Gender disparity in stoke: Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage

OBJECTIVE

To determine what if any differences in presentation exist between men and women who present with acute intracerebral hemorrhage (ICH) to the emergency department (ED).

METHODS

This was an IRB approved prospective cohort study of ED patients presenting with acute intracerebral hemorrhage. Statistical analyses were performed in JMP 14.1. Non parametric methods were used for skewed variables. The study was conducted in a comprehensive stroke center. The independent variable was the ICH score, and the dependent variable of interest was ultimate disposition (death or hospice vs. home or skilled nursing facility).

RESULTS

The cohort consisted of 129 patients (54 women and 75 men). The median age was 71 years (IQR 58-81). The baseline co-morbidities were similar between both men and women and whether or not they were independent in their activities of daily living prior to experiencing their ICH. The overall median ICH score for women was 2, IQR 1-4, and 1 for men, IQR 1-2 (P = 0.0369) . A higher ICH score was significantly associated with in-hospital death and or hospice status (P = .0095, 95% CI 0.6340 - 0.4825). Conversely, a lower ICH score was significantly associated with being discharged home (P< 0.001, 95% CI -0.1694 to -0.0759).

CONCLUSION

Women have higher ICH scores than men at initial ED presentation for intracerebral hemorrhage. A higher ICH score is significantly associated with the worse outcomes of death and/or hospice.

Physician-Perceived Barriers to Treating Opioid Use Disorder in the Emergency Department

Objective We aimed to assess physicians' perceptions of barriers to starting medication-assisted treatment (MAT) in the Emergency Department (ED), views of the utility of MAT, and abilities to link patients with opioid use disorder (OUD) to MAT programs in their respective communities. Methods This was a cross-sectional survey study of American emergency medicine (EM) physicians with a self-administered online survey via SurveyMonkey (Survey Monkey, San Mateo, California). The survey was emailed to the Council of Residency Directors in Emergency Medicine (CORD) listserv and HCA Healthcare affiliated EM residency programs' listservs. Attendings and residents of all post-graduate years participated. Questions assessed perceptions of barriers to starting OUD patients on MAT, knowledge of the X-waiver, and knowledge of MAT details. Statistics were performed with JMP software (SAS Institute Inc., Cary, NC) using the two-tailed Z-test for proportions. Results There were 98 responses, with 33% female, 55% resident physicians, and an overall 17% response rate. Residents were more eager to start OUD patients on MAT (71% vs 52%, p=0.04) than attendings but were less familiar with the X-waiver (38% vs 73%, p=0.001) or where community outpatient MAT facilities were (21% vs 43%, p=0.02). Conclusion Barriers in the ED were identified as a shortage of qualified prescribers, the lengthy X-waiver process, and the poor availability of outpatient MAT resources. EM residents showed more willingness to prescribe MAT but lacked a core understanding of the process. This shows an area of improvement for residency training as well as advocacy among attendings.

Respiratory Distress with Minimal Exertion: A Case of 2019 Novel Coronavirus (COVID-19) Pneumonia

Description COVID-19 is a new coronavirus that can cause severe respiratory distress. Interestingly, patients can present with COVID-19 and appear relatively well but with significant hypoxia, even with minimal movement. The authors present the case of a well-appearing gentleman who became acutely short of breath while undergoing chest imaging, stating he could not breathe. He tested positive for COVID-19 and recovered. His presentation, clinical course and imaging findings are discussed.

Ingested Fish Bone Lodged in the Vallecula

Although foreign body ingestions are less common in adults than children, when they do occur, it is often due to a fish or chicken bone. The authors present a case of a fish bone ingestion, and highlight its appearance on imaging.

Pericardial effusion with tamponade: bedside ultrasonography saves another life

In these video clinical images, the authors present the cause for an elderly gentleman’s shortness of breath. It was presumed to be an exacerbation of chronic obstructive pulmonary disease, a condition for which he was in the process of being evaluated. However, bedside ultrasonography revealed a large pericardial effusion with tamponade. This timely diagnosis resulted in the patient being taken expeditiously to the operating room and saving his life.

A Case of Hyponatremia-induced Seizures in an Infant Secondary to Water Intoxication from the Use of Almond Milk

Pediatric seizures are a common presentation to the emergency department. It is important to separate non-febrile seizures from febrile seizures, as non-febrile seizures have a much broader differential diagnosis. For infants less than six months of age with a normal exam, hyponatremia is the leading cause of new onset non-febrile seizure. Most commonly, this is secondary to water intoxication from inappropriate feeding practices. This case report will review the initial workup of new onset non-febrile seizures in an infant and treatment recommendations for seizures secondary to hyponatremia.

Preseptal and Postseptal Orbital Cellulitis of Odontogenic Origin

The authors present a case of combined preseptal and postseptal cellulitis of odontogenic origin. The infection started as a dental abscess associated with a first maxillary molar. The infection spread into the paranasal sinus, developed into a pansinusitis, and then spread into the preseptal and postseptal tissues. In addition to extraction of the infected tooth, the patient underwent bilateral nasal endoscopy, maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with balloon dilation. Sinus cultures were positive for 2+ microaerophilic streptococci.

Orbital Compartment Syndrome: How a Young Man's Vision was Saved by the Timely Actions of an Emergency Medicine Physician

In the following case presentation, a young man who incurred orbital compartment syndrome (OCS) from physical trauma significantly improved from timely lateral canthotomy. Lateral canthotomy is recommended to be performed as soon as possible to avoid permanent vision loss, which is the most feared complication associated with orbital compartment syndrome. This procedure completely restored vision in the patient and permitted prompt discharge.

A Local Epidemic of Laced Heroin Causing Skin Necrosis

The authors present a case of severe skin necrosis resulting from injecting heroin laced with a substance known as "Rizzy" powder. This powder is a toxic substance used to color the petals of plants. This report reviews how to manage the complications of such adulterated heroin.

Tropospheric Emissions: Monitoring of Pollution (TEMPO)

TEMPO was selected in 2012 by NASA as the first Earth Venture Instrument, for launch between 2018 and 2021. It will measure atmospheric pollution for greater North America from space using ultraviolet and visible spectroscopy. TEMPO observes from Mexico City, Cuba, and the Bahamas to the Canadian oil sands, and from the Atlantic to the Pacific, hourly and at high spatial resolution (~2.1 km N/S×4.4 km E/W at 36.5°N, 100°W). TEMPO provides a tropospheric measurement suite that includes the key elements of tropospheric air pollution chemistry, as well as contributing to carbon cycle knowledge. Measurements are made hourly from geostationary (GEO) orbit, to capture the high variability present in the diurnal cycle of emissions and chemistry that are unobservable from current low-Earth orbit (LEO) satellites that measure once per day. The small product spatial footprint resolves pollution sources at sub-urban scale. Together, this temporal and spatial resolution improves emission inventories, monitors population exposure, and enables effective emission-control strategies. TEMPO takes advantage of a commercial GEO host spacecraft to provide a modest cost mission that measures the spectra required to retrieve ozone (O3), nitrogen dioxide (NO2), sulfur dioxide (SO2), formaldehyde (H2CO), glyoxal (C2H2O2), bromine monoxide (BrO), IO (iodine monoxide),water vapor, aerosols, cloud parameters, ultraviolet radiation, and foliage properties. TEMPO thus measures the major elements, directly or by proxy, in the tropospheric O3 chemistry cycle. Multi-spectral observations provide sensitivity to O3 in the lowermost troposphere, substantially reducing uncertainty in air quality predictions. TEMPO quantifies and tracks the evolution of aerosol loading. It provides these near-real-time air quality products that will be made publicly available. TEMPO will launch at a prime time to be the North American component of the global geostationary constellation of pollution monitoring together with the European Sentinel-4 (S4) and Korean Geostationary Environment Monitoring Spectrometer (GEMS) instruments.

Dissecting x-ray-emitting gas around the center of our galaxy

Most supermassive black holes (SMBHs) are accreting at very low levels and are difficult to distinguish from the galaxy centers where they reside. Our own Galaxy's SMBH provides an instructive exception, and we present a close-up view of its quiescent x-ray emission based on 3 megaseconds of Chandra observations. Although the x-ray emission is elongated and aligns well with a surrounding disk of massive stars, we can rule out a concentration of low-mass coronally active stars as the origin of the emission on the basis of the lack of predicted iron (Fe) Kα emission. The extremely weak hydrogen (H)-like Fe Kα line further suggests the presence of an outflow from the accretion flow onto the SMBH. These results provide important constraints for models of the prevalent radiatively inefficient accretion state.

Giving way event during a combined stepping and crossover cutting task in an individual with anterior cruciate ligament deficiency

STUDY DESIGN

Case study.

OBJECTIVE

To compare knee kinematics and moments of nongiving way trials to a giving way trial during a combined stepping and crossover cutting activity.

BACKGROUND

The knee kinematics and moments associated with giving way episodes suggest motor control strategies that lead to instability and recovery of stability during movement.

METHODS AND MEASURES

A 27-year-old woman with anterior cruciate ligament deficiency reported giving way while performing a combined stepping and crossover cutting activity. A motion analysis system recorded motion of the pelvis, femur, tibia, and foot using 3 infrared emitting diodes placed on each segment at 60 Hz. Force plate recordings at 300 Hz were combined with limb inertial properties and position data to estimate net knee joint moments. The stance time, foot progression angle, and cutting angle were also included to evaluate performance between trials.

RESULTS

Knee internal rotation during the giving way trial increased 3.2 degrees at 54% of stance relative to the nongiving way trials. Knee flexion during the giving way trial increased to 33.1 degrees at 66% of stance, and the knee moment switched from a nominal flexor moment to a knee extensor moment at 64% of stance. The knee abductor moment and external rotation moment during the giving way trial deviated in early stance.

CONCLUSIONS

The observed response to the giving way event suggests that increasing knee flexion may enhance knee stability for this subject. The transverse and frontal plane moments appear important in contributing to the giving way event. Further research that assists clinicians in understanding how interventions can impact control of movements in these planes is necessary.

The sequence of the human genome

A 2.91-billion base pair (bp) consensus sequence of the euchromatic portion of the human genome was generated by the whole-genome shotgun sequencing method. The 14.8-billion bp DNA sequence was generated over 9 months from 27,271,853 high-quality sequence reads (5.11-fold coverage of the genome) from both ends of plasmid clones made from the DNA of five individuals. Two assembly strategies-a whole-genome assembly and a regional chromosome assembly-were used, each combining sequence data from Celera and the publicly funded genome effort. The public data were shredded into 550-bp segments to create a 2.9-fold coverage of those genome regions that had been sequenced, without including biases inherent in the cloning and assembly procedure used by the publicly funded group. This brought the effective coverage in the assemblies to eightfold, reducing the number and size of gaps in the final assembly over what would be obtained with 5.11-fold coverage. The two assembly strategies yielded very similar results that largely agree with independent mapping data. The assemblies effectively cover the euchromatic regions of the human chromosomes. More than 90% of the genome is in scaffold assemblies of 100,000 bp or more, and 25% of the genome is in scaffolds of 10 million bp or larger. Analysis of the genome sequence revealed 26,588 protein-encoding transcripts for which there was strong corroborating evidence and an additional approximately 12,000 computationally derived genes with mouse matches or other weak supporting evidence. Although gene-dense clusters are obvious, almost half the genes are dispersed in low G+C sequence separated by large tracts of apparently noncoding sequence. Only 1.1% of the genome is spanned by exons, whereas 24% is in introns, with 75% of the genome being intergenic DNA. Duplications of segmental blocks, ranging in size up to chromosomal lengths, are abundant throughout the genome and reveal a complex evolutionary history. Comparative genomic analysis indicates vertebrate expansions of genes associated with neuronal function, with tissue-specific developmental regulation, and with the hemostasis and immune systems. DNA sequence comparisons between the consensus sequence and publicly funded genome data provided locations of 2.1 million single-nucleotide polymorphisms (SNPs). A random pair of human haploid genomes differed at a rate of 1 bp per 1250 on average, but there was marked heterogeneity in the level of polymorphism across the genome. Less than 1% of all SNPs resulted in variation in proteins, but the task of determining which SNPs have functional consequences remains an open challenge.

Evaluation of locus heterogeneity and EXT1 mutations in 34 families with hereditary multiple exostoses

Hereditary multiple exostoses (EXT) is an autosomal dominant disorder characterized by growth of benign bone tumors. Three chromosomal loci have been implicated in this genetically heterogeneous disease: EXT1 at 8q24, EXT2 at 11p13, and EXT3 on 19p. EXT1 and EXT2 were recently cloned. We evaluated 34 families with EXT to estimate the proportion of disease attributable to EXT1, EXT2, and EXT3 and to investigate the spectrum of EXT1 mutations. Linkage analyses combined with heterogeneity testing provides strong evidence in favor of linkage of disease to both chromosomes 8 and 11, but does not support evidence of linkage to chromosome 19 in this data set. The 11 EXT1 exons were PCR-amplified and sequenced in all 11 isolated cases and in 20 of the 23 familial cases. Twelve different novel EXT1 mutations were detected, including 5 frame-shift deletions or insertions, 1 codon deletion, and 6 single base-pair substitutions distributed across 8 of the exons. Only 2 of the mutations were detected in more than one family. Three mutations affect sites in which alterations were previously reported. Nonchain-terminating missense mutations were identified in codons 280 and 340, both coding for conserved arginine residues. These residues may be crucial to the function of this protein. Although the prevalence of EXT has been estimated to be approximately 1/50,000 individuals, the disease has been reported to occur much more frequently in the Chamorro natives on Guam. Our detection of an EXT1 mutation in one Chamorro subject will allow investigation of a possible founder effect in this population. Combined mutational and heterogeneity analyses in this set of families with multiple exostoses suggest that 66% of our total sample, including 45% of isolated and 77% of familial cases, are attributable to abnormalities in EXT1.

The genome sequence of Drosophila melanogaster

The fly Drosophila melanogaster is one of the most intensively studied organisms in biology and serves as a model system for the investigation of many developmental and cellular processes common to higher eukaryotes, including humans. We have determined the nucleotide sequence of nearly all of the approximately 120-megabase euchromatic portion of the Drosophila genome using a whole-genome shotgun sequencing strategy supported by extensive clone-based sequence and a high-quality bacterial artificial chromosome physical map. Efforts are under way to close the remaining gaps; however, the sequence is of sufficient accuracy and contiguity to be declared substantially complete and to support an initial analysis of genome structure and preliminary gene annotation and interpretation. The genome encodes approximately 13,600 genes, somewhat fewer than the smaller Caenorhabditis elegans genome, but with comparable functional diversity.

Incidence of phrenic neuropathy after isolated lung transplantation. The Loyola University Lung Transplant Group

BACKGROUND

Isolated lung transplantation is a viable therapeutic option for many patients with end-stage pulmonary disease. Other intrathoracic surgical procedures have a well documented incidence of phrenic nerve dysfunction, although the incidence after lung transplantation has not been studied.

METHODS

Thirty-one patients who underwent lung transplantation were evaluated for evidence of phrenic nerve dysfunction and subsequent recovery. Risk factors contributing to the incidence of injury were examined. Phrenic nerve injury was defined by two separate diagnostic tests (Transcutaneous Phrenic Nerve Conduction Studies and Fluoroscopic evaluation of diaphragmatic movement) used in combination.

RESULTS

Of the 27 patients who were completely evaluated after the operation, eight had defining criteria for nerve injury--an incidence of 29.6%. Of those affected, the majority of injuries (89%) resulted in complete paralysis of the affected hemidiaphragm. The highest incidence of injury occurred in patients who underwent bilateral single lung transplantation (41%), with the right phrenic nerve being injured most often (78%). Fortunately, no significant postoperative morbidity was attributable to the occurrence of phrenic nerve injury when compared with those patients who did not sustain injury.

CONCLUSIONS

The analysis of possible risk factors resulted in the hypothesis that the likely mechanism of injury in these patients was due to stretching or direct instrumentation of the nerve, and thus measures should be instituted to minimize the possibility of injury.

Optimal size matching in single lung transplantation

BACKGROUND

Single lung transplantation for patients with end-stage obstructive lung disease has been highly effective in providing symptomatic relief, and it has been performed at a much increased frequency since 1983. However, there still lacks a convincing study showing the effect of size match and other preoperative variables in predicting functional outcome of patients after transplantation.

METHODS

We evaluated 23 single lung transplantations performed for obstructive lung disease over a 34-month period. Multiple physiologic variables and size match criteria were evaluated for their contribution in determining the postoperative forced expiratory volume in 1 second at 3 months after transplantation.

RESULTS

The size match ratio that was based on inframammary chest wall circumference was the most useful criterion to adopt, and the optimal donor/recipient size match ratio was 0.89. Furthermore, forced expiratory volume in 1 second at 3 months after transplantation could be predicted with a simple mathematical model that was based on the size match ratio and the recipient's calculated vital capacity of the transplanted hemithorax.

CONCLUSIONS

This model could be applied in a clinical setting to maximize functional outcome of the recipients undergoing single lung transplantation.

Survival and functional outcome after single and bilateral lung transplantation. Loyola Lung Transplant Team

BACKGROUND

The experience at Loyola University Chicago was retrospectively reviewed to evaluate survival and functional outcome after single lung transplantation (SLT) and bilateral lung transplantation (BLT).

METHODS

Ninety patients underwent lung transplantation at Loyola University Chicago between April 1990 and December 1993. Mean age was 45 years (range, 13 to 66 years). Fifty percent were male. Pre-lung transplant pulmonary diseases were as follows: emphysema and/or chronic obstructive pulmonary disease in 43 patients, pulmonary fibrosis in 13, cystic fibrosis in 14, pulmonary hypertension in eight, repeated transplantation for obliterative bronchiolitis in four, bronchiectasis in two, bronchoalveolar cell carcinoma in two, sarcoidosis in one, primary obliterative bronchiolitis in one, histiocytosis X in one, and lymphangiomyomatosis in one. Fifty-seven patients underwent SLT, and 33 had BLT. Maintenance immunosuppression medications consisted of cyclosporine, azathioprine, and prednisone.

RESULTS

Perioperative complications were as follows: seven of 33 patients bled after BLT, and two of 57 bled after SLT. Bronchial complications were found in six of 66 (9%) BLT anastomoses and eight of 57 (14%) SLT anastomoses. Nine operative deaths occurred in SLT patients: six from allograft failure, one from infection, one from intrapulmonary hemorrhage, and one from bronchial dehiscence. Only two patients died in the perioperative period after BLT and that was of infection. Three late deaths occurred after BLT, all as a result of infection; 13 recipients died late after SLT: five of infection, four patients from lymphoma, two of pancreatitis, one of tension pneumothorax, and one of pulmonary embolism. For the entire patient population the actuarial 1- and 2-year survival rates were 72% and 68%, respectively. One-year survival rates were significantly better for patients undergoing lung transplantation for obstructive and nonrestrictive lung diseases than those of patients undergoing lung transplantation for vascular or restrictive pulmonary disease. Recipients of BLT had a trend toward better survival than recipients of SLT. Lung function 6 months after transplantation measured by forced expiratory volume in 1 second was significantly better in BLT than SLT, 71% of predicted versus 54%.

CONCLUSIONS

Patients who undergo BLT have significantly better postoperative pulmonary function than those who undergo SLT. On the basis of the study there was a trend toward better survival with BLT.

HLA antigens influence resistance to lung carcinoma

The concept of genetic factors playing a role in the pathogenesis of lung cancer has gained increased attention. The present study was undertaken to reexamine the question of HLA antigen association with carcinoma of the lung. In a study of 90 patients, a significant association occurred between HLA-DR7 and resistance to lung cancer, after accounting for smoking status and sex. HLA class I antigens were also implicated. These results suggest that major histocompatibility complex loci affect carcinoma of the lung.

Technique and pitfalls of retrograde continuous warm blood cardioplegia

The recent development of normothermic myocardial preservation and systemic perfusion during bypass has questioned the fundamental need for hypothermia during cardiac operations. The antegrade technique of almost continuous perfusion by the aortic root and vein grafts has been supplemented by continuous normothermic blood cardioplegia through the coronary sinus. Recently, great interest has been shown in this technique. It is important to describe the method in detail along with its potential shortcomings and dangers. This communication describes the technical details, pitfalls, and shortcomings of retrograde continuous warm blood cardioplegia.

Airway obstruction due to lymphoma of the larynx and trachea

Involvement of the larynx and trachea by lymphoma is an uncommon problem that can cause life-threatening airway obstruction. High grade obstruction, involvement of the soft tissue of the neck, and tracheal deviation can make intubation and tracheotomy hazardous, if not impossible. Tracheotomy can be ineffective with obstruction of the distal trachea. The clinical presentation and treatment of eight patients with lymphoma involving the larynx or trachea are presented with emphasis on airway management. Dramatic tumor response with relief of airway symptoms was achieved with a regimen of radiotherapy, chemotherapy, corticosteroids, helium-oxygen mixtures, humidity, and intensive care unit monitoring. Direct airway intervention, including tracheotomy, was usually successfully and safely avoided.

Single session treatment for bleeding hemorrhoids

Fifty consecutive outpatients with bleeding internal hemorrhoids were prospectively treated with a single application of rubber band ligation or infrared coagulation. Complete follow-up observation was obtained in 48 patients (23 underwent rubber band ligation and 25 underwent infrared coagulation). At one month after treatment, 22 patients who underwent rubber band ligation and 16 who underwent infrared coagulation, were symptomatically improved (p less than 0.05). At six months, 15 patients who had undergone rubber band ligation and ten who had infrared coagulation treatment, remained improved (p less than 0.05). There was no statistical difference in the discomfort experienced by either group during or after the procedure as determined by a self-assessment scale. Two patients who underwent rubber band ligation experienced complications--a thrombosed external hemorrhoid developed in one patient and another had delayed rectal bleeding. Although associated with occasional complications after treatment, rubber band ligation is more effective than in infrared coagulation for single session treatment of bleeding internal hemorrhoids.

Computer analysis of portal hemodynamics after small-diameter portacaval H-grafts: the theoretical basis for partial shunting

We have previously reported on the clinical results of partial shunting using small-diameter portacaval H-grafts. In this study, we defined the theoretical basis for partial shunting using the Wheatstone bridge model of the splanchnic circulation. The model was modified to include a variable resistance for a portacaval shunt and was programmed as a computer simulation. We calculated portal flow as a function of shunt resistance to determine the resistance necessary to maintain prograde portal flow in patients with portal hypertension. The resistance of 8- and 10-mm portacaval H-grafts, as positioned clinically, was determined using a laboratory apparatus. The experimentally derived values for resistance were inserted into the graph of portal flow predicted by the computer program. Portacaval H-grafts 8 mm in diameter should produce prograde portal flow, 10-mm H-grafts should be borderline, and shunts larger than 10 mm should routinely result in reversed flow. These predictions were confirmed by clinical observations in 29 patients undergoing portacaval H-grafts.