Ali Seifi

Ethical Implications of Patients and Families Secretly Recording Conversations With Physicians

Withrecentadvances intechnology,smartphonescan become recording devices with the touch of a button. This technological capability gives patients and their families the ability to easily and surreptitiously record conversations with physicians. The frequency of such recordings or whether they even occur is unknown. The ubiquity of smartphones, however, suggests the potential for secret recordings to occur. As of January 2014, 58% of Americans owned a smartphone, including 83% of young adults.1 Although recording conversations with physicians may provide some benefit for patients and their families, secret recordings can undermine patient-physician relationships and ultimately affect the provision of health care. Federal lawprohibits recording a private conversation unless at least one party to the conversation consents to the recording.2 That party may include either thepersonoperatingtherecordingdeviceorothers.Several states, such as California and Florida, provide additional protections by requiring that all parties to a conversationconsent to the recording. In stateswithout the additionalprotections, apatientor familymembercould

Atomoxetine-induced myocardial infarction.

Atomoxetine (Strattera®, Eli Lilly and Co.) is the first non-stimulant drug in the United States (US) to be approved for the treatment of attention deficit hyperactivity disorder (ADHD). In the past, physicians have been concerned about the safety of a variety of ADHD medications. As a result, non-stimulant drugs were developed with claims of fewer side effects and limited abuse potential. The data regarding this new group of drugs and its effect on the cardiovascular system is limited. We report a case of atomoxetine induced myocardial infarction (MI) in a young woman.

The Incidence and Risk Factors of Associated Acute Myocardial Infarction (AMI) in Acute Cerebral Ischemic (ACI) Events in the United States

Objectives To determine the association between myocardial infarction (AMI) and clinical outcome in patients with primary admissions diagnosis of acute cerebral ischemia (ACI) in the US. Methods Data from Nationwide Inpatient Sample (NIS) was queried from 2002–2011 for inpatient admissions of patients with a primary diagnosis of ACI with and without AMI using International Classification of Diseases, Ninth Revision, Clinical Modification coding (ICD-9). A multivariate stepwise regression analysis was performed to assess the correlation between identifiable risk factors and clinical outcomes. Results During 10 years the NIS recorded 886,094 ACI admissions with 17,526 diagnoses of AMI (1.98%). The overall cumulative mortality of cohort was 5.65%. In-hospital mortality was associated with AMI (aOR 3.68; 95% CI 3.49–3.88, p≤0.0001), rTPA administration (aOR 2.39 CI, 2.11–2.71, p<0.0001), older age (aOR 1.03, 95% CI, 1.03–1.03, P<0.0001) and women (aOR 1.06, 95% CI 1.03–1.08, P<0.0001). Overall, mortality risk declined over the course of study; from 20.46% in 2002 to 11.8% in 2011 (OR 0.96, 95% CI 0.95–0.96, P<0.0001). Survival analysis demonstrated divergence between the AMI and non-AMI sub-groups over the course of study (log-rank p<0.0001). Conclusion Our study demonstrates that although the prevalence of AMI in patients hospitalized with primary diagnosis of ACI is low, it negatively impacts survival. Considering the high clinical burden of AMI on mortality of ACI patients, a high quality monitoring in the event of cardiac events should be maintained in this patient cohort. Whether prompt diagnosis and treatment of associated cardiovascular diseases may improve outcome, deserves further study.

Cannabis Use and Outcomes in Patients With Aneurysmal Subarachnoid Hemorrhage

Background and Purpose— The incidence of cannabis use in patients with aneurysmal subarachnoid hemorrhage (aSAH) and its impact on morbidity, mortality, and outcomes are unknown. Our objective was to evaluate the relationship between cannabis use and outcomes in patients with aSAH. Methods— Records of consecutive patients admitted with aSAH between 2010 and 2015 were reviewed. Clinical features and outcomes of aSAH patients with negative urine drug screen and cannabinoids-positive (CB+) were compared. Regression analyses were used to assess for associations. Results— The study group consisted of 108 patients; 25.9% with CB+. Delayed cerebral ischemia was diagnosed in 50% of CB+ and 23.8% of urine drug screen negative patients (P=0.01). CB+ was independently associated with development of delayed cerebral ischemia (odds ratio, 2.68; 95% confidence interval, 1.03–6.99; P=0.01). A significantly higher number of CB+ than urine drug screen negative patients had poor outcome (35.7% versus 13.8%; P=0.01). In univariate analysis, CB+ was associated with the composite end point of hospital mortality/severe disability (odds ratio, 2.93; 95% confidence interval, 1.07–8.01; P=0.04). However, after adjusting for other predictors, this effect was no longer significant. Conclusions— We offer preliminary data that CB+ is independently associated with delayed cerebral ischemia and possibly poor outcome in patients with aSAH. Our findings add to the growing evidence on the association of cannabis with cerebrovascular risk.

Incidence and morbidity of craniocervical arterial dissections in atraumatic subarachnoid hemorrhage patients who underwent aneurysmal repair

Background No studies have assessed the incidence of craniocervical arterial dissections (CCADs) and its association to mortality in hospitalized patients with a primary diagnosis of atraumatic subarachnoid hemorrhage (SAH) requiring aneurysmal repair. We hypothesize that the incidence of CCADs in these patients has increased over time as well as its association to mortality. Methods We conducted a 9 year retrospective assessment of the incidence of CCADs in patients hospitalized with a primary diagnosis of an SAH requiring repair and the effect of CCAD on mortality. Using the Nationwide Inpatient Sample (NIS), we queried records from 2003 to 2011 for an ICD-9 (International Classification of Diseases-9) code corresponding to admissions for atraumatic SAH. Demographical data, incidence of CCADs, type of aneurysmal repair, length of hospital stay, and hospital mortality were recorded. Multivariate logistical regression models were fitted to assess for the impact of CCAD on inhospital mortality and morbidity. Results During the period 2003–2011, of the NIS reported 18 260 patients who required aneurysmal SAH repair, 9737 (53.32%) underwent endovascular coiling and 8523 (46.48%) had surgical clipping. There were 131 patients in the cohort with reported CCADs: 94 (71.75%) of these patients had received endovascular coiling repair and 37 (28.25%) had undergone surgical clipping repair. Patients who underwent endovascular coiling had a higher rate of CCADs in this cohort (OR 2.94; 95% CI 2.00 to 4.31, p<0.0001). The incidence of CCADs in this population increased by an average rate of 9.4% per year (OR 1.14; 95% CI 1.06 to 1.23, p<0.0006), from 0.49% in 2003 to 1.10% in 2011. The diagnosis of CCAD added 3 and 6 more days to median length of hospitalization stay for surgical clipping and endovascular coiling, respectively. The unadjusted rate of mortality was 8.4% in the CCADs subgroup, and the presence of CCAD was not a predictor of mortality in our multivariate regression model (OR 0.68; 95% CI 0.36 to 1.27, p=0.2244). Conclusions Our study indicates an annual increase in the incidence of CCADs in patients admitted with SAH who require aneurysmal repair. More than two-thirds of these patients that developed CCADs had undergone endovascular coiling repair. A diagnosis of CCAD increased the length of hospital stay but had no statistically significant association with mortality in this patient population.

Management of dyskinesia in anti-NMDAR encephalitis with tramadol

Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephaliis is a fairly new diagnosis that was discovered in 2005 after our young women developed ovarian teratomas with psychiatric ymptoms, seizures, altered mental status, and eventual central ypoventilation [1]. It is an autoimmune encephalitis of variable araneoplastic origin caused by IgG antibodies against NMDARs 1,2]. Dyskinesia is observed in a majority of patients with antiMDAR encephalitis and frequently includes orofacial dyskinesia hat is characteristic of the disease [1,2]. Movement disorder often resents within the first month of the disease and may include horeoathetosis, facial and/or limb dyskinesia, and dystonia of varible severity [2]. Although a majority of anti-NMDAR encephalitis atients experience dyskinesia, no specific symptomatic treatment xists for its control. Thus, we present a case of anti-NMDAR ncephalitis where tramadol, an NMDAR inhibitor, effectively conrolled dyskinesia.

The impact of tackle football injuries on the American healthcare system with a neurological focus

Background Recent interest in the study of concussion and other neurological injuries has heightened awareness of the medical implications of American tackle football injuries amongst the public. Objective Using the National Emergency Department Sample (NEDS) and the National Inpatient Sample (NIS), the largest publicly available all-payer emergency department and inpatient healthcare databases in the United States, we sought to describe the impact of tackle football injuries on the American healthcare system by delineating injuries, specifically neurological in nature, suffered as a consequence of tackle football between 2010 and 2013. Methods The NEDS and NIS databases were queried to collect data on all patients presented to the emergency department (ED) and/or were admitted to hospitals with an ICD code for injuries related to American tackle football between the years 2010 and 2013. Subsequently those with football-related neurological injuries were abstracted using ICD codes for concussion, skull/face injury, intracranial injury, spine injury, and spinal cord injury (SCI). Patient demographics, length of hospital stay (LOS), cost and charge data, neurosurgical interventions, hospital type, and disposition were collected and analyzed. Results A total of 819,000 patients presented to EDs for evaluation of injuries secondary to American tackle football between 2010 and 2013, with 1.13% having injuries requiring inpatient admission (average length of stay 2.4 days). 80.4% of the ED visits were from the pediatric population. Of note, a statistically significant increase in the number of pediatric concussions over time was demonstrated (OR = 1.1, 95% CI 1.1 to 1.2). Patients were more likely to be admitted to trauma centers, teaching hospitals, the south or west regions, or with private insurance. There were 471 spinal cord injuries and 1,908 total spine injuries. Ten patients died during the study time period. The combined ED and inpatient charges were

Hyperventilation therapy for control of posttraumatic intracranial hypertension

1.35 billion. Conclusion Injuries related to tackle football are a frequent cause of emergency room visits, specifically in the pediatric population, but severe acute trauma requiring inpatient admission or operative interventions are rare. Continued investigation in the long-term health impact of football related concussion and other repetitive lower impact trauma is warranted.

The Scrub Revolution: From Hospital Uniform to Public Attire

During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO2 reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO2), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications.

Incidence of iatrogenic pneumothorax in the United States in teaching vs. non-teaching hospitals from 2000 to 2012

Wander into a coffee shop in the heart of a medical center around 3 PM and you will find many people wearing ‘‘scrub’’ uniforms as they order their afternoon pick-me-up. These people may be physicians, nurses, or surgical assistants, but they also could be technicians, receptionists, veterinarians, or even individualswhohave noconnection to health care at all. The growing trend of people wearing scrubs outside the clinical setting has sparked a debate about the propriety of this conduct, particularly when the individual wearing scrubs is a physician. Although the uniforms of many other professions go unnoticed in public spaces, scrubs have the tendency to stand out. Scrubs are easily identified and often associated with the risk of biological hazards. Some claim that such attire is unprofessional when worn outside the clinical setting and doing so erodes the trust that patients have in their healthcare providers. Even though there is no conclusive evidence that scrubs aid in the spread of infection, those who wear them in public continue to raise eyebrows and draw criticism. In thewake of this controversy, we are left asking the question: Should healthcare professionals be allowed to wear scrubs outside a clinical setting? In the late 1800s, Joseph Lister established the foundational principles of antiseptic surgery by applying Louis Pasteur’s advances in germ theory and pasteurization. By 1970, sterile technique was transforming health care, and surgical attire had changed froma simple apronworn over the surgeon’s clothes into a uniform consisting of a simple short-sleeve V-neck shirt and drawstring pants. This uniform would become a symbol of cleanliness in health care and eventually be called scrubs, as a result of being worn in a disinfected or ‘‘scrubbed’’ environment. Patients’ perceptions of scrubs are complex; they vary greatly based on the hospital setting, physician specialty, patient age, and location. Healthcare workers’ attire has been shown to affect patient satisfaction, trust, and confidence. Older patients tend to favor physicians dressed in formal attire, whereas younger patients are more accepting of casual attire and scrubs. In the United States, patients are less concerned about formal dress compared with patients elsewhere in the world. Patients in Asia, Europe, and Canada prefer to see formal attire in private healthcare settings and favor scrubs for surgeons, emergency department personnel, and intensive care physicians. Regardless of nationality, patients consistently favor formal attire for primary care physicians because of the long-term nature of the relationships they form with those physicians. Understanding the impact of the visual presentation of healthcareworkers under different circumstances can help us determine whether scrub uniforms enhance or diminish the relationship between the physician and patient. Scrubs have numerous benefits aside from their function in the operating room. The most notable is that they enable physicians to be more efficient in their timemanagement. At the end of a shift, clinicians can change quickly into casual attire and dispose of their soiled scrubs. Wearing scrubs to work also significantly reduces the time that healthcare professionals must spend on wardrobe selection, preparation, and alteration. Some people, however, become apprehensive when they see scrubs worn in public by clinicians. They object to this uniform being worn in public spaces because they are concerned about the risk of contamination and the possible spread of infection. Although there are no conclusive data to suggest that wearing scrubs in public spaces contributes to the dissemination of infection, clinicians should still examine their daily habits for any problematic practices that may increase their risk for contamination. Home laundering is another factor that complicates the issue of wearing scrubs outside a hospital setting. Home laundering has been shown to be significantly inferior in terms of efficacy when compared with commercial processing; it also can lead to cross-contamination if hospital scrubs are washed with other garments. Evidence shows that 44% of scrubs washed at home tested positive for coliform bacteria, which increases the risk of these harmful bacteria reaching household members and communities, and even returning to hospitals. These inconsistent standards and frightening statistics suggest that the present dress code policies are inadequate. Proposing new strategies can reshape hospital policies to be specific and address attire guidelines for settings outside the operating room and for hospital laundering services. Administrators should actively educate staff regarding the professionalism of their attire and encourage them not to leave the hospital wearing scrubs. Hospitals can educate and monitor healthcare personnel by offeringmandatory trainingmodules and arranging quality improvement projects. Providing locker rooms to all staff will permit them to change into their personal attire before leaving the hospital and will encourage the use of hospital laundering services for scrubs. By establishing stricter regulations that prevent scrubs from being worn outside a healthcare setting,we strengthen their associatedhealthbenefits for patients, physicians, and all members of the community. Perspective