or mealtimes.Conclusions and RelevanceResidents of congregate shelters are at increased risk for asymptomatic transmission of SARS-CoV-2. To reduce transmission and enable continuation of low-threshold shelter services, there is a need for universal testing, implementation of infection control and physical distancing measures within congregate shelters, and expansion of non-congregate supportive housing.

Author(s): Napoli, Anthony; Ali, Shihab; Lawrence, Alexis; Baird, Janette | Abstract: Introduction: Boarding of patients in the emergency department (ED) is associated with decreased ED efficiency. The provider-in-triage (PIT) model has been shown to improve ED throughput, but it is unclear how these improvements are affected by boarding. We sought to assess the effects of boarding on ED throughput and whether implementation of a PIT model mitigated those effects.Methods: We performed a multi-site retrospective review of 955 days of ED operations data at a tertiary care academic ED (AED) and a high-volume community ED (CED) before and after implementation of PIT. Key outcome variables were door to provider time (D2P), total length of stay of discharged patients (LOSD), and boarding time (admit request to ED departure [A2D]).Results: Implementation of PIT was associated with a decrease in median D2P by 22 minutes or 43% at the AED (p l 0.01), and 18 minutes (31%) at the CED (p l 0.01). LOSD also decreased by 19 minutes (5.9%) at the AED and 8 minutes (3.3%) at the CED (pl0.01). After adjusting for variations in daily census, the effect of boarding (A2D) on D2P and LOSD was unchanged, despite the implementation of PIT. At the AED, 7.7 minutes of boarding increased median D2P by one additional minute (p l 0.01), and every four minutes of boarding increased median LOSD by one minute (p l 0.01). At the CED, 7.1 minutes of boarding added one additional minute to D2P (p l 0.01), and 4.8 minutes of boarding added one minute to median LOSD (p l 0.01).Conclusion: In this retrospective, observational multicenter study, ED operational efficiency was improved with the implementation of a PIT model but worsened with boarding. The PIT model was unable to mitigate any of the effects of boarding. This suggests that PIT is associated with increased efficiency of ED intake and throughput, but boarding continues to have the same effect on ED efficiency regardless of upstream efficiency measures that may be designed to minimize its impact.

Purpose Measurement of inferior vena cava collapsibility (cIVC) by point-of-care ultrasound (POCUS) has been proposed as a viable, non-invasive means of assessing fluid responsiveness. We aimed to determine the ability of cIVC to identify patients who will respond to additional intravenous fluid (IVF) administration among spontaneously breathing critically-ill patients. Methods Prospective observational trial of spontaneously breathing critically-ill patients. cIVC was obtained 3 cm caudal from the right atrium and IVC junction using POCUS. Fluid responsiveness was defined as a ≥ 10% increase in cardiac index following a 500 ml IVF bolus; measured using bioreactance (NICOM™, Cheetah Medical). cIVC was compared with fluid responsiveness and a cIVC optimal value was identified. Results Of the 124 participants, 49% were fluid responders. cIVC was able to detect fluid responsiveness: AUC = 0.84 [0.76, 0.91]. The optimum cutoff point for cIVC was identified as 25% (LR + 4.56 [2.72, 7.66], LR- 0.16 [0.08, 0.31]). A cIVC of 25% produced a lower misclassification rate (16.1%) for determining fluid responsiveness than the previous suggested cutoff values of 40% (34.7%). Conclusion IVC collapsibility, as measured by POCUS, performs well in distinguishing fluid responders from non-responders, and may be used to guide IVF resuscitation among spontaneously breathing critically-ill patients.

Background A shared language and vocabulary are essential for managing emergency department (ED) operations. This Fourth Emergency Department Benchmarking Alliance (EDBA) Summit brought together experts in the field to review, update, and add to key definitions and metrics of ED operations. Objective Summit objectives were to review and revise existing definitions, define and characterize new practices related to ED operations, and introduce financial and regulatory definitions affecting ED reimbursement. Methods Forty-six ED operations, data management, and benchmarking experts were invited to participate in the EDBA summit. Before arrival, experts were provided with documents from the three prior summits and assigned to update the terminology. Materials and publications related to standards of ED operations were considered and discussed. Each group submitted a revised set of definitions prior to the summit. Significantly revised, topical, or controversial recommendations were discussed among all summit participants. The goal of the in-person discussion was to reach consensus on definitions. Work group leaders made changes to reflect the discussion, which was revised with public and stakeholder feedback. Results The entire EDBA dictionary was updated and expanded. This article focuses on an update and discussion of definitions related to specific topics that changed since the last summit, specifically ED intake, boarding, diversion, and observation care. In addition, an extensive new glossary of financial and regulatory terminology germane to the practice of emergency medicine is included. Conclusions A complete and precise set of operational definitions, time intervals, and utilization measures is necessary for timely and effective ED care. A common language of financial and regulatory definitions that affect ED operations is included for the first time. This article and its companion dictionary should serve as a resource to ED leadership, researchers, informatics and health policy leaders, and regulatory bodies.

The immune checkpoint inhibitors, a class of drugs able to block immune suppressive pathways in order to prime an anticancer immunity, revolutionized standard of care in platinum-refractory recurrent and/or metastatic head and neck carcinoma (R/M HNSCC). The PD-1/ PD-L1 axis is involved in the genesis, maintenance and progression of HNSCC and represents the target of checkpoint inhibitors. HNSCC is an immunosuppressive disease with a high inflammatory component in tumor microenvironment. Recent clinical trials showed that only a small subset of patients really benefits from immunotherapy. This review aims to highlight the five W-points of immunotherapy: why immunotherapy is promising in HNSCC, what is currently available in daily clinical practice, when immunotherapy can be integrated into the therapeutic strategy, where it can be useful according to predictive response biomarker, who, among patients, could get the best benefit from immunotherapy and how improve the achieved results.

Objectives: Nerve block administration in concert with general anesthesia can help manage post-operative pain and provide favorable muscle relaxation of the operative leg in hip surgery. However, the optimal nerve blockade_if any_for arthroscopic surgery of the hip remains undefined. Considerations specific to hip arthroscopy include control of intra-operative pain, adequate muscle relaxation to allow for distraction for work in the central compartment, and post-operative pain control. Dold et al. recently reported in AJSM that a pre-operative femoral nerve block administered in concert with general anesthesia led to decreased patient-reported pain scores at the 60 minute mark post-operatively. Given this demonstrated benefit of the pre-operative femoral nerve block, we hypothesized that a regional block that anesthetized the femoral nerve and the lateral femoral cutaneous nerve (as the fascia iliaca block does), or one that anesthetized the obturator nerve in addition to the femoral and lateral femoral cutaneous nerves (i.e. the lumbar plexus block), would provide additional benefit. The purpose of this study is to examine the effects of pre-operative fascia iliaca and lumbar plexus nerve blocks on post-operative pain and secondary post-operative variables following arthroscopic surgery of the hip. Methods: A retrospective chart analysis was conducted on 145 patients undergoing arthroscopic surgery of the hip in 3 groups. Group 1 (n=55) received general anesthesia only, Group 2 (n=30) received general anesthesia and a fascia iliaca nerve block, and Group 3 (n=60) received general anesthesia and a lumbar plexus nerve block. Post-operative measures were recorded, examined and compared. The primary outcome measure was patient reported pain scores (0-10) at 0, 30, 60, 90 and 120 minutes in the post-anesthesia care unit (PACU). Secondary variables examined included time spent in the PACU, morphine equivalent administered, and presence of nausea requiring anti-emetic medication. Results: Mid-term analysis revealed no benefit to the fascia iliaca block; this regional anesthesia technique showed no significant effect on any of the measured post-operative variables when compared to general anesthesia alone. We therefore abandoned this block in favor of the lumbar plexus block. Patients receiving a lumbar plexus block exhibited significantly decreased pain at each time point when compared to the fascia iliaca group, and at all but one time point when compared to the general anesthesia group (P

INTRODUCTION: The surge of SARS-CoV-2 patients presenting to New York City (NYC) hospitals quickly overwhelmed and outnumbered the available acute care and intensive care resources in NYC Upon arrival of military medical assets to the Javits Convention Center in New York City, more than 100,000 local residents had already been infected and 5,000 residents had died METHODS: The JNYMS (Javits New York Medical Station) constructed by the Army Corps of Engineers with a capacity to house more than 4,000 patients Healthcare professionals from every branch of the uniformed services, augmented by state and local resources, staffed the JNYMS for April, 2020 All patient demographic data was collected on a computerized registry (maintained by the NY Department of Health) and clinical documentation was done using paper charts RESULTS: During the 28 days of patient intake at the JNYMS, 1,095 SARS-CoV-2 patients were transferred from NYC hospitals At its peak, the JNYMS accepted 119 patients in a single day (Figure 1), had a maximum census of 453, and had a peak ICU census of 35 The median length of stay was 4 6 days [IQR: 3 1-6 9 days] 103 patients [9 4%, 95% CI 7 7-11 3] were transferred back to local hospitals (87) or the USNS Comfort (16) There were 6 deaths, for an overall mortality rate of 0 6% [95% CI 0 3-1 2] however 27 ICU patients were transferred back to NYC hospitals, half were on ventilators and the majority were critically ill CONCLUSIONS: This is the first report of the care provided at the JNYMS Within 2 weeks, this multi-agency effort was able to mobilize to care for over 1000 SARS-CoV-2 patients with varying degrees of illness in a one-month period This large-scale mobilization at the height of the epidemic in NYC saved many more lives, as high-level medical care was afforded patients that would have over-loaded New York hospitals It allowed them to decompress while offering much needed healthcare provider relief In addition to the volume of patients cared for over this short period of time, this circumstance is unique in that this field hospital provided ICU level of care Notably, the JNYMS was able to discharge SARS-CoV-2 patients home in under 5 days, with a full supply of their required medications, thus freeing up NY City case management resources for other patients

The benefit of adjuvant chemotherapy has been clearly established in the adjuvant setting for node-positive colon cancer. A number of trials in the adjuvant setting have analyzed the efficacy of multiple-agent combinations, including irinotecan, oxaliplatin, bevacizumab and cetuximab. Only oxaliplatin added to fluorouracil/capecitabine has been shown to be superior beyond a fluropyrimidine alone in the adjuvant setting. As such, standard treatment options include fluorouracil (FU) or capecitabine with or without oxaliplatin. However, oxaliplatin is associated with cumulative dose-dependent neurotoxicity, characterized by distal or perioral paresthesias or dysesthesias; for this reason, in this review we discuss the results of the International Duration Evaluation of Adjuvant Chemotherapy (IDEA) trial. The IDEA trail is the largest prospective clinical trial ever conducted in colorectal cancer, wherein patients were treated with either 3 months or 6 months of adjuvant chemotherapy. In the era of cancer gene expression-based subtyping, the Colorectal Cancer Subtyping Consortium has proposed a four-subgroup molecular classification system for colorectal cancer, consisting of CMS1 (immune), CMS2 (canonical), CMS3 (metabolic) and CMS4 (mesenchymal). In this review, we present and analyze the available data on efficacy and toxicity of the combination regimen approved for treatment of resected colon cancer, and discuss the questions of when, how and how long we need to treat such patients.

Physicians' gender may impact test utilization in the diagnosis of acute cardiovascular disease. We sought to determine if physician gender affected stress test utilization by patient gender in a low-risk chest pain observation unit.This was a retrospective consecutive cohort study of patients admitted to a chest pain unit in a large volume academic urban emergency department (ED). Inclusion criteria were age18, American Heart Association low-to-intermediate risk, electrocardiogram nondiagnostic for acute coronary syndrome, and negative initial troponin I. Exclusion criteria were age75 with a history of coronary artery disease, active comorbid medical problems, or inability to obtain stress testing in the ED for any reason. T-tests were used for univariate comparisons and logistic regression was used to estimate odds ratios (ORs) for receiving testing based on physician gender, controlling for race, insurance, and Thrombolysis In Myocardial Infarction (TIMI) score.Three thousand eight hundred and seventy-three index visits were enrolled during a 2.5-year period. Mean age was 53±20, 55% (95% CI, 53-56%) were female. There was no difference in overall stress utilization based upon physician gender (P=0.28). However, after controlling for other variables, male physicians had significantly lower odds of stress testing female patients (ORM, 0.82; 95% CI, 0.68-0.99), whereas no difference was found in female physicians (ORF, 0.80; 95% CI, 0.57-1.14).Male physicians appear less likely to utilize stress testing in female patients even after controlling for objective clinical variables, including TIMI score. Although adverse outcomes are uncommon in this patient cohort, further investigation into provider-specific practice patterns based on patient gender is necessary.

Coexistence of orbital cavernous hemangioma and other vascular malformations is unusual and few cases have been reported. We describe the clinical and radiological features of three cases of orbital cavernous hemangiomas associated with other vascular malformations, selected reviewing a series of 181 cases of cavernous hemangiomas. All patients were males (age ranging from 43 to 67 years) without vascular systemic disorders and/or a clinical syndrome. They experienced slow progressive exophthalmos. One of them developed acute pulsatile proptosis (case 2), while another experienced slow progressive diplopia (case 3). In one case vascular lesions were bilateral (case 3) and in two patients two different lesions coexisted in the same orbit (cases 1 and 2). All patients underwent surgical excision, which was partial in two cases. Two patients had cavernous hemangiomas in association with a venous malformation (a varix in case 1 and a lymphangioma in case 2), while in the other ones (case 3) cavernous hemangioma was associated with a low-flow arteriovenous malformation. No patient denied visual impairment postoperatively. Few cases of orbital cavernous hemangiomas coexisting with other vascular malformations have been reported in the literature. This entity seems to be an association of different variants of orbital vascular malformations, presenting with a wide spectrum of clinical forms and probably with the same pathogenesis.

Lipoic acid plays a crucial role as antioxidant and metabolic component of enzymes involved in glucose metabolism of different cell types. Choline alphoscerate (α-glyceryl-phosphoryl-choline [αGPC]) is a semisynthetic derivative of phosphatidylcholines representing, among acetilcholine precursors, a cholinergic drug. In the present study, we evaluated the expression of some proliferation and differentiation markers in 15 or 21 DIV astrocyte cultures treated with 50 μM (+)lipoic acid or (+/-)lipoic acid and/or 10 mM αGPC for 24 hr. In addition, we evaluated the possible genoprotective effect by analysis of DNA status detected by alkaline comet assay. The addition of single drugs [(+)lipoic acid, (+/-)lipoic acid, or αGPC] induced an "upward modulation" of the expression of biomarkers used in our study. On the contrary, the cotreatment with either (+)lipoic acid + αGPC or (+/-)lipoic + αGPC surprisingly showed no significant modification or even a downregulation of the above-mentioned biomarkers. This latter finding demonstrated no additional effect after the cotreatment with both drugs with respect to the single treatments alone. Further studies are necessary to clarify the specific mechanism evoked by the processing of these neuroprotective agents in our in vitro models. Finally, these preliminary findings may represent a good tool with which to clarify the antioxidant and metabolic roles played by lipoic acid in proliferating and differentiating astroglial cell cultures, during an interactive cross-talk between glial and neuronal cells, after brain lesions or damage correlated with oxidative stress that may occur in some degenerative diseases.

OBJECTIVES Nearly 40% of all previously admitted chest pain patients re-present to the emergency department (ED) within 1 year regardless of stress testing, and nearly 5% of patients return with a major adverse cardiac event (MACE). The primary objective of this study was to determine the prevalence of return visits to the ED among patients previously admitted to an ED chest pain observation unit (CPU). We also identified the patient characteristics and health risk factors associated with these return ED visits. METHODS This was a prospective cohort study of patients admitted to a CPU in a large-volume academic urban ED who were subsequently followed over a period of 1 year. Inclusion criteria were age ≥18 years old, American Heart Association low-to-intermediate assessed risk, electrocardiogram nondiagnostic for acute coronary syndrome (ACS), and a negative initial troponin I. Excluded patients were those age >75 years with a history of coronary artery disease. Patients were followed throughout their observation unit stay and then subsequently for 1 year. On all repeat ED evaluations, standardized chart abstractions forms were used, charts were reviewed by 2 trained abstractors blinded to the study hypothesis, and a random sample of charts was examined for interrater reliability. Return visits were categorized as MACE, cardiac non-MACE, or noncardiac based on a priori criteria. Social security death index searches were performed on all patients. Univariate and multivariate ordinal logistic regressions were conducted to determine demographics, medical procedures, and comorbid conditions that predicted return visits to the ED. RESULTS A total of 2139 patients were enrolled over 17 months. The median age was 52 years, 55% were female. Forty-four patients (2.1%) had ACS on index visit. A total of 36.2% of CPU patients returned to the ED within 1 year vs. 5.4% of all ED patients (P < 0.01). However, the overall incidence of MACE at 1 year in all patients and in those without an index visit diagnosis of ACS was 0.5% (95% confidence interval [CI], 0.4%-06%) and 0.4% (95% CI, 0.2%-0.7%), respectively. Patients who received a stress test on index visit were less likely to return (adjusted odds ratio [AOR] = 0.64 [95% CI, 0.51-0.80]) but patients who smoked (AOR = 1.51 [95% CI, 1.16-1.96]) or had diabetes (AOR = 1.36 [95% CI, 1.07-1.87]) were more likely to return. Hispanic and African-American patients had increased odds of multiple return ED visits (AOR=1.23 [95% CI, 1.04-1.46] and AOR =1.74 [95% CI, 1.45-2.13], respectively). CONCLUSION Patients treated in an ED CPU have a very low rate of MACE at 1 year. However, these same patients have very high rates of subsequent ED utilization. The associations between certain comparative demographics and ED utilization suggest the need for further research to identify and address the needs of these patient populations that precipitate the higher than expected return rate.

The ability to accurately assess the level of immunosuppression in HIV+ patients in the emergency department (ED) is often limited and can affect management of these patients.To evaluate the relationship between the absolute lymphocyte count (ALC) and CD4 count in HIV patients admitted through the ED with pneumonia and how utilization of this relationship may affect early consideration and evaluation of Pneumocystis jiroveci pneumonia (PCP).Retrospective multicenter 5-year study of HIV+ patients with an ICD-9 diagnosis of pneumonia. Included patients had an ALC measured on ED presentation and a CD4 count measured in24 h. A receiver operator curve (ROC), decision plot analysis, and McNemar test of proportions were used to characterize the relationship between study variables.Six hundred eighty six patients were enrolled, 23.2% (95% confidence interval [CI] 20.2-26.1) were diagnosed with PCP. The geometric mean CD4 count and ALC were 81 and 1089, respectively. The correlation between ALC and CD4 was r = 0.60 (95% CI 0.55-65, p0.01). The ROC was 0.78 (0.75-0.82). An ALC1700 cells/mm(3) had a sensitivity of 84% (95% CI 80-87) and specificity of 55% (95% CI 48-70) for a CD4200 cells/mm(3). An ALC threshold of 1700 cells/mm(3) would have identified 86% of patients with PCP but falsely identified 2.5 patients without PCP for every one accurately identified.The ALC threshold of 1700 cells/mm(3) retains significant discriminatory value and would moderately improve identification of patients with a CD4200 cells/mm(3) but is not likely to be reliable as the sole method of early recognition and evaluation of PCP.

The objective of this study is to investigate potential racial disparities in time to antibiotics among patients presenting to the emergency department (ED) with severe sepsis or septic shock. This was a retrospective observational study of adults >18 years with severe sepsis or septic shock presenting to a large, urban, academic ED and admitted to the ICU from 10/2005 to 2/2012. Time to antibiotic data was abstracted by ICU research staff; other data were abstracted by blinded trained research assistants using standardized abstraction forms. Time from ED arrival to antibiotics was compared in white vs. non-white patients using cumulative events curves followed by Cox proportional hazards regression, controlling for age, gender, ethnicity, source of infection, and SOFA score. Seven hundred sixty-eight patients were included; 19.5 % (n = 150) were non-white. Median minutes to antibiotics was 131 in white patients vs. 158 in non-white patients (p = 0.03, log-rank test). The unadjusted hazard ratio for non-white patients was 0.82 (95 %CI 0.58–0.98). After adjustment, the hazard ratio for race was not significant (0.90, 95 %CI 0.73–1.10). In a single-center sample of patients with severe sepsis or septic shock, adjustment for factors including age and infectious source eliminated the difference in time to antibiotics by race. Further research should investigate disparities in sepsis care between hospitals with differing patient populations.

Objective: Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on preload dependence. The objectives of this study were to determine if a fluid responsiveness protocol would decrease progression of organ dysfunction, and a fluid responsiveness protocol would facilitate a more aggressive resuscitation. Methods: Prospective, 10-center, randomized interventional trial. Inclusion criteria: suspected sepsis and lactate 2.0 to 4.0 mmol/L. Exclusion criteria (abbreviated): systolic blood pressure more than 90 mmHg, and contraindication to aggressive fluid resuscitation. Intervention: fluid responsiveness protocol using Non-Invasive Cardiac Output Monitor (NICOM) to assess for fluid responsiveness (>10% increase in stroke volume in response to 5 mL/kg fluid bolus) with balance of a liter given in responsive patients. Control: standard clinical care. Outcomes: primary—change in Sepsis-related Organ Failure Assessment (SOFA) score at least 1 over 72 h; secondary—fluids administered. Trial was initially powered at 600 patients, but stopped early due to a change in sponsor's funding priorities. Results: Sixty-four patients were enrolled with 32 in the treatment arm. There were no significant differences between arms in age, comorbidities, baseline vital signs, or SOFA scores (P > 0.05 for all). Comparing treatment versus Standard of Care—there was no difference in proportion of increase in SOFA score of at least 1 point (30% vs. 33%) (note bene underpowered, P = 1.0) or mean preprotocol fluids 1,050 mL (95% confidence interval [CI]: 786–1,314) vs. 1,031 mL (95% CI: 741–1,325) (P = 0.93); however, treatment patients received more fluids during the protocol (2,633 mL [95% CI: 2,264–3,001] vs. 1,002 mL [95% CI: 707–1,298]) (P

Background Commonly cited barriers to effective teaching in emergency medicine include lack of time, competing demands for patient care, and a lack of formal teaching experience. Teaching may be negatively affected by demands for increased clinical productivity, or positively influenced by clinical experience. Objective To examine the association between faculty teaching scores and clinical productivity, years of clinical experience, and amount of clinical contact with resident physicians. Methods We conducted a retrospective, observational study with existing data on full-time faculty at a high-volume, urban emergency medicine residency training program for academic year 2008–2009. Residents rated faculty on 9 domains of teaching, including willingness to teach, enthusiasm for teaching, medical knowledge, preparation, and communication. Clinical productivity data for relative value units per hour and number of patients per hour, years of clinical experience, and annual clinical hours were obtained from existing databases. Results For the 25 core faculty members included in the study, there was no relationship between faculty teaching scores and clinical productivity measures (relative value units per hour: r2 = 0.01, P = .96, patients per hour: r2 = 0.00, P = .76), or between teaching scores and total clinical hours with residents (r2 = 0.07, P = .19). There was a significant negative relationship between years of experience and teaching scores (r2 = 0.27, P Conclusions Our study demonstrated that teaching scores for core emergency medicine faculty did not correlate with clinical productivity or amount of clinical contact with residents. Teaching scores were inversely related to number of years of clinical experience, with more experienced faculty earning the lowest teaching scores. Further study is necessary to determine if there are clinical measures that identify good educators.

Meningioma is one of the most common spinal extramedullary tumors, largely intradural. An extradural localization is possible but less frequent. There are two morphologically different types of meningioma: one is round, and the other is the “en-plaque” form, that grows along the dura mater like a sheet. The “en-plaque” form, is unusual. We report on an unusual case of epidural and extraspinal “en-plaque” meningioma, describing the MRI and CT features and discussing the possible principal differential diagnosis (neurolymphomatosis, plexiform neurofibromas/schwannomas and metastasis).

Syringomyelia is a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called syrinx, can expand and elongate over time, destroying the spinal cord. We describe the case of a young patient with partial spontaneous regression of syringomyelia in Chiari I malformation, confirmed by magnetic resonance imaging three years after the diagnosis. During this period the patient did not experience any clinical symptoms. Although described in literature, spontaneous regression is an unusual event and very few cases have been reported. This case report supports the belief that conservative management together with both clinical and imaging periodic controls should be preferred in stable mild-symptomatic patients.

Objectives Sonographic measurement of the inferior vena cava (IVC) caval index predicts central venous pressure in ED patients. Fluid responsiveness (FR) is a measure of preload dependence defined as an increase in cardiac output secondary to volume expansion. We sought to determine if the caval index is an accurate measurement of FR in ED patients. Methods We conducted a prospective, observational trial at an urban, academic, adult ED with an annual census >105 000. Included patients were clinically suspected of eu- and hypovolemia. Excluded patients were 10% by impedance cardiography (BioZ; Sonosite) following passive leg raise. The primary outcome was analysed using Spearman correlations for non-parametric data and the area under the receiver operating characteristics curve by Wilcoxon method. Results Thirty patients were enrolled; four were excluded because of incomplete data collection. Thirty-one per cent (95% CI 13–48) of the patients were FR. The mean initial caval and cardiac index were 15.8% (95% CI 9.5–22) and 2.9 L/min/m2 (95% CI 2.6–3.2), respectively. Caval index did not predict FR (receiver operating curve = 0.46, 95% CI 0.21–0.71, P = 0.63). Conclusion Bedside sonographic measurement of IVC caval index does not predict FR in a heterogeneous ED patient population. Further research using this technique in targeted patient subsets and a variety of shock etiologies is needed.

Exocytosis of granules containing the cytolytic effector (CE) molecules granzyme A (GzmA), granzyme B (GzmB), and perforin is one major pathway of lymphocyte-mediated cytotoxicity. Studies in murine models and the finding of elevated granzyme levels in the plasma of septic patients have implicated cytotoxic lymphocytes in the pathogenesis of sepsis. We sought to evaluate the role of cytotoxic cells and CE in sepsis and determine if intracellular levels of CE in cytotoxic cells correlate with disease severity. We conducted a prospective cohort study of 40 patients enrolled into one of three groups: controls (C), acutely ill nonseptic illnesses, or patients with severe sepsis (SS) (lactate, >4 mmol/L; systolic blood pressure

Clinical assessment and vital signs are poor predictors of the overall hemodynamic state. Optimal measurement of the response to fluid resuscitation and hemodynamics has previously required invasive measurement with radial and pulmonary artery catheterization. Newer noninvasive resuscitation technology offers the hope of more accurately and safely monitoring a broader range of critically ill patients while using fewer resources. Fluid responsiveness, the cardiac response to volume loading, represents a dynamic method of improving upon the assessment of preload when compared to static measures like central venous pressure. Multiple new hemodynamic monitors now exist that can noninvasively report cardiac output and oxygen delivery in a continuous manner. Proper assessment of the potential future role of these techniques in resuscitation requires understanding the underlying physiologic and clinical principles, reviewing the most recent literature examining their clinical validity, and evaluating their respective advantages and limitations.

ACADEMIC EMERGENCY MEDICINE 2011; 18:385–389 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: This study sought to determine if the automated absolute lymphocyte count (ALC) predicts a “low” (

Previous analyses of physiologic parameter changes during ascent to altitude have incorporated small numbers of well-trained climbers. The effects of altitude illness are more likely to occur and may come to medical attention more frequently in unacclimatized recreational individuals. We sought to evaluate acute changes in physiologic parameters during ascent to high altitude (14,100 ft) in recreational climbers.We performed a prospective naturalistic study of 221 recreational climbers at Mount Shasta (peak altitude of 14,162 ft). Baseline vital signs were recorded at 3500 ft (blood pressure, heart rate, respiratory rate, pulse oximetry, and peak flow). Subsequent measurements were obtained at 6700 ft, 10,400 ft, and at the summit. Mean vital signs and the amount they changed with altitude were estimated using mixed linear models.One hundred twenty-five climbers (56.6%) reached the summit. Heart rate increased and pulse oximetry decreased with ascent (mean, 71.9, 79, 97, and 102.4 beats/min and 96.9%, 93.9%, 88.8%, and 80.8%, respectively), with estimates at each altitude differing statistically at P.0001. Mean systolic and diastolic blood pressures varied significantly by altitude (not measured at summit), but the changes were not monotonic. Peak flow progressively declined with ascent, but the difference between 6700 and 10,400 was not statistically significant. Respiratory rate did not change significantly.Acute compensation for altitude-induced hypoxia involves numerous physiologic changes; this is supported by our data that demonstrate significant changes in blood pressure and stepwise changes in pulse oximetry, peak flow, and heart rate. Consideration of these changes can be incorporated in future studies of the affect of altitude on recreational climbers.

Cerebral aneurysms are occasionally associated with anomalies of the cerebral arteries. Most reports on anomalies of the anterior cerebral artery have been concerned with hypoplasia, fenestration and the infra-optic course of the A1, variant A1 perforators or Heubner's artery, multi-channeled anterior communicating artery, and azygos anterior cerebral artery. Distal anterior cerebral artery (ACA) aneurysms are known to have a poor clinical course and prognosis compared to other supratentorial aneurysms. The presence of the unpaired, distal, postcommunicating (A2) segment of the ACA is very rare in adults. We describe a patient with a ruptured aneurysm arising from the proximal end of the azygos ACA, first surgically treated with clipping and then with endovascular coiling. A 37-year-old woman at 34 weeks' gestation was transferred to our emergency room with sudden onset of severe headache and vomiting. Computed tomography (CT) revealed subarachnoid hemorrhage in the basal cisterna and the sylvian and interhemispheric fissures. Cerebral angiography showed an azygos ACA, a saccular aneurysm at the junction of the azygos ACA and the right A1 segment. A right fronto-temporal craniotomy was performed in the day of admission, and the neck of the aneurysm was clipped. One year later, an angiographic control examination revealed a regrowth of the aneurysm. The patient underwent endovascular treatment with coiling. Aneurysms of the azygos ACA are rare and their pathogenesis and course are still a matter of discussion. Developmental abnormalities or dynamic vessel wall stresses can explain the high incidence of aneurysms in these cases. The association of a rare anatomical variant with an aneurysm in the same location may suggest an embryogenesis alteration in the Willis circulation.

Background— The identification and assessment of myocardial infarction (MI) are important for therapeutic and prognostic purposes, yet current recommended diagnostic strategies have significant limitations. We prospectively tested the performance of delayed-enhancement magnetic resonance imaging (MRI) with gadolinium-based contrast for the detection of MI in an international, multicenter trial. Methods and Results— Patients with their first MI were enrolled in an acute (≤16 days after MI; n=282) or chronic (17 days to 6 months; n=284) arm and then randomized to 1 of 4 doses of gadoversetamide: 0.05, 0.1, 0.2, or 0.3 mmol/kg. Standard delayed-enhancement MRI was performed before contrast (control) and 10 and 30 minutes after gadoversetamide. For blinded analysis, precontrast and postcontrast MRIs were randomized and then scored for enhanced regions by 3 independent readers not associated with the study. The infarct-related artery perfusion territory was scored from x-ray angiograms separately. In total, 566 scans were performed in 26 centers using commercially available scanners from all major US/European vendors. All scans were included in the analysis. The sensitivity of MRI for detecting MI increased with rising dose of gadoversetamide ( P P P Conclusions— Gadoversetamide-enhanced MRI using doses of ≥0.2 mmol/kg is effective in the detection and assessment of both acute and chronic MI. This study represents the first multicenter trial designed to evaluate an imaging approach for detecting MI.

Introduction: The association of intracranial aneurysms and autosomal-dominant polycystic kidney disease (ADPKD) is well recognized. The aim of this study was to assess the prevalence of asymptomatic intracranial aneurysms and to verify the presence of other cerebral abnormalities in patients with ADPKD by Magnetic Resonance Angiography screening. Materials and methods: From January 2009 to September 2013, 56 patients with ADPKD (25 M, 31 F; mean age 40 years, range 24- 63 years) underwent brain Magnetic Resonance Imaging including 3D time-of-flight MR angiography and T2-weighted Turbo-Spin-Echo axial sequences. Magnetic Resonance studies were examined by two experienced neuroradiologists (20 years). If an intracranial aneurysm was detected, cerebral Computed Tomography Angiography was recommended and further action were discussed with the interventional neuroradiologist. Results: Nine saccular intracranial aneurysms were detected in 56 patients, located in the anterior circulation (5 internal carotid arteries, 1 anterior communicating artery and 3 middle cerebral arteries). Four patients underwent endovascular treatment with flow-diverter devices. We additionally found internal carotid artery abnormal diameter and course (6), basilar artery hypoplasia (1), basilar artery dolichoectasia (1), asymmetric anterior cerebral (4) and vertebral (14) arteries, vascular anatomic variants (3), venous drainage anomaly (1), arachnoid cysts (6), large bilateral choroid plexus cysts (1) and mega cisterna magna (2). Conclusions: The prevalence of asymptomatic intracranial aneurysms (16.1%), higher compared to the general population (1%) and similar to literature reports in autosomal dominant polycystic kidney disease (6-16%), confirmed the importance of the Magnetic Resonance Angiography screening in these patients.

HydroCoils are platinum helical coils coated with a layer of hydrophilic acrylic polymer (hydrogel), which on contact with blood causes disentanglement of polymer chains and expansion. We retrospectively reviewed a series of 29 patients harboring 29 cerebral aneurysms treated with the Hydrocoil Embolic System in the period 2004–2005, discussing the results of endovascular procedures in terms of safety and efficacy. The immediate post-procedure angiographic control demonstrated complete aneurysm occlusion in 21 cases (72.4%), near-complete occlusion in seven cases (24.1%), whereas in one case (3.4%) there was a procedure failure with major perfusion of the sac. Five patients (17.2%) experienced thromboembolic complications, including an asymptomatic lacunar stroke of the head of the caudate nucleus, a thalamic infarct following hypotension secondary to pulmonary edema, temporal ischemia secondary to vasospasm and a small right occipital ischemic lesion. Only one patient (3.4%) suffered a major ischemic accident. No other procedure-related complication occurred. Three-month follow-up control with MR angiography and 12-month follow-up angiography demonstrated no recurrence of aneurysms. Overall, after a mean follow-up of 12 months, the clinical outcome was good recovery in 26 patients (89.6%), moderate disability in three patients (10.3%) and no vegetative status or death. Our HydroCoil series supports the safety and midterm durability of hydrogel-coated aneurysm coils in the treatment of cerebral aneurysms.

Cardiology consensus guidelines recommend use of the DiamondForrester (DF) score in augmenting the decision to pursue stress testing. We have recently shown that it may have value in safely reducing stress utilization in an emergency department chest pain unit (CPU). However, full application necessitates demonstration of a good inter-rater reliability of the DF score in the CPU setting. We hypothesized that DF pretest probability would have good inter-rater reliability in CPU patients.This was a chart review of randomly selected patients from a previously collected prospective observational trial of admitted CPU patients in a large-volume academic urban emergency department. Inclusion criteria were: age18 years, American Heart Association low/intermediate risk, nondynamic electrocardiograms, and normal initial troponin I. Exclusion criteria were: age75 years with coronary artery disease. A DF score for likelihood of coronary artery disease was calculated on each patient by 2 trained chart abstractors using a standardized data abstraction instrument. Abstractors were trained to specifically categorize presenting symptoms as fitting 1 of 3 types of chest pain symptoms: nonanginal, atypical, or anginal based on previously published prespecified criteria. Approximately 20% of charts in a CPU registry were abstracted by 2 chart abstractors who were blind to each other's categorization, the patient outcomes, and the study hypothesis. The primary outcome was the kappa statistic for agreement between the 2 raters.The charts of 705 random patients were reviewed. The mean age was 55.1±11.8 years, 52% were female. Forty four percentage of patients received stress testing, and 2.4% of patients had acute coronary syndrome. The mean DF score was 39±24. There was good inter-rater agreement of chest pain characteristics (κ=0.77, 95% confidence interval, 0.72-0.81; P0.01).This study supports the use of the DF score as a reliable indicator of pretest probability in CPU patients by demonstrating that there is good inter-rater reliability. Prospective validation is necessary at the point of patient assessment, in conjunction with application of the DF score to augment stress utilization decision making.

This report describes endovascular approaches for occlusion of vertebro-vertebral arteriovenous fistula (W-AVF) in a series of three cases and a review of the literature. Complete neuroimaging assessment, including CT, MR and DSA was performed in three patients (two female, one male) with W-AVF. Based on DSA findings, the W-AVF were occluded by endovascular positioning of detachable balloons (case 1), coils (case 2), or a combination of both (case 3) with parent artery patency in two out of three cases. In this small series, endovascular techniques for occlusion of W-AVF were safe and effective methods of treatment. To date, there are no guidelines on the best treatment for W-AVF. Detachable balloons, endovascular coiling, combined embolization procedures could all be considered well-tolerated treatments.

BACKGROUND Fluid responsiveness is a measure of preload dependence and is defined as an increase in cardiac output due to volume expansion. Recent publications have suggested that variation in amplitude of the pulse oximetry waveform may be predictive of fluid responsiveness. The pleth variability index (PVI) was developed as a noninvasive bedside measurement of this variation in the pulse oximetry waveform. OBJECTIVES To measure the discriminatory value of PVI for predicting fluid responsiveness as measured by pulmonary artery catheter thermodilution in patients after cardiothoracic surgery. METHODS A prospective observational study of hemodynamically stable postoperative cardiac surgery patients with pulmonary artery catheters. A fingertip sensor was used to measure PVI. Vital signs, PVI, and cardiac index were measured before, during, and after passive leg raise. Fluid responsiveness was defined by increase in cardiac index of greater than 15% during passive leg raise. The discriminatory value of PVI was assessed by using the Wilcoxon method to measure the area under the receiver operating curve. RESULTS In 13 months, 47 patients (24 receiving mechanical ventilation, 23 spontaneously breathing) were enrolled. Fluid responsiveness was noted in 42% of intubated patients and 48% of spontaneously breathing patients. PVI was not adequate to discriminate fluid responsiveness in intubated patients (area under curve, 0.63; P = .16) or spontaneously breathing patients (area under curve, 0.41; P = .75). CONCLUSIONS Among postoperative cardiac surgery patients, PVI is not reliable for predicting fluid responsiveness as measured by pulmonary artery catheter thermodilution, regardless of ventilatory status.

We describe the case of a 62-year-old woman who presented with a small fusiform left superior cerebellar artery (SCA) aneurysm. Aneurysms located on the SCA are uncommon and their presentation, natural history and clinical management are poorly understood. Reports on the endovascular or surgical management of SCA aneurysms are rare and usually incorporated in clinical series of basilar artery or posterior circulation aneurysms. The patient was treated by delivery of a flow-diverter Pipeline Embolization Device (PET) - Chestnut Medical/ev3) at the origin of vessel. She had no procedural complications and the aneurysm volume was reduced. This paper presents additional evidence to literature reports suggesting that the new endovascular flow-diverter devices are an effective and well-tolerated treatment for complex aneurysms. Our review contributes data on the incidence of recurrence as a measure of long-term efficacy of this therapeutic approach.

Facial nerve paralysis (Cranial Nerve VII, CN VII) can be a disfiguring disorder with profound impact upon the patient. The etiology of facial nerve paralysis may be congenital, iatrogenic, or result from neoplasm, infection, trauma, or toxic exposure. In the emergency department, the most common cause of unilateral facial paralysis is Bell's palsy, also known as idiopathic facial paralysis (IFP). We report a case of delayed presentation of unilateral facial nerve paralysis 3 days after sustaining a traumatic head injury. Re-evaluation and imaging of this patient revealed a full facial paralysis and temporal bone fracture extending into the facial canal. Because cranial nerve injuries occur in approximately 5-10% of head-injured patients, a good history and physical examination is important to differentiate IFP from another etiology. Newer generation high-resolution computed tomography (CT) scans are commonly demonstrating these fractures. An understanding of this complication, appropriate patient follow-up, and early involvement of the Otolaryngologist is important in management of these patients. The mechanism as well as the timing of facial nerve paralysis will determine the proper evaluation, consultation, and management for the patient. Patients with total or immediate paralysis as well as those with poorly prognostic audiogram results are good candidates for surgical repair.

A rare case of segmental hypoplasia of the basilar artery is described in a 49-year-old man with transient vertebrobasilar ischemia, explored by magnetic resonance imaging (MRI) and digital angiography (DA). The embryology, clinical relevance and magnetic resonance findings of this arterial anomaly are discussed, with a review of six previously reported cases. Segmental aplasia was suggested in our case by magnetic resonance, and subsequently confirmed not only by time-of-flight magnetic resonance, but also by DA. Only ultrathin-slice T2-weighted images revealed the real finding of basilar artery hypoplasia. This sequence, not employed in previously reported cases, is mandatory to allow a clear differential diagnosis between basilar artery aplasia and hypoplasia.

Emergent conditions resulting from head and neck neoplasms and their treatment include acute airway obstruction, hemorrhage, spinal cord compression, bilateral vocal cord paralysis, and septic thrombophlebitis. These conditions require accurate diagnosis and rapid intervention to avoid severe permanent damage or death. Successful treatment requires a coordinated response by emergency medicine physicians, otolaryngologists, vascular surgeons, and radiologists. We review these head and neck oncological conditions, which present emergently, with a focus on radiological evaluation and interpretation.

Purpose To evaluate the safety of OptiMARK® (gadoversetamide injection) administered via power injector. Materials and Methods The study population included 144 healthy volunteers aged 18 years or older randomly assigned to one of seven treatment groups (N = 20/group). The safety assessment was based on changes in physical examination, vital signs, electrocardiograms (ECGs), standard clinical laboratory tests, and adverse events (AEs) through a 24-hour postinjection period. Results OptiMARK caused no serious AEs or unexpected changes in physical examinations or laboratory parameters. The changes observed in vital signs and ECG intervals did not vary with changes in injection rate and were not significantly (P < 0.05) different from those elicited by saline administration at the same rates. Conclusion This study demonstrated the safety of OptiMARK when administered via a power injector at rates of 2, 4, and 6 mL/second. J. Magn. Reson. Imaging 2004;19:133–140. © 2003 Wiley-Liss, Inc.