New York Methodist Hospital

About: New York Methodist Hospital is a healthcare organization based out in Brooklyn, New York, United States. It is known for research contribution in the topics: Myocardial infarction & Percutaneous coronary intervention. The organization has 948 authors who have published 936 publications receiving 29954 citations.

Evaluating outcomes associated with a discharge action plan employing single-dose home use of ondansetron in patients with acute gastroenteritis

Abstract: Acute gastroenteritis accounts for 1-2 million annual pediatric emergency department visits in the US. The current literature supports the use of antiemetics, such as ondansetron, in the emergency department, reporting improved oral rehydration, cessation of vomiting, and reduction in the need for intravenous rehydration. However, there remains concern that using these agents may "mask alternative diagnoses" and negatively impact patient care. We present a case series of 29 patients who received a pediatric emergency department discharge action plan which allowed for a dose of ondansetron to be dispensed by the clinician at the time of discharge. Patients were instructed to administer the ondansetron at home for treatment of ongoing nausea and vomiting any time after 6 hours from the time of emergency department discharge. These patients were followed up at 3-5 days following discharge to assess for outcomes. Implications of this discharge action plan and future directions are discussed.

Aspiration during electroconvulsive therapy under general anesthesia.

Abstract: Electroconvulsive Therapy Under General Anesthesia To the Editor: We often assume that patients who have had nothing by mouth (NPO) for more than 8 hours have nothing in their stomach. Exceptions include the very anxious (eg, trauma), the big-bellied patient (eg, pregnancy, obese), the neurologically impaired patient (eg, diabetes, renal failure), ileus or bowel obstruction, hiatal hernia, and enteral tube feeding. We present a case of aspiration during electroconvulsive therapy (ECT) under general anesthesia. A 51-year-old man (weight 77 kg) was admitted to the hospital for major depression because he was not responding to antidepressants. After evaluation by the psychiatric team, the patient was scheduled for ECT in the morning. The patient had a history of hyperlipidemia. His medications included rosuvastatin, quetiapine, and venlafaxine. The patient did not have any surgical history. The preanesthetic evaluation revealed a severely depressed patient communicating in a low voice, with no anticipated airway difficulties. The patient had nothing by mouth for approximately 14 hours before the procedure. The patient complained of constipation and lower abdominal discomfort that had fully resolved 4 hours before the procedure, after a normal bowel movement. Anesthetic Management The patient was connected to standard American Society of Anesthesiologists monitors in the ECT room. The patient was scheduled to undergo a standard-dose titration protocol for the ECTVstarting with a low dose of right unilateral ultrabrief pulse of 0.3 millisecond, 1-second duration, 20 Hz, at 800 mA. Isolated limb technique (left lower limb isolation by using the tourniquet inflation before the muscle relaxant) was used during ECT to measure the motor activity along with electroencephalogram monitoring. He was preoxygenated with 100% oxygen as he was spontaneously breathing through a transparent facemask covering the nose and mouth with a tight seal using a Mapleson F (Jackson-Rees) anesthesia circuit for 3 minutes. General anesthesia was induced with methohexital 80 mg (È1 mg/kg) intravenously (IV). Succinylcholine 60 mg (È0.75 mg/kg) IV was given next after a bite block was placed, and ventilation was possible with the transparent facemask secured with head straps. The first stimulus of ECTwas administered following clinical cessation of eyelid fasciculation. No nerve stimulator was used to assess the depth of paralysis. The first dose of ECT was administered without a response. After 30 seconds, a second stimulus was administered, and the patient started convulsing, but without arching his back. The motor seizure duration was 65 seconds and the electroencephalogram seizure duration was 94 seconds. He immediately began producing copious amounts of semisolid food and secretions through the mouth and nose. His heart rate was 124 beats/min, blood pressure 156/86 mm Hg, and oxygen saturation (SpO2) 96%. At this juncture, the patient was given an additional dose of methohexital 60 mg IV and succinylcholine 40 mg IV. He was rapidly intubated orally with a 7-mm cuffed endotracheal tube (ETT). Aspiration from the ETT revealed particulate matter, whereas aspiration from an orogastric tube revealed minimal secretions. The patient was sedated with a propofol infusion 25 to 50 Hg/kg per minute and transferred to the intensive care unit maintaining an SpO2 of 88% to 90% on 100% oxygen. Bronchoscopy and lavage through the ETT tube showed partially digested rice and beans that were consumed more than 20 hours before the procedure. The consulting gastroenterologist diagnosed a ‘‘possible depression-associated gastroparesis.’’ The patient appeared to have had sustained an irreversible pulmonary injury and died 35 days after the event because of sepsis and multiorgan failure.

Sonographic identification of peripheral nerves in the forearm.

Abstract: Background: With the growing utilization of ultrasonography in emergency medicine combined with the concern over adequate pain management in the emergency department (ED), ultrasound guidance for peripheral nerve blockade in ED is an area of increasing interest. The medical literature has multiple reports supporting the use of ultrasound guidance in peripheral nerve blocks. However, to perform a peripheral nerve block, one must first be able to reliably identify the specific nerve before the procedure. Objective: The primary purpose of this study is to describe the number of supervised peripheral nerve examinations that are necessary for an emergency medicine physician to gain proficiency in accurately locating and identifying the median, radial, and ulnar nerves of the forearm via ultrasound. Methods: The proficiency outcome was defined as the number of attempts before a resident is able to correctly locate and identify the nerves on ten consecutive examinations. Didactic education was provided via a 1 h lecture on forearm anatomy, sonographic technique, and identification of the nerves. Participants also received two supervised hands-on examinations for each nerve. Count data are summarized using percentages or medians and range. Random effects negative binomial regression was used for modeling panel count data. Results: Complete data for the number of attempts, gender, and postgraduate year (PGY) training year were available for 38 residents. Nineteen males and 19 females performed examinations. The median PGY year in practice was 3 (range 1-3), with 10 (27%) in year 1, 8 (22%) in year 2, and 19 (51%) in year 3 or beyond. The median number (range) of required supervised attempts for radial, median, and ulnar nerves was 1 (0-12), 0 (0-10), and 0 (0-17), respectively. Conclusion: We can conclude that the maximum number of supervised attempts to achieve accurate nerve identification was 17 (ulnar), 12 (radial), and 10 (median) in our study. The only significant association was found between years in practice and proficiency ( P = 0.025). We plan to expound upon this research with an additional future study that aims to assess the physician's ability to adequately perform peripheral nerve blocks in efforts to decrease the need for more generalized procedural sedation.

Cerebrovascular Events After a Primary Percutaneous Coronary Intervention Strategy for Acute ST-Segment– Elevation Myocardial Infarction Analysis From the HORIZONS-AMI Trial

Abstract: Background— Patients with ST-segment–elevation myocardial infarction are at increased risk of cerebrovascular events. We assessed the incidence, predictors, and implications of cerebrovascular events in patients with ST-segment–elevation myocardial infarction managed with a primary percutaneous coronary intervention strategy. Methods and Results— In the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, 72 of 3602 patients (2.0%) experienced at least 1 cerebrovascular event (stroke: 63 patients; transient ischemic attack: 12 patients) during the 3-year follow-up (40.3% within 30 days, 20.8% between 30 days and 1 year, and 38.9% between 1 and 3 years). Stroke was ischemic in 58 (92.1%) patients and hemorrhagic in 5 (7.9%) patients. More than half of all strokes (52.3%) were disabling. By principal management strategy, cerebrovascular events developed in 2.0%, 14.9%, and 1.9% of patients triaged to primary percutaneous coronary intervention, coronary artery bypass grafting, and medical therapy, respectively ( P <0.0001). Cerebrovascular events were independently predicted by older age, creatinine clearance <60 mL/min, treatment with coronary artery bypass grafting, anemia, and diabetes mellitus. Cerebrovascular events were associated with significantly increased rates of 3-year mortality (20.5% versus 6.5%; P <0.0001), as well as reinfarction (14.3% versus 3.8%; P =0.0007), ischemia-driven target vessel revascularization (22.8% versus 13.0%; P =0.006), and major bleeding (23.5% versus 8.4%; P <0.0001). Conclusions— In HORIZONS-AMI, cerebrovascular events within 3 years after ST-segment–elevation myocardial infarction in patients undergoing a primary percutaneous coronary intervention management strategy occurred in 2.0% of patients and were most frequent after coronary artery bypass grafting. Cerebrovascular events were often disabling and were strongly associated with high rates of death, reinfarction, recurrent ischemia, and major bleeding. Clinical Trial Registration— URL: . Unique identifier: [NCT00433966][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00433966&atom=%2Fcirccvint%2F8%2F4%2Fe002283.atom