Rahul Damani

Variability in Carotid Endarterectomy Practice Patterns Within a Metropolitan Area

Background and Purpose— Previous clinical studies have suggested that patients with carotid stenosis with high surgical risk features may fare better with carotid artery stenting or aggressive medical therapy. The extent to which carotid endarterectomy is still being performed in this group of patients is unclear. Methods— A retrospective audit was performed among 4 hospitals over a 2-year period. The proportion of high surgical risk patients was compared and the in-hospital stroke, myocardial infarction, and death rates were compared among conventional and high surgical risk patients. Results— Three hundred thirty-five carotid endarterectomy operations were performed (63% asymptomatic) with 37.9% being high surgical risk subjects. The stroke, myocardial infarction, and death rate was 4.6% in conventional risk subjects and 10.2% in high surgical risk patients (P<0.05). The only hospital with multidisciplinary carotid conferences had the lowest proportion of carotid endarterectomy operations in asymptomatic patients. Conclusions— A substantial proportion of carotid endarterectomy operations are performed in patients with high surgical risk features. These patients experienced a 2-fold increase in major in-hospital complications, raising doubts about whether they benefit from carotid surgery. The use of preintervention multidisciplinary conferences may improve patient safety.

Emotional intimacy predicts condom use: findings in a group at high sexually transmitted disease risk.

Previous studies have reported an inverse relationship between condom use and emotional intimacy. The aim of this study was to determine the relationship between condom use and emotional intimacy. The study was a gonorrhoea case-comparison study with the samples being drawn from public health clinics (cases) and select bars/nightclubs (places) of Houston, TX (n = 215). Data were collected by questionnaires administered on a laptop computer. The majority of respondents were African-American (97.7%), women (69.3%) and had either high school or GED education (72.6%). Condom use with the last sexual partner was analysed along with intimacy with that partner assessed on a 3-point scale. Analysis showed that higher intimacy was related to greater condom use which was significant in men but not in women. In conclusion, these data were opposite to those of previous studies, which showed an inverse relationship between condom use and emotional intimacy. We hypothesize that in a high-risk environment, people exert more effort in protecting those they feel closer to. These data suggest a need to further explore the complex relationship between emotional intimacy and condom use.

Secondary Stroke Prevention in Nonvalvular Atrial Fibrillation.

Abstract Approximately 750,000 US adults per year experience a stroke. On average, the annual risk for future ischemic stroke (secondary stroke) after an initial ischemic stroke or transient ischemic attack is approximately 3% to 4%. Cardioembolic strokes account for 20% to 25% of all strokes, with nonvalvular atrial fibrillation (NVAF) considered one of the main sources of embolism; this explains up to half of all cardioembolic strokes. We present the risk factors for stroke in NVAF, risk stratification, a diagnosis of NVAF, and treatment and prevention of stroke in NVAF. We reviewed the literature by performing a PubMed search of articles focusing on secondary stroke prevention in NVAF. This review examines the findings of major clinical trials and society guidelines for secondary stroke prevention in NVAF and presents a cost-effectiveness analysis.

A brief history of acute stroke care

Stroke is leading cause of disability and fifth leading cause of mortality in the US. Approximately 800,000 stroke occurs in the US each year which translates roughly in one stroke every 40 seconds [1]. Not only stroke is an important healthcare burden but with estimated direct and indirect cost of stroke care over

Vertical upbeat nystagmus with isolated acute middle cerebellar peduncle stroke

100 billion a year it is also an economic one. Despite the magnitude of problem there was therapeutic nihilism for patients with acute ischemic stroke for centuries. However, in 1995 a landmark NINDS tissuetype plasminogen activator (tPA) trial [2] created paradigm shift in management of acute ischemic stroke. This randomized controlled trial showed tPA improved functional outcome at 90 days in acute stroke with Number Needed to Treat (NNT) of 7.7. Since then there have been multiple randomized controlled trial including ECASS III which showed efficacy of tPA up to 4.5 hours from symptom onset albeit at higher NNT of 13.7. A 2014 individual patient level meta-analysis of all tPA randomized trials showed efficacy of tPA in 04.5 hour time window, irrespective of age and severity of stroke but with strong relationship with treatment time [3]. However, given small therapeutic window for treatment only a fraction of eligible patients with acute ischemic stroke receive tPA. There is room for individual (hospital) and system level (regional, county, state and national) improvements to maximize the benefits of tPA, by giving it to more eligible patients and by giving it faster. Such improvements at individual hospital level can and has been achieved by creating a protocol based approach of early identification and treatment of acute stroke patients, multidisciplinary stroke teams, education and awareness among EMS & emergency nurses, mobile stroke units and establishing telemedicine/tele-stroke services for small rural hospital, however, similar improvement at system level has been elusive. Need of hour is to develop simple, novel, effective, cost neutral, easy to implement intervention which would not only increase systemic thrombolysis rate for eligible stroke patients but also reduce their door to needle (DTN) times on a larger scale. One of such example comes out of Southeast Texas study [4]. This regional intervention study was designed to investigate effect of un-blinding data on tPA administration and sharing data with CEO of 26 participating hospital of Southeast Texas Regional Advisory Council (SETRAC). Study showed that simple Editorial

Clinical Validation of a Transcranial Doppler-Based Noninvasive Intracranial Pressure Meter: A Prospective Cross-Sectional Study

A 68-year-old female with diabetes mellitus, hypertension, hyperlipidemia presents with hypertensive urgency, severe nausea, vomiting, and visual impairment. Initial blood pressure was 236/110 mmHg. She had a Glasgow Coma Scale of 15 and National Institute of Health Stroke Scale (NIHSS) of 3 (1 gaze impairment, 1 face weakness and 1 sensory loss). Neurological examination was significant for binocular vertical diplopia in all directions of gaze, worse on far gaze. She also had left lateral rectus weakness, left skew deviation, right hypertropia and a characteristic vertical upbeat nystagmus (left eye more than right eye), which was mostly evident in up and leftward gaze (Video 1). Routine laboratory testing for complete blood count, basic metabolic panel, and cardiac enzymes was unremarkable except for blood glucose of 260. Head computed tomography scan showed no acute abnormality. Brain magnetic resonance imaging scan (Figure 1) demonstrated an acute infarct in the medial aspect of left middle cerebellar peduncle. Her remaining workup, including magnetic resonance angiogram of head and neck and cardiac echo was unremarkable. The etiology of her ischemic stroke were thought to be related to small vessel disease.