James Walter

Clinical presentation of patients with acute cervical spine injury

A retrospective review of 67 patients with acute cervical spine fracture and/or dislocation was conducted at two suburban community hospital emergency departments. The mean age was 39, and two-thirds of the patients were male. Motor vehicle accidents and falls accounted for more than 80% of all injuries. On emergency department evaluation, it was found that there was no history of loss of consciousness in 42 patients (63%), no associated cranio-facial injuries in 31 patients (46%), and a normal sensorimotor examination in 59 patients (88%). Thirty-four patients (50%) were evaluated for cervical range of motion, which was found to be normal in one-third of the cases. The absence of mental status changes, cranio-facial injuries, range of motion abnormalities, and focal neurological findings is, therefore, not uncommon in patients who have sustained cervical spine injury.

Prehospital Triage to Primary Stroke Centers and Rate of Stroke Thrombolysis

IMPORTANCE Implementation of prehospital stroke triage is a public policy intervention that can have an immediate impact on acute stroke care in a region. OBJECTIVE To evaluate the impact that a citywide policy recommending prehospital triage of patients with suspected stroke to the nearest primary stroke center had on intravenous tissue plasminogen activator (tPA) use in Chicago, Illinois. DESIGN Retrospective multicenter cohort study from September 1, 2010, to August 31, 2011 (6 months before and after intervention that began March 1, 2011). SETTING Ten primary stroke center hospitals in Chicago. PATIENTS All admitted patients with stroke and transient ischemic attack. INTERVENTION Prehospital triage policy of patients with stroke to primary stroke centers. MAIN OUTCOMES AND MEASURES Intravenous tPA use (measured as a fraction of patients with ischemic strokes arriving through the emergency department). RESULTS There were 1075 stroke and transient ischemic attack admissions in the pretriage period and 1172 in the posttriage period. Patient demographic characteristics including age, sex, and risk factors were similar between the 2 periods (mean age, 65 years; 53% female). Compared with the pretriage period, use of emergency medical services increased from 30.2% to 38.1% (P < .001) and emergency medical services prenotification increased from 65.5% to 76.5% (P = .001) after implementation. Rates of intravenous tPA use were 3.8% and 10.1% (P < .001) and onset-to-treatment times decreased from 171.7 to 145.7 minutes (P = .03) in the pretriage and posttriage periods, respectively. Stroke unit admission, symptomatic intracranial hemorrhage rates, and in-hospital mortality were not significantly different between periods. Adjusting for mode of arrival, prehospital notification, and onset-to-arrival time, the posttriage period was independently associated with increased tPA use for patients with ischemic stroke presenting through the emergency department (adjusted odds ratio = 2.21; 95% CI, 1.34-3.64). CONCLUSIONS AND RELEVANCE Implementation of a prehospital stroke triage policy in Chicago resulted in significant improvements in emergency medical services use and prenotification and more than doubled intravenous tPA use at primary stroke centers.

The Effect of Alcohol Abuse on the Health Status of Older Adults Seen in the Emergency Department

OBJECTIVE To examine the effect of alcohol abuse on the subsequent health status of elderly patients seen in an emergency department (ED). PATIENTS AND METHODS A sample of 966 patients aged 65 or older who presented to one urban academic ED between the hours of 8 A.M. and 12 midnight was followed for 1 year. A personal interview was administered during the ED visit. Current problem drinkers had a score of 1 or greater on the CAGE questionnaire at ED presentation and drank within the prior 6 months; former problem drinkers had a score of 1 or greater on the CAGE questionnaire at ED presentation and a last drink more than 6 months previously. We used 13 items from the Medical Outcomes Study short form adapted to the ED setting and 6 items from the Index of Activities of Daily Living (ADL) to measure health status. RESULTS In multivariate models for repeated-measures controlling for potential confounding factors, current problem drinkers had worse overall health (parameter estimate beta -3.6; 95% CI -7.1 to -0.04), and former problem drinkers had worse mental health (beta -3.6; CI -6.9 to -0.24) on follow-up. We could find no effect of problem drinking on physical health or social function. CONCLUSIONS Current problem drinking is associated with worse self-perceived health among elderly patients in the year following presentation to an ED. The magnitude of decline in health perception may approximate the effect of having back pain, sciatica, or other musculoskeletal complaints. Elderly former problem drinkers suffer from more severe mental health problems over that same period.

Myocardial Perfusion: Near-automated Evaluation from Contrast-enhanced MR Images Obtained at Rest and during Vasodilator Stress

PURPOSE To develop and validate a technique for near-automated definition of myocardial regions of interest suitable for perfusion evaluation during vasodilator stress cardiac magnetic resonance (MR) imaging. MATERIALS AND METHODS The institutional review board approved the study protocol, and all patients provided informed consent. Image noise density distribution was used as a basis for endocardial and epicardial border detection combined with nonrigid registration. This method was tested in 42 patients undergoing contrast material-enhanced cardiac MR imaging (at 1.5 T) at rest and during vasodilator (adenosine or regadenoson) stress, including 15 subjects with normal myocardial perfusion and 27 patients referred for coronary angiography. Contrast enhancement-time curves were near-automatically generated and were used to calculate perfusion indexes. The results were compared with results of conventional manual analysis, using quantitative coronary angiography results as a reference for stenosis greater than 50%. Statistical analyses included the Student t test, linear regression, Bland-Altman analysis, and κ statistics. RESULTS Analysis of one sequence required less than 1 minute and resulted in high-quality contrast enhancement curves both at rest and stress (mean signal-to-noise ratios, 17±7 [standard deviation] and 22±8, respectively), showing expected patterns of first-pass perfusion. Perfusion indexes accurately depicted stress-induced hyperemia (increased upslope, from 6.7 sec(-1)±2.3 to 15.6 sec(-1)±5.9; P<.0001). Measured segmental pixel intensities correlated highly with results of manual analysis (r=0.95). The derived perfusion indexes also correlated highly with (r up to 0.94) and showed the same diagnostic accuracy as manual analysis (area under the receiver operating characteristic curve, up to 0.72 vs 0.73). CONCLUSION Despite the dynamic nature of contrast-enhanced image sequences and respiratory motion, fast near-automated detection of myocardial segments and accurate quantification of tissue contrast is feasible at rest and during vasodilator stress. This technique, shown to be as accurate as conventional manual analysis, allows detection of stress-induced perfusion abnormalities.

Improving pediatric asthma care through surveillance : The illinois emergency department asthma collaborative

OBJECTIVES. To better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services. METHODS. A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children’s pre-ED, ED, and post-ED experience. RESULTS. At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity. CONCLUSIONS. Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed.

The asthma emergency department visit: treating a crisis in the midst of uncontrolled disease

BACKGROUND Patients with asthma who require emergency department (ED) care are burdened with asthma symptoms, are at risk for hospitalization, and use expensive resources. OBJECTIVE To examine whether an ED-based surveillance system that characterized asthma symptoms and care before, during, and after an ED visit enhances our understanding of the natural history of asthma exacerbations. METHODS This cross-sectional follow-up enrolled 225 adult patients who presented to 1 of 6 Illinois EDs for asthma care. Clinical characteristics before ED presentation, care provided in the EDs, and 1-month follow-up status were assessed by self-administered questionnaire, medical record review, and telephone interview, respectively. RESULTS Persistent asthma symptoms were reported by 85.8% and 84.9% (P = .37) of patients before their ED visit and follow-up call, respectively. For patients with persistent symptoms before the ED visit and follow-up call, 54.4% and 73.8% (P = .02) reported using an inhaled corticosteroid, respectively. Inhaled corticosteroids were recommended for 49.4% of discharged patients with persistent symptoms. Relapse rates for return ED visits and return hospitalizations were 26.4% and 9.6%, respectively. Patients had low asthma-specific and general quality-of-life scores at follow-up. CONCLUSIONS Patients with asthma exacerbations most often had uncontrolled asthma before the ED visit that subsequently deteriorated, temporarily improved with ED treatment, and continued as uncontrolled asthma after the ED visit. Although improvements in care were reported 1 month after the ED visit, opportunities for additional improvement were observed.

Non-invasive assessment of the haemodynamic significance of coronary stenosis using fusion of cardiac computed tomography and 3D echocardiography

Aims Abnormal computed tomography coronary angiography (CTCA) often leads to stress testing to determine haemodynamic significance of stenosis. We hypothesized that instead, this could be achieved by fusion imaging of the coronary anatomy with 3D echocardiography (3DE)-derived resting myocardial deformation. Methods and results We developed fusion software that creates combined 3D displays of the coronary arteries with colour maps of longitudinal strain and tested it in 28 patients with chest pain, referred for CTCA (256 Philips scanner) who underwent 3DE (Philips iE33) and regadenoson stress CT. To obtain a reference for stenosis significance, coronaries were also fused with colour maps of stress myocardial perfusion. 3D displays were used to detect stress perfusion defect (SPD) and/or resting strain abnormality (RSA) in each territory. CTCA showed 56 normal arteries, stenosis <50% in 17, and >50% in 8 arteries. Of the 81 coronary territories, SPDs were noted in 20 and RSAs in 29. Of the 59 arteries with no stenosis >50% and no SPDs, considered as normal, 12 (20%) had RSAs. Conversely, with stenosis >50% and SPDs (haemodynamically significant), RSAs were considerably more frequent (5/6 = 83%). Overall, resting strain and stress perfusion findings were concordant in 64/81 arteries (79% agreement). Conclusions Fusion of CTCA and 3DE-derived data allows direct visualization of each coronary artery and strain in its territory. In this feasibility study, resting strain showed good agreement with stress perfusion, indicating that it may be potentially used to assess haemodynamic impact of coronary stenosis, as an alternative to stress testing that entails additional radiation exposure.

Mask ventilation, hypocapnia, and seizure duration in electroconvulsive therapy

STUDY OBJECTIVE To compare the Mapleson D circuit and the bag-valve-mask device for mask ventilation of patients undergoing electroconvulsive therapy (ECT). DESIGN Cross-over study. SETTING Single-center academic medical center. PATIENTS 18 patients undergoing ECT for major depressive disorder. INTERVENTIONS Patients were randomized to undergo mask ventilation by the Mapleson D circuit or the bag-valve-mask device. MEASUREMENTS End-tidal CO(2), seizure duration, and airway pressure values were recorded. MAIN RESULTS End-tidal CO(2) was significantly lower with the bag-valve-mask device. When compared with the bag-valve-mask device, ventilation with the Mapleson circuit resulted in rebreathing of CO(2) in nearly all patients, shorter expiratory time, and lower pressure ramp slope. CONCLUSIONS Hypocapnia was not associated with longer seizures, and the user-device interaction might affect device performance.

Expanded HIV Testing and Linkage to Care: Conventional vs. Point-of-Care Testing and Assignment of Patient Notification and Linkage to Care to an HIV Care Program

Objective. The University of Chicago Medicine (UCM) led the Expanded Testing and Linkage to Care (X-TLC) program for disproportionately affected populations on the South Side of Chicago. The X-TLC program aimed to expand routine HIV testing to high-prevalence communities with disproportionately affected populations (i.e., minority men and women, men who have sex with men, and intravenous drug users) according to CDC guidelines at multiple clinical sites. Methods. The X-TLC program used standard blood-based laboratory testing vs. point-of-care rapid testing or rapid laboratory testing with point-of-care results notification. Site coordinators and the linkage-to-care coordinator at UCM oversaw testing, test notification, and linkage to care. Results. From February 1, 2011, through December 31, 2013, the X-TLC program completed 75,345 HIV tests on 67,153 unique patients. Of the total tests, 48,044 (63.8%) were performed on patients who self-identified as African American and 6,606 (8.8%) were performed on patients who self-identified as Hispanic. Of the 67,153 patients tested, 395 (0.6%) tested positive and 176 (0.3%) were previously unaware of their HIV-positive status. Seroprevalence was even higher for EDs, where 127 of 12,957 patients tested positive for HIV (1.0% seroprevalence), than for other patient care sites, including for new diagnoses, where 50 of 12,957 patients tested positive for HIV (0.4% seroprevalence). Of the 176 newly diagnosed patients, 166 of 173 (96.0%) patients who were still alive when testing was complete received their test results, and 148 of the 166 patients who were eligible for care (89.0%) were linked to care. Patients linked to X-TLC physicians did well with respect to the continuum of care: 77 of 123 (62.6%) patients achieved HIV viral load of <200 copies/milliliter. Conclusion. Lead organizations such as UCM were able to assist and oversee HIV screening and linkage to care for HIV patients diagnosed at community sites. HIV screening and linkage to care can be accomplished by incorporating standard testing for HIV into routine medical care.

Searching for Staircases: Strengthening the Connections Between the Emergency Department and the Intensive Care Unit

On a fall day in Chicago, a middle-aged man stepped out of a northbound train, appeared to choke, and collapsed. Paramedics arrived within minutes and administered several rounds of defibrillation and intravenous epinephrine. The patient was rapidly transported to an academic medical center, resuscitated in the Emergency Department (ED), and was soon surrounded by a multidisciplinary team of doctors, nurses, and respiratory therapists in the Intensive Care Unit (ICU). This article is protected by copyright. All rights reserved.