Showing papers by "Lincoln Hospital published in 2016"

Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings

Abstract: Introduction Although dehydration from diarrhea is a leading cause of morbidity and mortality in children under five, existing methods of assessing dehydration status in children have limited accuracy. Objective To assess the accuracy of point-of-care ultrasound measurement of the aorta-to-IVC ratio as a predictor of dehydration in children. Methods A prospective cohort study of children under five years with acute diarrhea was conducted in the rehydration unit of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Ultrasound measurements of aorta-to-IVC ratio and dehydrated weight were obtained on patient arrival. Percent weight change was monitored during rehydration to classify children as having “some dehydration” with weight change 3–9% or “severe dehydration” with weight change > 9%. Logistic regression analysis and Receiver-Operator Characteristic (ROC) curves were used to evaluate the accuracy of aorta-to-IVC ratio as a predictor of dehydration severity. Results 850 children were enrolled, of which 771 were included in the final analysis. Aorta to IVC ratio was a significant predictor of the percent dehydration in children with acute diarrhea, with each 1-point increase in the aorta to IVC ratio predicting a 1.1% increase in the percent dehydration of the child. However, the area under the ROC curve (0.60), sensitivity (67%), and specificity (49%), for predicting severe dehydration were all poor. Conclusions Point-of-care ultrasound of the aorta-to-IVC ratio was statistically associated with volume status, but was not accurate enough to be used as an independent screening tool for dehydration in children under five years presenting with acute diarrhea in a resource-limited setting.

The importance of empiric antibiotic dosing in critically ill trauma patients: Are we under-dosing based on augmented renal clearance and inaccurate renal clearance estimates?

Abstract: BACKGROUNDAn accurate assessment of creatinine clearance (CrCl) is essential when dosing medications in critically ill trauma patients. Trauma patients are known to experience augmented renal clearance (i.e., CrCl ≥130 mL/min), and the use of CrCl estimations may be inaccurate leading to under-/over

Results from the Trial Using Motivational Interviewing, Positive Affect, and Self-Affirmation in African Americans with Hypertension (TRIUMPH)

Abstract: Objective: Our objective was to determine the the effectiveness in combining positive affect and self-affirmation strategies with motivational interviewing in improving blood pressure control among hypertensive African Americans compared with AA hypertensives in an education-only control group. Design: Randomized trial. Setting: Ambulatory practices in the South Bronx and Harlem, New York City. Participants: African American adults with uncontrolled hypertension. Interventions: Participants were randomized to a positive affect and self-affirmation intervention or an education control group. The positive affect and self-affirmation intervention involved having participants think about things that made them happy and that reminded them of their core values on a daily basis. These strategies were reinforced every two months through motivational interviewing. The control arm received a workbook of strategies on blood pressure control. All participants were called every two months for one year. Main outcomes: Blood pressure control rate. Results: A total of 238 participants were randomized. The average age was 56 + 11, approximately 70% were female, 80% were not married, and up to 70% completed high school. There was no difference in control rates between the intervention and the control group. However, at one year, female participants were more likely to be controlled. Participants with high depressive symptoms or high perceived stress at baseline were less likely to be controlled. Conclusions: While this study did not demonstrate an intervention effect, it does provide important insight into the psychosocial factors that may underlie blood pressure control in African Americans. Implications for future behavioral intervention trials are discussed. Ethn Dis. 2016;26(1):51-60; doi:10.18865/ed.26.1.51

Spontaneous Heterotopic Pregnancy: Dual Case Report and Review of Literature

Abstract: Introduction. Heterotopic pregnancy is a rare complication usually seen in populations at risk for ectopic pregnancy or those undergoing fertility treatments. It is a potentially dangerous condition occurring in only 1 in 30,000 spontaneous pregnancies. With the advent of Assisted Reproduction Techniques (ART) and ovulation induction, the overall incidence of heterotopic pregnancy has risen to approximately 1 in 3,900 pregnancies. Other risk factors include a history of pelvic inflammatory disease (PID), tubal damage, pelvic surgery, uterine Mullerian abnormalities, and prior tubal surgery. Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. Most commonly, heterotopic pregnancy is diagnosed at the time of rupture when surgical management is required. Case. This paper represents two cases of heterotopic pregnancies as well as a literature review. Conclusion. Heterotopic pregnancy should be suspected in patients with an adnexal mass, even in the absence of risk factors. Clinicians must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy. A high index of suspicion in women is needed for early and timely diagnosis, and management with laparotomy or laparoscopy can result in a favorable and successful obstetrical outcome.

Pain Treatment of Underserved Older African Americans.

Abstract: Older African Americans who experience pain are especially at high risk of underassessment and undertreatment. This study examined patterns and correlates of pain medication use: severity of pain, medical conditions, and access to care. African Americans aged 65 and older were recruited from 16 churches located in south Los Angeles (N = 400). Structured face-to-face interviews and visual inspection of each participant's medications were conducted. More than 39% of participants were aged 75 and older, and 65% were female. Forty-seven percent used at least one type of pain medication. The frequency of pain medication use according to pharmaceutical class was nonopioid, 33%; opioid, 12%; adjuvant, 9%; and other drug, 8%. Seventy-seven percent of nonopioids were nonsteroidal anti-inflammatory drugs (NSAIDs), which 25% of participants with hypertension, 28% with stroke, 26% with kidney disease, and 28% with gastrointestinal problems used. Ninety-eight percent of participants who used NSAIDs, 98% experienced potentially inappropriate medication (PIM) use, 69% experienced drug duplication, and 65% experienced drug-drug interactions. This study suggests severe mismanagement of pain in underserved older African Americans, particularly those with comorbidity, multiple providers, and limited access to health care. The use of pain medication was associated with drug-drug interactions, drug duplication, and PIM use. The data show that many participants with severe pain are not taking pain medication or experience PIM use. One in four participants was taking NSAIDs, which can cause serious side effects in older African Americans with multiple chronic conditions.

Systemic Lupus Erythematosus Presenting as Refractory Thrombotic Thrombocytopenic Purpura: A Diagnostic and Management Challenge. A Case Report and Concise Review of the Literature

Abstract: BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is one of the thrombotic microangiopathic (TMA) syndromes, caused by severely reduced activity of the vWF-cleaving protease ADAMTS13. Systemic lupus erythematosus (SLE), on the other hand, is an autoimmune disease that affects various organs in the body, including the hematopoietic system. SLE can present with TMA, and differentiating between SLE and TTP in those cases can be very challenging, particularly in patients with no prior history of SLE. Furthermore, an association between these 2 diseases has been described in the literature, with most of the TTP cases occurring after the diagnosis of SLE. In rare cases, TTP may precede the diagnosis of SLE or occur concurrently. CASE REPORT We present a case of a previously healthy 34-year-old female who presented with dizziness and flu-like symptoms and was found to have thrombocytopenia, hemolytic anemia, and schistocytes in the peripheral smear. She was subsequently diagnosed with TTP and started on plasmapheresis and high-dose steroids, but without a sustained response. A diagnosis of refractory TTP was made, and she was transferred to our facility for further management. Initially, the patient was started on rituximab, but her condition continued to deteriorate, with worsening thrombocytopenia. Later, she also fulfilled the Systemic Lupus International Collaborating Clinics (SLICC) criteria for diagnosis of SLE. Treatment of TTP in SLE patients is generally similar to that in the general population, but in refractory cases there are few reports in the literature that show the efficacy of cyclophosphamide. We started our patient on cyclophosphamide and noticed a sustained improvement in the platelet count in the following weeks. CONCLUSIONS Thrombotic thrombocytopenic purpura is a life-threatening hematological emergency which must be diagnosed and treated in a timely manner. Refractory cases of TTP have been described in the literature, but without clear evidence-based guidelines for its management, and is solely based on expert opinion and previous case reports. Further studies are needed to establish guidelines for its management. We present this case to highlight the role that cyclophosphamide might carry in those cases and to be a foundation for these future studies.

CRH as a Predictor of Preterm Birth in Minority Women.

Abstract: Objective To determine the predictive capability of corticotropin-releasing hormone (CRH) as a biomarker of preterm birth (PTB) in minority women. Study design Venous blood samples were obtained at 22-24 weeks' gestation in a prospective, descriptive study of 707 minority women experiencing low-risk pregnancies. CRH was analyzed using a radioimmunoassay and methanol extraction protocol. Result CRH predicted PTB in both African American and Hispanic women. The odds ratio was 1.8 times greater for having a PTB if the CRH level was >24 pg/ml. The median CRH for African American women having a PTB was 46.6 pg/ml and for Hispanic women was 35.03 pg/ml. Using a receiver-operating characteristic curve, the threshold for CRH among the African American women was 30.6 pg/ml and among the Hispanic women was 27.4 pg/ml. Conclusion CRH may be an important biomarker for predicting PTB in minority women, especially when combined with other predictors.

Temporal Trends, Predictors, and Outcomes of In-Hospital Gastrointestinal Bleeding Associated With Percutaneous Coronary Intervention

Abstract: Since the introduction of new antiplatelet and anticoagulant agents in the last decade, large-scale data studying gastrointestinal bleeding (GIB) in patients undergoing percutaneous coronary intervention (PCI) are lacking. Using the Nationwide Inpatient Sample, we identified all hospitalizations from 2006 to 2012 that required PCI. Temporal trends in the incidence and multivariate predictors of GIB associated with PCI were analyzed. A total of 4,376,950 patients underwent PCI in the United States during the study period. The incidence of GIB was 1.1%. Mortality rate in the GIB group was significantly higher (9.71% vs 1.1%, p <0.0001). Although the incidence of GIB remained stable during the study period (0.97% in 2006 to 1.19% in 2012), in-hospital mortality rate increased significantly from 7.9% in 2006 to 10.78% in 2012, with a peak of 12% in 2010. The GIB group had a longer median length of stay (5.80 vs 1.57 days) and an increased median cost of hospitalization ($26,564 vs $16,879). The predictors of GIB included cardiovascular co-morbidities such as acute myocardial infarction, cardiogenic shock, atrial fibrillation, congestive heart failure, valvular heart diseases, and a history of transient ischemic attack/stroke. Gastrointestinal co-morbidities including diverticulosis, esophageal cancer, stomach cancer, small intestine cancer, large intestine cancer, rectosigmoid cancer, gastrointestinal ulcer, and liver disease were predictors of GIB. Interestingly, a lower risk of GIB was associated with obese patients and patients with private insurance. A higher risk of GIB was noted in urgent versus elective admissions and weekend versus weekday admissions. In conclusion, the incidence of GIB in patients who underwent PCI remained stable from 2006 to 2012; however, the in-hospital mortality increased significantly. Identifying patients at higher risk for GIB is critically important to develop preventive strategies to reduce morbidity and mortality.

Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate?

Abstract: Objective The main objective of the present study was to examine the perceived versus actual time to intubation (TTI) as an indication to help determine the situational awareness of Emergency Physicians during rapid sequence intubation and, additionally, to determine the physician's perception of desaturation events. Methods A timed, observation prospective cohort study was conducted. A post-intubation survey was administered to the intubating physician. Each step of the procedure was timed by an observer in order to determine actual TTI. The number of desaturation events was also recorded. Results One hundred individual intubations were included. The provider perceived TTI was significantly different and underestimated when compared with the actual TTI (23 s, 95% confidence interval (CI) 20.4–25.49 vs 45.5 s, 95% CI 40.2–50.7, P < 0.001, respectively). Pearson correlation coefficient of perceived TTI to actual TTI was r2 = 0.39 (95% CI 0.21–0.54, P < 0.001). The provider perceived desaturation rate was also significantly different from actual desaturation rate (13, 95% CI 3–12 vs 23, 95% CI 13–29, P = 0.05, respectively). The overall time to desaturation was 65.1 s. Conclusions Our findings have shown that provider's perception of TTI occurs sooner than actually observed. Also, the providers were less aware of desaturation during the procedure.

Essure Surgical Removal and Subsequent Resolution of Chronic Pelvic Pain: A Case Report and Review of the Literature

Abstract: Background. Hysteroscopic tubal sterilization (Essure) is a minimally invasive option for permanent contraception with high reported rates of patient satisfaction. A small percentage of these women subsequently choose to have the tubal inserts removed due to regret or perceived side effects such as late-onset pelvic pain secondary to placement of the Essure device. Case. A twenty-nine-year-old woman G4P4014 presented with a two-year complaint of chronic pelvic pain and dyspareunia after the hysteroscopic placement of an Essure device for sterilization. On reviewing the images of the HSG, it was noted that although tubal occlusion was confirmed, the left Essure coil appeared curved on itself in an elliptical fashion and did not seem to follow the expected anatomic trajectory of the fallopian tube. The patient reported resolution of chronic pelvic pain following laparoscopic removal of Essure device. Conclusion. A misplaced Essure device should be considered in the differential diagnosis of chronic pelvic pain in women who had difficult placement of the device. In addition to demonstrating tubal occlusion, careful examination of the configuration of the Essure microinserts on HSG examination provides valuable information in patients with pelvic pain after Essure placement.

Novel model of direct and indirect cost-benefit analysis of mechanical embolectomy over IV tPA for large vessel occlusions: a real-world dollar analysis based on improvements in mRS.

Abstract: Background Ischemic strokes result in significant healthcare expenditures (direct costs) and loss of quality-adjusted life years (QALYs) (indirect costs). Interventional therapy has demonstrated improved functional outcomes in patients with large vessel occlusions (LVOs), which are likely to reduce the economic burden of strokes. Objective To develop a novel real-world dollar model to assess the direct and indirect cost–benefit of mechanical embolectomy compared with medical treatment with intravenous tissue plasminogen activator (IV tPA) based on shifts in modified Rankin scores (mRS). Method A cost model was developed including multiple parameters to account for both direct and indirect stroke costs. These were adjusted based upon functional outcome (mRS). The model compared IV tPA with mechanical embolectomy to assess the costs and benefits of both therapies. Direct stroke-related costs included hospitalization, inpatient and outpatient rehabilitation, home care, skilled nursing facilities, and long-term care facility costs. Indirect costs included years of life expectancy lost and lost QALYs. Values for the model cost parameters were derived from numerous resources and functional outcomes were derived from the MR CLEAN study as a reflective sample of LVOs. Direct and indirect costs and benefits for the two treatments were assessed using Microsoft Excel 2013. Results This cost–benefit model found a cost–benefit of mechanical embolectomy over IV tPA of $163 624.27 per patient and the cost benefit for 50 000 patients on an annual basis is $8 181 213 653.77. Conclusions If applied widely within the USA, mechanical embolectomy will significantly reduce the direct and indirect financial burden of stroke ($8 billion/50 000 patients).

Assessing Fluid Responsiveness in Spontaneously Breathing Patients.

Abstract: Objectives The primary objective of this study was to test if fasting volunteers exhibit fluid responsiveness using noninvasive hemodynamic measurements. The secondary objective was to test a passive leg raise (PLR) maneuver as a diagnostic predictor of fluid responsiveness. Methods This was a quasi-experimental design involving healthy volunteers. Subjects were excluded for pregnancy and congestive heart failure. Following a 12-hour fast, subjects had baseline hemodynamic monitoring recorded using noninvasive, continuous pulse contour analysis. Subjects then had a PLR maneuver performed, followed by an intravenous bolus of crystalloid. A rise in stroke volume ≥ 10% from baseline with the bolus was considered consistent with fluid responsiveness, and the same rise with a PLR was consistent with a positive PLR maneuver. The primary outcome was the change in stroke volume with a fluid bolus. Univariate analysis assessed changes in hemodynamic parameters. Logistic regression analysis determined the test characteristics of the PLR in predicting subjects who were ultimately fluid responsive. Results Forty subjects completed the study. The mean change in stroke volume with a crystalloid bolus was 19% (95% confidence interval [CI] = 16% to 21%). Thirty-six (90%) subjects were fluid responsive. The mean PLR response for the overall cohort was 16% (95% CI = 12% to 19%), and 26 (65%) subjects had a positive PLR maneuver. The PLR was 72% sensitive (95% CI = 55% to 85%) and 100% specific (95% CI = 40% to 100%) for predicting the presence of fluid responsiveness. Conclusions Noninvasive assessment of fluid responsiveness in healthy volunteers and prediction of this response with a PLR maneuver is achievable. Further work is indicated to test these methods in acutely ill patients.

Does Resident Trauma Exposure Affect Advanced Trauma Operative Management Course Experience

Abstract: The Advanced Trauma Operative Management (ATOM) course is a simulation course adopted by the American College of Surgeons to teach operative management of primarily penetrating, traumatic injuries. Although it is clear that overall operative trauma exposure is decreasing, the educational benefit of ATOM for residents with different amounts of trauma exposure remains unclear. Our aim was to determine whether residents from trauma centers experienced less benefit from the ATOM course when compared with residents from nontrauma centers. We compared two groups of residents who take ATOM through our institutional course, those from trauma centers and those from nontrauma centers. ATOM pre- and postcourse evaluations of knowledge and self-efficacy were collected from October 2007 to June 2013. Overall residents from three institutions, two trauma centers (100 residents) and one nontrauma center (34 residents), were included in the study. All resident groups had statistically significant improvement in knowledge and self-efficacy after taking the ATOM course (P < 0.0001). There was no statistically significant difference in improvement relative to each of the groups in the ATOM categories of knowledge and self-efficacy. Our data show that residents with different levels of trauma exposure had similar pre- and postcourse scores as well as improvement in the ATOM evaluations. As operative trauma continues to decrease the ATOM course shows benefit for all residents regardless of the depth of their clinical trauma exposure in surgical residency.

Diabetes prevention: Reproductive age women affected by insulin resistance.

Abstract: In the United States, 29.1 million people are affected by diabetes, of which 95% have type 2 diabetes. There has been a fivefold increase in type 2 diabetes in the latter half of the 20th century, an increase strongly linked to the obesity epidemic in the United States. In addition, insulin resistance affects 86 million Americans, or more than one-third of the adult population, as manifested by impaired fasting glucose tolerance with random glucose values ranging from ⩾100 to <126 mg/dL. In all, 90% of those affected by impaired fasting glucose tolerance or pre-diabetes are unaware of their metabolic derangement. Although impaired fasting glucose tolerance increases one’s risk of developing type 2 diabetes, once identified, application of lifestyle changes by affected individuals may avoid or delay the onset of type 2 diabetes. For reproductive age women who are found to have impaired fasting glucose tolerance, lifestyle changes may be an effective tool to diminish the reproductive health consequences of ...

Diagnosis of Acquired Uterine Arteriovenous Malformation by Doppler Ultrasound.

Abstract: Background Acquired uterine arteriovenous malformation (AVM) is a rare cause of postpartum vaginal bleeding and can often be confused with retained products of conception (RPOC). Certain findings on ultrasound (US) increase the likelihood for AVM, such as hypoechoic areas in the myometrium and high velocity, multidirectional blood flow. Recognizing these changes on bedside US can cue the physician to send the patient for further studying and lead to the correct diagnosis. Case Report A 31-year-old, multigravida, multiparous female presented 5 weeks post–cesarean section with heavy, intermittent vaginal bleeding. Patient had multiple previous visits for similar bleeding, including an evaluation for RPOC. Upon current presentation, the patient underwent an US in the emergency department with color and pulse wave Doppler. US revealed a hypoechoic area within the myometrium, with high velocity, bidirectional blood flow, raising the clinical suspicion for uterine AVM. Following confirmatory studies, the patient underwent successful embolization of the AVM. Why Should an Emergency Physician Be Aware of This? The proper diagnosis of AVM is crucial, because the primary treatment modality for the alternative diagnosis of RPOC (i.e., dilation and curettage) can worsen vaginal bleeding and lead to shock or death, and is therefore contraindicated for uterine AVM. US is a quick bedside tool that can be used for rapid diagnosis of uterine AVM.

The identity development of urban minority boys in single mother households

Abstract: This phenomenological study explored the gender and career identity development of 13 urban minority young men, with an emphasis on the potential impact of father absence and single-mother parenting. Six themes were identified: (a) emotional intelligence and maternal appreciation and internalization, (b) consequent assumption of a parentified role, (c) nontraditional perception of masculinity, (d) experienced paternal void, (e) resilience, and (f) the limitations and aspirations in career pathways. Implications for practice and research are discussed.

Woven coronary arteries: A detailed review.

Abstract: A woven coronary artery is a rare congenital vascular variation that involves the separation of the artery into several thin channels, which later merge distally to form a single lumen. This mesh of intertwining small vessels may occur anywhere along the vessel and may be present in multiple coronaries. Although generally a benign incidental finding, there have been reported cases of associated ischemia, thrombus and atherosclerotic plaque formation and complications with cardiac intervention procedures. In this review, we have analyzed and compiled all the reported data pertaining to woven coronary arteries and highlighted its relevance to clinical practice.

Husband/Partner Intoxication and Intimate Partner Violence Against Women in the Philippines

Abstract: This study examined husband/partner intoxication and experience with physical, sexual, and emotional intimate partner violence against women (IPVAW) using data derived from a nationally representative survey conducted in the Philippines in 2013. Multivariate logistic regression analyses were used to examine the association between intoxication and 3 different types of intimate partner violence against women. Multinomial logistic regression was used to examine intoxication and severity of violence. In this sample, 28.8% of women reported experiencing any form of intimate partner violence and 92.9% of women reported their partner being intoxicated at least sometimes. Intoxication was significantly associated with all 3 types of intimate partner violence, while the odds of experiencing one form of IPVAW versus no form of IPVAW and 2 forms of IPVAW versus 1 form of IPVAW was greater among women reporting frequency of husband/partner intoxication as often.

Focused Training for Humanitarian Responders in Regional Anesthesia Techniques for a Planned Randomized Controlled Trial in a Disaster Setting.

Abstract: BACKGROUND Lower extremity trauma during earthquakes accounts for the largest burden of geophysical disaster-related injuries. Insufficient pain management is common in disaster settings, and regional anesthesia (RA) has the potential to reduce pain in injured patients beyond current standards. To date, no prospective research has evaluated the use of RA in a disaster setting. This cross-sectional study assesses knowledge translation and skill acquisition outcomes for lower extremity RA performed with and without ultrasound guidance among a cohort of Medecins Sans Frontieres (MSF) volunteers who will function as proceduralists in a planned randomized controlled trial evaluating the efficacy of RA for pain management in an earthquake setting. METHODS Generalist humanitarian healthcare responders, including both physicians and nurses, were trained in ultrasound guided femoral nerve block (USGFNB) and landmark guided fascia iliaca compartment block (LGFICB) techniques using didactic sessions and interactive simulations during a one-day focused course. Outcome measures evaluated interval knowledge attainment and technical proficiency in performing the RA procedures. Knowledge attainment was assessed via pre- and post-test evaluations and procedural proficiency was evaluated through monitored simulations, with performance of critical actions graded by two independent observers. RESULTS Twelve humanitarian response providers were enrolled and completed the trainings and assessments. Knowledge scores significantly increased from a mean pre-test score of 79% to post-test score of 88% (p<0.001). In practical evaluation of the LGFICB, participants correctly performed a median of 15.0 (Interquartile Range (IQR) 14.0-16.0) out of 16 critical actions. For the USGFNB, the median score was also 15.0 (IQR 14.0-16.0) out of 16 critical actions. Inter-rater reliability for completion of critical actions was excellent, with inter-rater agreement of 83.3% and 91.7% for the LGFICB and USGFNB evaluations, respectively. DISCUSSION Prior to conducting a trial of RA in a disaster setting, providers need to gain understanding and skills necessary to perform the interventions. This evaluation demonstrated attainment of high knowledge and technical skill scores in both physicians and nurses after a brief training in regional anesthesia techniques. This study demonstrates the feasibility of rapidly training generalist humanitarian responders to provide both LGFICB and USGFNB during humanitarian emergencies.

“Stuttering” after minor head trauma

Abstract: Traumatic brain injury (TBI) is defined as impairment in brain function as a result of mechanical force. It is classified based on clinical findings using the Glasgow Coma Scale (GCS). Mild TBI is defined as GCS 14-15; moderate, 9-13; and severe, 3-8. Patients with the same TBI classification may have very different underlying pathology. In moderate to severe TBI, the primary pathology may include contusions, hemorrhage, diffuse axonal injury, direct cellular damage, "tearing and shearing of the tissues, loss of the blood-brain barrier, disruption of the neurochemical homeostasis and loss of the electrochemical function". Although the primary pathology associated with mild TBI may be milder versions of the same pathology associated with moderate and severe TBI, it is generally a metabolic injury. However, it is reported that 15% of patients with mild TBI and a GCS score of 14 or 15 will have an intracranial lesion; less than 1% of these require neurosurgical intervention. Although patients with mild TBI may have intracranial lesions, it is rare that the presenting and only physical examination finding is an isolated neurologic finding. Here we present a case of isolated head trauma with a single physical examination finding--expressive aphasia.

Impact of a Rural Regional Myocardial Infarction System of Care in Wyoming

Abstract: Background Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST‐segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times. Methods and Results We developed a standardized treatment and transfer protocol for ST‐segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time‐to‐treatment outcomes during the pre‐ and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI‐capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P =0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes ( P P Conclusions Rural systems of care for ST‐segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.

Severe Traumatic Brain Injury: A Case Report

Abstract: Patient: Male, 28 Final Diagnosis: Closed head injury Symptoms: Bilateral mydriasis • coma Medication: — Clinical Procedure: Ventriculostomy and hemicraniectomy Specialty: Neurology Objective: Unusual clinical course

An Audit of Top Citations Published in Pediatric Emergency Care.

Abstract: ObjectiveThe aim of this study was to identify and compare the 100 articles published in Pediatric Emergency Care (PEC) from its inception in 1985 to date that are most often cited.MethodsThree online citation indices, Scopus, Web of Science, and Google Scholar, were examined to identify the 100 top

Dix-Hallpike Maneuver

Abstract: The Dix-Hallpike maneuver, also termed the “head-hanging positioning maneuver,” is helpful in confirming the clinical suspicion of benign paroxysmal positional vertigo (BPPV). This maneuver provokes abnormal nystagmus, which is a characteristic feature of BPPV.