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Introduction and Aims. The first COVID-19 case in Malta was confirmed on the 7th of March 2020. This study is aimed at investigating a significant difference between the number of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) admissions and their inpatient outcome at Mater Dei Hospital during the COVID-19 pandemic when compared to the same period in 2019. Furthermore, we aim to determine predictors of mortality in AECOPD inpatients. Method. Data was collected retrospectively from electronic hospital records during the periods 1st March until 10th May in 2019 and 2020. Results. There was a marked decrease in AECOPD admissions in 2020, with a 54.2% drop in admissions (n = 119 in 2020 vs. n = 259 in 2019). There was no significant difference in patient demographics or medical comorbidities. In 2020, there was a significantly lower number of patients with AECOPD who received nebulised medications during admission (60.4% in 2020 vs. 84.9% in 2019; p ≤ 0:001). There were also significantly lower numbers of AECOPD patients admitted in 2020 who received controlled oxygen via venturi masks (69.0% in 2020 vs. 84.5% in 2019; p = 0:006). There was a significant increase in inpatient mortality in 2020 (19.3% [n = 23] and 8.4% [n = 22] for 2020 and 2019, respectively, p = 0:003). Year was found to be the best predictor of mortality outcome (p = 0:001). The lack of use of SABA pre-admission treatment (p = 0:002), active malignancy (p = 0:003), and increased length of hospital stay (p = 0:046) were also found to be predictors of mortality for AECOPD patients; however, these parameters were unchanged between 2019 and 2020 and therefore could not account for the increase in mortality. Conclusions. There was a decrease in the number of admissions with AECOPD in 2020 during the COVID-19 pandemic, when compared to 2019. The year 2020 proved to be a significant predictor for inpatient mortality, with a significant increase in mortality in 2020. The decrease in nebuliser and controlled oxygen treatment noted in the study period did not prove to be a significant predictor of mortality when corrected for other variables. Therefore, the difference in mortality cannot be explained with certainty in this retrospective cohort study., peer-reviewed

The window for acute ischemic stroke treatment was previously limited to 4.5 hours for intravenous tissue plasminogen activator and to 6 hours for thrombectomy. Recent studies using advanced imaging selection expand this window for select patients up to 24 hours from last known well. These studies directly affect emergency stroke management, including prehospital triage and emergency department (ED) management of suspected stroke patients. This narrative review summarizes the data expanding the treatment window for ischemic stroke to 24 hours and discusses these implications on stroke systems of care. It analyzes the implications on prehospital protocols to identify and transfer large-vessel occlusion stroke patients, on issues of distributive justice, and on ED management to provide advanced imaging and access to thrombectomy centers. The creation of high-performing systems of care to manage acute ischemic stroke patients requires academic emergency physician leadership attentive to the rapidly changing science of stroke care.

OBJECTIVES: Neurovascular and neurocritical care emergencies constitute a leading cause of morbidity/mortality. There has been great evolution in this field, including but not limited to extended time‐window therapeutic interventions for acute ischemic stroke. The intent of this article is to evaluate the goals and future direction of clinical rotations in neurovascular and neurocritical care for emergency medicine (EM) residents. METHODS: A panel of 13 board‐certified emergency physicians from the Society for Academic Emergency Medicine (SAEM) neurologic emergencies interest group (IG) convened in response to a call for publications—three with fellowship training/board certification in stroke and/or neurocritical care; five with advanced research degrees; three who have been authors on national practice guidelines; and six who have held clinical duties within neurology, neurosurgery, or neurocritical care. A mixed‐methods analysis was performed including a review of the literature, a survey of Council of Emergency Medicine Residency Directors (CORD) residency leaders/faculty and SAEM neuro‐IG members, and a consensus review by this panel of select neurology rotations provided by IG faculty. RESULTS: Thirteen articles for residency neurovascular education were identified: three studies on curriculum, three studies evaluating knowledge, and seven studies evaluating knowledge after an educational intervention. Intervention outcomes included the ability to recognize and manage acute strokes, manage intracerebral hemorrhage, calculate National Institutes of Health Stroke Scale (NIHSS), and interpret images. In the survey sent to CORD residency leaders and neuro‐IG faculty, response was obtained from 48 programs. A total of 52.1% indicated having a required rotation (6.2% general neurology, 2% stroke service, 18.8% neurologic intensive care unit, 2% neurosurgery, 22.9% on a combination of services). The majority of programs with required rotations have a combination rotation (residents rotate through multiple services) and evaluations were positive. CONCLUSIONS: Variability exists in the availability of neurovascular/neurocritical care rotations for EM trainees. Dedicated clinical time in neurologic education was beneficial to participants. Given recent advancements in the field, augmentation of EM residency training in this area merits strong consideration.

Background Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place. Methods Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting. Results We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms. Conclusions These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference. Electronic supplementary material The online version of this article (10.1007/s00134-019-05900-x) contains supplementary material, which is available to authorized users.

Introduction: The time from 911 activation (i.e. alarm) to administration of intravenous (IV) alteplase in acute ischemic stroke is associated with functional, patient centered-outcomes. Mobile stroke treatment units (MSTUs) have emerged as a stroke system tool that may hasten treatment times. Optimal workflows on MSTUs remain to fully elucidated. Methods: Retrospective review of a QA database of patients treated on a MSTU with door-to-needle-times (DTN) of Results: In October of 2018 the University of Rochester Medical Center launched a MSTU, initially operating on Monday through Friday in the city of Rochester from 8am until 4 pm. Over the initial 3 months, there were 96 MSTU responses leading to 54 transported patients, 3 of which were treated with IV alteplase. One patient with an initial NIHSS of 17 was treated with IV alteplase within 9 minutes of reaching the MSTU door. Workflow elements felt to hasten treatment included registration of the patient in the electronic health record (EHR) prior to the patient reaching the MSTU and enabling the telestroke provider to listen to the initial history and physical being performed by the MSTU RN at the scene. The later is accomplished by using a telestroke iPhone application that allows for a “3-way-call” between the MSTU RN, the MSTU, and the telestroke provider. The MSTU RN wears a Bluetooth earpiece that captures the conversation with the patient, witnesses on scene, and initial EMS responders and enables the MSTU RN to summarizes key history and exam findings, vitals, and blood glucose results while keeping their hands available for patient care. Simultaneously, the telestroke provider reviews the patient’s chart in the EHR for alteplase contraindications, prior imaging results, and pertinent medical history. Conclusion: Registering the patient in the EHR and integrating the telestroke provider into the initial patient assessment at the scene in the prehospital setting may allow for consistent door to needle times of < 15 minutes on MSTUs, which may further improve patient outcomes.

Introduction: Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care. Methods: Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC), Cayuga Medical Center (CMC), and Geneva General Hospital (GGH) are NYS-DSCs located 115, 91, and 50 miles from SMH, respectively. Clinical leaders at each site collaborated to implement an integrated regional system of care for LVO-AIS, dubbed “Code LVO”, which includes the auto-launching of an interfacility transport to the referring hospital for presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of /= 6 and proximal anterior circulation LVO on a CTA at the referring hospital to identify the door-in-door-out (DIDO) times, thrombectomy attempt rate, and mortality of patients before and after Code LVO implementation. Wilcoxon Rank-Sum was used to analyze median DIDO times and Fisher’s exact was used to analyze the proportion of DIDO times of < 90 minutes, < 60 minutes, thrombectomy attempt rate, and mortality. Results: There were 51 pre- Code LVO versus 12 post Code-LVO transfers. The median DIDO times were significantly reduced post-Code LVO (80 vs 127 minutes, p=0.001). The proportion of DIDO times < 90 minutes and < 60 minutes were significantly improved (58% vs 16%, p=0.005 and 17% vs 0%, p=0.034, respectively). Mortality was numerically, but not significantly, reduced (17% vs 22%). Median DIDO times were significantly shorter in those undergoing thrombectomy (97 vs 136 minutes, p=0.008) and numerically longer in those who died (138 vs 112 minutes, p=0.24). Conclusions: Auto-launching of interfacility transport within an integrated regional system care for LVO-AIS decreases DIDO times and may improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.

Objective Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation. Data sources PubMed was queried for publications with the Medical Subject Headings (MeSH) terms “mechanical ventilation” and “aneurysmal subarachnoid hemorrhage” published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest. Study selection Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies. Data extraction Articles were reviewed by one team member, and interpretation was verified by a second team member. Data synthesis Thirty-one articles met the inclusion criteria for this review. Conclusions We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.

Acute coronary syndrome occurring during the course of a type I hypersensitivity reaction constitutes Kounis syndrome. We report a case of a 64-year-old man who presented with a non-ST elevation myocardial infarction and peripheral blood eosinophilia. He had rhinitis and constitutional symptoms for several days prior to presentation. Blood investigations revealed moderate eosinophilia and elevated IgE levels. A cardiac MRI showed generalised oedema with a subtle wall motion abnormality in basal inferior/inferolateral wall, and subendocardial high signal on late gadolinium enhancement suggesting a localised myocardial infarction. A coronary angiogram then revealed triple vessel disease. A diagnosis of Kounis syndrome was made. Within days of starting appropriate treatment, the patient’s eosinophil count returned to normal with improvement of clinical picture.

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-hours PM2.5 indoor/outdoor monitoring. PM2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM2.5, Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM2.5, Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children

Prothrombin complex concentrates (4F-PCC) for anticoagulation reversal pose a risk of thromboembolism although data are limited. This study aims to quantify thromboembolic events (TE) and describe associations.Retrospective, two-center, study of patients receiving 4F-PCC between September 2013 and December 2017 for warfarin or direct oral anticoagulant (DOAC) reversal. Primary outcome was in-hospital TE incidence and secondary outcomes were to describe characteristics associated with TE. Data are reported descriptively and analyzed with bivariate and multivariate analyses.542 patients were included (mean age 73 ± 14 years, 58% male, 76.6% warfarin/23.4% DOAC reversal). Most had intracranial hemorrhage (68.5%) or were undergoing an emergent procedure (13.4%). Fifty patients (9.2%) experienced in-hospital TE and most (62%) occurred within 7 days of 4F-PCC. Younger age (66 vs. 74 years, p 0.01), presence of a hypercoagulable risk factor (46% vs. 26%, p 0.01), indication for anticoagulation (p = 0.008), higher 4F-PCC dose (2148 vs. 2000 units, p 0.01), and longer hospital length of stay (LOS) (21.5 vs. 7 days, p 0.01) were associated with TE following bivariate analysis. Multivariate analysis identified anticoagulation indication of venous thromboembolism or "other" (e.g., antiphospholipid syndrome, Factor V Leiden) were independently associated with higher incidence of TE compared to receiving anticoagulation for atrial arrhythmia (p = 0.05). Hospital LOS ≥ 7 days was associated with threefold greater odds of TE compared to7 days (p = 0.003).In-hospital TE following 4F-PCC was 9.2%, most events occurred within 7 days, and younger age, indication for anticoagulation, and LOS were independently associated with TE which may influence treatment selection.

Brain injury; Head trauma; Algorithm Daño cerebral; Trauma en la cabeza; Algoritmo Lesió cerebral; Trauma al cap; Algoritme Background: Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation’s sTBI Management Guidelines, as they were not evidence-based. Methods: We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole- and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists’ decision tendencies were the focus of recommendations. Results: We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination. Conclusions: Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management recommendations based on combined expert opinion. It reflects neither a standard-of-care nor a substitute for thoughtful individualized management. We thank our financial supporters who include Adler/Geirsch Attorney at Law, the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Neurotrauma and Critical Care, Bard, the Brain Trauma Foundation, DePuy, Hemedex, Integra, the Neurointensive Care Section of the European Society of Intensive Care Medicine, Neurosurgical Society of Australasia, Medtronic, Moberg Research, Natus, Neuroptics, Raumedic, Sophysa, Stryker, and Zoll.

In the original article [...]

EBUS-TBNA at Mater Dei Hospital (MDH), which serves a population of about 432000, was audited over a 2 year period. Our aim was to assess results obtained and factors associated with improved diagnostic yield. All patients who underwent EBUS-TBNA at MDH were included and data was collected retrospectively. 71 EBUS TBNA procedures were performed on 70 patients. Sensitivity for malignancy was 93% (40/43) and sensitivity for granulomatous disease was 72% (16/22). The overall diagnostic sensitivity was 84.5% (60/71). Sampling multiple stations as opposed to a single station was associated with a better histology diagnostic yield (90.3% vs 60% p=0.004) as well as a better yield on cytology (83.9% vs 50% p=0.003). It also led to an improved overall combined diagnostic yield (93.5% vs 77.5%) although this narrowly missed statistical significance (p=0.06). Targeting multiple stations also correlated with obtaining an adequate histology sample (96.8% vs 82.5% p=0.05). This effect was even more pronounced for granulomatous disease with improved diagnostic histology yield (100% vs 43.8% p=0.005) diagnostic cytology yield (89% vs 25% p=0.002) and overall combined diagnostic yield (100% vs 62.5% p=0.035) Increasing lesion size was predictive of obtaining an adequate tissue sample (p=0.03) histology diagnostic yield (p=0.05) and overall diagnostic yield (p=0.04) but there was no correlation between lesion size and yield on cytology (p=0.389). Sampling multiple stations and targeting larger lesions led to an improved diagnostic yield; the effect of targeting multiple stations was even more pronounced in granulomatous disease.

BACKGROUND: Lobar intracerebral hemorrhage (ICH) is known to have better clinical outcomes and preliminary evidence of less hematoma expansion compared to deep ICH. No functional coagulation differences between lobar and deep ICH have been identified using traditional plasma-based coagulation tests. We investigated for coagulation differences between lobar and deep ICH using whole-blood coagulation testing (Rotational Thromboelastometry: ROTEM). METHODS: Clinical, radiographic and laboratory data were prospectively collected for primary ICH patients enrolled in a single-center ICH study. Patients with preceding anticoagulant use or admission coagulopathy on traditional laboratory testing were excluded. Lobar and deep ICH patients receiving admission ROTEM were analyzed. Linear regression was used to assess the association of ICH location with coagulation test results after adjusting for potential confounders. RESULTS: There were 12 lobar and 19 deep ICH patients meeting inclusion criteria. Lobar ICH patients were significantly older and predominantly female. Lobar ICH had faster intrinsic pathway coagulation times (139.8 vs 203.2 seconds; 95% CI: −179.91 to −45.96; p=0.002) on ROTEM testing compared to deep ICH after adjusting for age, sex, and hematoma volume. This revealed functional coagulation differences, specifically quicker clot formation in lobar compared to deep ICH. No differences were noted using traditional coagulation testing (PT/PTT/platelet count). CONCLUSIONS: Our pilot data may suggest that there are functional coagulation differences between lobar and deep ICH identified using ROTEM. Whole-blood coagulation testing may be useful in assessing coagulopathy in ICH patients and in determining reversal treatment paradigms, though further work is needed.

Introduction: Despite smaller baseline hematoma volumes, deep primary intracerebral hemorrhage (ICH) is known to have worse clinical outcomes and preliminary evidence of more hematoma expansion compared to lobar ICH. This is not thought to be related to differences in functional coagulation as prior studies have not identified differences in traditional, plasma-based coagulation tests between these locations. We investigated for clotting differences between deep and lobar ICH using Thromboelastography (TEG: whole-blood coagulation assessment). Methods: Clinical, radiographic and laboratory data was prospectively collected between 2009-2018 for primary ICH patients admitted to University of Texas Health Sciences Center at Houston. Deep and lobar ICH patients, without preceding history of anticoagulation use or coagulopathy on admission testing, who received admission TEG and traditional plasma coagulation tests were included for analysis. Patients receiving hemorrhage reversal transfusions prior to TEG were excluded. Multivariable linear regression assessed the association of ICH location with functional coagulation tests after adjusting for age, sex, NIHSS, and baseline hematoma volume. Results: Of 207 ICH patients included for analysis, there were 154 (74%) deep and 53 (26%) lobar ICH. Deep ICH patients were significantly younger (mean: 56 vs 68 years), had higher admission systolic blood pressures (mean: 200 vs 182mmHg) and smaller admission hematoma volumes (median: 16.2 vs 28.7mL) than lobar ICH patients. Deep ICH had longer TEG R times (mean: 5.1 vs 4.4 minutes) indicating a slower and less optimal time to clot formation compared to lobar ICH. After controlling for potential confounders, the adjusted mean R times continued to be longer in deep compared to lobar ICH by 0.57 minutes (95% CI 0.02-1.11, p=0.04). Conclusions: Our findings suggest that there may be functional coagulation differences detected with whole blood coagulation testing between deep and lobar ICH. Further work is needed to determine whether whole blood coagulation testing to assess coagulopathy after ICH should play a role in hemorrhage reversal treatment paradigms.

Background: Rapid treatment for acute ischemic stroke (AIS) improves patient outcomes. In an academic medical center AIS treatment often involves a large team including trainees. A clear process allowing for rotating team members and varied experience in AIS care across disciplines is key for timely intervention. Purpose: To improve the percentage of patients with door to needle (DTN) and door to puncture (DTP) times within 45 and 90 minutes. Methods: A multidisciplinary team including EMS, Emergency Medicine (EM), Nursing, Radiology, Neurology, Neurosurgery, Pharmacy, Surgical Services, and Operations Excellence, along with residents from each specialty, convened for a Lean initiative to reduce door to treatment (DTT) times in an academic Comprehensive Stroke Center. An extensive process map was generated that identified 1) unclear role delineation for EM, Neurology, and Neurosurgery residents, and 2) uncertainty in optimizing the simultaneous processes of history-taking, NIHSS assessment and imaging determination. A model clarifying CT decision–making guidelines and designating a team leader or “Stroke Quarterback” was developed. A three month test of the process was conducted. Results: There was a 42% improvement in DTN within 45 minutes and 33.4% improvement in DTP within 90 minutes when compared to the same 3 month period one year prior to the test of change (figure 1). The rate of DTT within goal varied from month to month. Conclusions: Despite the varied levels of experience and training of providers at an academic hospital, the acute stroke response team must provide consistent and expeditious care in every instance. Identifying a team leader as a “stroke quarterback” allows for real-time decision-making (audibles), clear delegation of responsibilities (player assignments) based on experience, and utilization of structured processes (playbook). Our model is well-suited for the academic medical center environment and appears to reduce time to treatment.

Introduction: Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care. Methods: Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC) is NYS-DSC located in Elmira, NY, 115 miles from SMH. Clinical leaders at SMH and AOMC collaborated to engineer a system of care to expeditiously transfer qualifying MT candidates. The system of care, dubbed Code LVO, included the auto-launching of an interfacility transport team (preferable a medical helicopter) to AOMC and notification to the SMH Vascular Neurologist (VN) on ED arrival for any presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of /=6 and an LVO via a cloud-based image sharing platform. We retrospectively reviewed the records of LVO-AIS transfers in a QA database to identify the door-in-door-out (DIDO) time, AOMC door to SMH door (D2D) time, and AOMC door to SMH skin puncture (D2S) time, and the outcomes of patients before and after Code LVO implementation. Results: Over an 18-month period pre- Code LVO, there were seven AOMC to SMH LVO-AIS transfers. None underwent MT due to large or completed infarcts on SMH arrival. Seventy-one percent died or went to hospice. The median DIDO time was 93 minutes (range 66-273) and D2D was 239 minutes (range 112-392). Post- Code LVO, six Code LVO evaluations were requested, and three were transferred. All LVO-AIS underwent successful MT, with a median DIDO time of 45 minutes (range 44-60), D2D time of 95 minutes (range 85-102), and DTS time of 141 minutes (124-158) and went to nursing home or acute rehab. Conclusions: Auto-launching of interfacility transport to referring hospitals for select presumed LVO-AIS may decrease time to MT and improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.

The global prevalence of allergic diseases have increased considerably and are a major socio-economic burden. Asthma is a complex disease and understanding asthma phenotypes and endotypes could eventually lead to individualised management, and offer better symptom control and quality of life. In this review, we first summarise the pathogenesis of atopic asthma and delve into the assessment of sensitisation to aeroallergens through skin prick testing and serological testing with total and specific immunoglobulin E testing. We will then analyse the distribution of aeroallergen sensitisation patterns in the United States and Europe and its effect on the population. This review gives a comprehensive overview on atopy and it compares the prevalence and effect of atopy within various regions of both continents using data from large multicentre studies. We will conclude this review by discussing the efficacy of add-on treatments in the most prevalent severe asthma phenotypes and endotypes., peer-reviewed

Background: Regional cerebral oxygen saturation (rScO2) measured by near-infrared spectroscopy (NIRS) can be used to monitor brain oxygenation in extracorporeal membrane oxygenation (ECMO). ECMO patients that develop acute brain injuries (ABIs) are observed to have worse outcomes. We evaluated the association between rScO2 and ABI in venoarterial (VA) ECMO patients.Methods: We retrospectively reviewed prospectively-collected NIRS data from patients undergoing VA ECMO from April 2016 to October 2016. Baseline demographics, ECMO and clinical characteristics, cerebral oximetry data, neuroradiographic images, and functional outcomes were reviewed for each patient. rScO2 desaturations were defined as a >25% decline from baseline or an absolute value < 40% and quantified by frequency, duration, and area under the curve per hour of NIRS monitoring (AUC rate, rScO2*min/h). The primary outcome was ABI, defined as abnormalities noted on brain computerized tomography (CT) or magnetic resonance imaging (MRI) obtained during or after ECMO therapy.Results: Eighteen of Twenty patients who underwent NIRS monitoring while on VA ECMO were included in analysis. Eleven patients (61%) experienced rScO2 desaturations. Patients with desaturations were more frequently female (73 vs. 14%, p = 0.05), had acute liver dysfunction (64 vs. 14%, p = 0.05), and higher peak total bilirubin (5.2 mg/dL vs. 1.4 mg/dL, p = 0.02). Six (33%) patients exhibited ABI, and had lower pre-ECMO Glasgow Coma Scale (GCS) scores (5 vs. 10, p = 0.03) and higher peak total bilirubin levels (7.3 vs. 1.4, p = 0.009). All ABI patients experienced rScO2 desaturation while 42% of patients without ABI experienced desaturation (p = 0.04). ABI patients had higher AUC rates than non-ABI patients (right hemisphere: 5.7 vs. 0, p = 0.01, left hemisphere: 119 vs. 0, p = 0.06), more desaturation events (13 vs. 0, p = 0.05), longer desaturation duration (2:33 vs. 0, p = 0.002), and more severe desaturation events with rScO2 < 40 (9 vs. 0, p = 0.05). Patients with ABI had lower GCS scores (post-ECMO initiation) before care withdrawal or discharge than those without ABI (10 vs. 15, p = 0.02).Conclusions: The presence and burden of cerebral desaturations noted on NIRS cerebral oximetry are associated with secondary neurologic injury in adults undergoing VA ECMO.

Stroke care in the US is increasingly regionalized. Many patients undergo interhospital transfer to access specialized, time-sensitive interventions such as mechanical thrombectomy.Using a stratified survey design of the US Nationwide Inpatient Sample (2009-2014) we examined trends in interhospital transfers for ischemic stroke resulting in mechanical thrombectomy. International Classification of Disease-Ninth Revision (ICD-9) codes were used to identify stroke admissions and inpatient procedures within endovascular-capable hospitals. Regression analysis was used to identify factors associated with patient outcomes.From 2009-2014, 772,437 ischemic stroke admissions were identified. Stroke admissions that arrived via interhospital transfer increased from 12.5% to 16.8%, 2009-2014 (P-trend.001). Transfers receiving thrombectomy increased from 4.0% to 5.2%, 2009-2014 (P-trend = .016), while those receiving tissue plasminogen activator increased from 16.0% to 20.0%, 2009-2014 (P-trend.001). One in 4 patients receiving thrombectomy were transferred from another acute care facility (n = 6,014 of 24,861). Compared to patients arriving via the hospital "front door" receiving mechanical thrombectomy, those arriving via transfer were more often from rural areas and received by teaching hospitals with greater frequency of thrombectomy. Those arriving via interhospital transfer undergoing thrombectomy had greater odds of symptomatic intracranial hemorrhage (adjusted odds ratio [AOR] 1.19, 95% CI: 1.01-1.42) versus "front door" arrivals. There were no differences in inpatient mortality (AOR 1.11, 95% CI: .93-1.33).From 2009 to 2014, interhospital stroke transfers to endovascular-capable hospitals increased by one-third. For every ∼15 additional transfers over the time period one additional patient received thrombectomy. Optimization of transfers presents an opportunity to increase access to thrombectomy.

Introduction: Stroke care in the US is becoming increasingly regionalized. Many patients undergo interhospital transfer to obtain access to specialized, time-sensitive interventions such as mechanical thrombectomy. Methods: We used the stratified survey design of the US Nationwide Inpatient Sample, 2009-2014, to examine nationwide trends in interhospital transfers for ischemic stroke and the relationship between transfers and thrombectomy. International Classification of Disease—Ninth Revision diagnosis and procedure codes were used to identify acute stroke admissions and inpatient procedures (tissue plasminogen activator [tPA] administration and thrombectomy), respectively. The analysis was restricted to hospitals with the capabilities to perform thrombectomy. Trends were assessed using a Cochran-Armitage test. Results: From 2009 to 2014, an estimated 759,648 ischemic stroke admissions were identified within hospitals offering thrombectomy (102,674 in 2009; 154,280 in 2014). The proportion of stroke admissions to these hospitals that underwent interhospital transfer prior to arrival increased from 13.5% (n=13,811) in 2009 to 18.9% (n=19,175) in 2014 ( P trendP P P trend=0.016). Approximately 30% of patients receiving thrombectomy for ischemic stroke were transferred from another acute care facility (n=7,328). Among patients receiving tPA, transferred patients were slightly less likely to receive thrombectomy compared to those arriving by “front door” at thrombectomy performing centers (13.9% vs. 15.4%; P =0.004). Conclusions: From 2009 to 2014, interhospital stroke transfers to thrombectomy performing hospitals more than doubled. For every ~5 additional stroke transfers over the time period examined, one additional transferred patient received thrombectomy. As stroke systems of care continue to evolve across the US, the optimization of stroke transfers presents an opportunity to increase access to meaningful interventions such as thrombectomy.

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM

An elderly woman, life-long non-smoker, presented to the emergency department with a dry cough and progressive dyspnoea for the past week. She had no relevant medical history. Physical examination revealed an elevated respiratory rate of 20 breaths per minute and low oxygen saturations of 91% at

Intro: RESPIRA (EU Funded - Italia-Malta 07-13) indicated that living in Malta is a risk factor for asthma. Aim: To determine the chemical profile of PM2.5 in Malta, and compare with reference values. Methods: Using FAI pumps at 10l/min/48hr, samples were collected on Teflon and Quartz filters from 6 schools and 46 homes in Malta. Total ICP-MS measurement (Residual+extracted), X ray Fluorescence, and thermo-optical methods(TO) were used for analysis by CNR in Rome. Aeroqual IQM60 counters were used for total PM2.5 mass. All data in ng/m3, Mean, (1st to 3rd quartile) of all 48 hour measurements., N/A

Sympathetic nervous system hyperactivity is common after subarachnoid hemorrhage (SAH). We sought to determine whether uncontrolled prolonged heart rate elevation is a risk factor for adverse cardiopulmonary events and poor outcome after SAH.We prospectively studied 447 SAH patients between March 2006 and April 2012. Prior studies define prolonged elevated heart rate (PEHR) as heart rate95 beats/min for12 h. Major adverse cardiopulmonary events were documented according to the predefined criteria. Global outcome at 3 months was assessed with the modified Rankin Scale (mRS).175 (39 %) patients experienced PEHR. Nonwhite race/ethnicity, admission Hunt-Hess grade ≥4, elevated APACHE-2 physiological subscore, and modified Fisher score were significant admission predictors of PEHR, whereas documented pre-hospital beta-blocker use was protective. After controlling for admission Hunt-Hess grade, Cox regression using time-lagged covariates revealed that PEHR onset in the previous 48 h was associated with an increased hazard for delayed cerebral ischemia, myocardial injury, and pulmonary edema. PEHR was associated with 3-month poor outcome (mRS 4-6) after controlling for known predictors.PEHR is associated with major adverse cardiopulmonary events and poor outcome after SAH. Further study is warranted to determine if early sympatholytic therapy targeted at sustained heart rate control can improve outcome after SAH.

ObjectiveTonic-clonic activity (TCA) at onset complicates 3% to 21% of cases of subarachnoid hemorrhage (SAH). The impact of onset TCA on in-hospital complications, including seizures, remains unclear. One study associated onset TCA with poor clinical outcome at 6 weeks after SAH, but to our knowledge no other studies have confirmed this relationship. This study aims to assess the impact of onset TCA on in-hospital complications, poor functional outcome, mortality, and epilepsy at 3 months.MethodsAnalysis of a prospective study cohort of 1479 SAH patients admitted to Columbia University Medical Center between 1996 and 2012. TCA within 6 hours of hemorrhage onset was identified based on accounts of emergency care providers or family witnesses.ResultsTCA at onset was described in 170 patients (11%). Patients with onset TCA were younger (P = 0.002), presented more often with poor clinical grade (55% vs. 26%, PConclusionsOnset TCA is not a rare event as it complicates 11% of cases of SAH. New and clinically relevant findings are the association of onset TCA with in-hospital seizures, pneumonia and delayed cerebral ischemia. Despite the increased risk of in-hospital complications, onset TCA is not associated with disability, mortality, and epilepsy at 3 months.

Traumatic brain injury is the most common cause of death and disability in young people, with an annual financial burden of over $50 billion per year in the United States. Traumatic brain injury is defined by both the initial primary injury and the subsequent secondary injuries. Fundamental to emergency department management is ensuring brain perfusion, oxygenation, and preventing even brief or transient episodes of hypotension, hypoxia, and hypocapnia. Cerebral perfusion pressure is a function of intracranial pressure and systemic blood pressure, and it must be monitored and maintained. Current research is devoted towards the prevention and treatment of secondary injury. The emergency clinician must be vigilant in maintaining homeostasis while coordinating the downstream care of the patient, including the intensive care unit and/or the operating room.

For the evaluation of patients at risk of hypobaric hypoxia during air travel, the British Thoracic Society Recommendations describe the normobaric hypoxic challenge as a substitute for the use of hypobaric chambers, which are not widely available.1 In the normobaric hypoxic challenge, breathing 15% oxygen at sea level replicates the reduced Po2 in ambient air at 8000 ft (2438 m), the maximum permissible cabin altitude during commercial flight. This method has been shown to produce results comparable with those obtained using hypobaric chambers and oxygen desaturation similar to that found in patients with chronic obstructive pulmonary disease (COPD) during flight.2 3 The methods described in the British Thoracic Society Recommendations include using a …

Measurements have been performed in the UK over more than a decade to determine the upset/disruption threshold of a wide range of equipment. Such information is critical to ensuring the safe operation of systems in the vicinity of high power microwave (HPM) fields. These measurements have been performed using a number of techniques to achieve high field levels including mode stirred chamber testing and the ORION HPM source (S. N. Spark and B. A. Kerr et al, "The high power microwave facility: Orion", in Proc. Inst. Elect. Eng. Symp. 2001, pp. 13/1-13/2.) A generic upset trend is described which has been computed from an ensemble of equipment trials. The equipment trialled only involved systems where the upset was due to back door coupling and not in band RF systems The generic trend is in general agreement with that of more specific equipment trends, [(R. Hoad et al., IEEE transactions on electromagnetic compatibility, Vol. 46, No. 3, August 2004, pp 390 -395)]. The useful frequency span of such a trend may well extend to 40 GHz.

In a study of 514 patients with increased serum low-density lipoprotein (LDL) cholesterol followed in a general medicine clinic at a university hospital, the serum LDL cholesterol in patients with coronary heart disease (CHD), other atherosclerotic vascular disease, or diabetes mellitus was100 mg/dl in 219 of 276 patients (79%) with Medicaid or private insurance and in 28 of 67 self-pay or Medicare patients (42%) without pharmaceutical coverage (p0.001). The serum LDL cholesterol was130 mg/dl in patients with 2+ risk factor and a 10-year risk for CHD ofor =20% or160 mg/dl in patients with a 0 to 1 risk factor, and a 10-year risk for CHD of10% in 54 of 141 patients (38%) with Medicaid or private insurance and in 5 of 30 self-pay or Medicare patients (17%) (p0.025).

Christopher Zammit, Helen Liddicoat, Ian Moonsie, Himender MakkerSleep and Ventilation Unit, Department of Respiratory Medicine, North Middlesex University Hospital, London, UKAbstract: The obesity epidemic is a global problem, which is set to increase over time. However, the effects of obesity on the respiratory system are often underappreciated. In this review, we will discuss the mechanical effects of obesity on lung physiology and the function of adipose tissue as an endocrine organ producing systemic inflammation and effecting central respiratory control. Obesity plays a key role in the development of obstructive sleep apnea and obesity hypoventilation syndrome. Asthma is more common and often harder to treat in the obese population, and in this study, we review the effects of obesity on airway inflammation and respiratory mechanics. We also discuss the compounding effects of obesity on chronic obstructive pulmonary disease (COPD) and the paradoxical interaction of body mass index and COPD severity. Many practical challenges exist in caring for obese patients, and we highlight the complications faced by patients undergoing surgical procedures, especially given the increased use of bariatric surgery. Ultimately, a greater understanding of the effects of obesity on the respiratory disease and the provision of adequate health care resources is vital in order to care for this increasingly important patient population.Keywords: obesity, lung function, obstructive sleep apnea, obesity hypoventilation syndrome, anesthesia