Utility of transesophageal echocardiography in the identification and treatment of occult mechanisms of cerebral infarction.

Cryptogenic stroke comprises approximately 25% of all cases of ischemic stroke. The diagnostic evaluation of these patients remains a challenge in clinical practice. Transesophageal echocardiography (TEE) has been shown to have superior diagnostic accuracy in identifying potential cardioembolic sources of ischemic stroke when compared to transthoracic echocardiography (TTE). However, there has been inconsistent data on the management implications of these new cardiac findings. The addition of TEE to the comprehensive stroke evaluation will better identify potential cardiac sources of embolism (CSE) and will result in significant management changes. A prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015-8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Of the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria and the median age was 53 (IQR 46-57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n = 29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. The addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes.

Cardiogenic shock in thyroid storm: A biventricular impella (Bi-Pella) approach.

The use of biventricular impella support in patients with acute, reversible causes of biventricular cardiogenic shock may play a role in shortening the time to recovery and preventing significant negative outcomes such as renal or hepatic failure.

Frequency of provision of CPAP in the inpatient setting: an observational study : "CPAP provision in the inpatient setting".

BACKGROUND: Little is known about the rates of provision of CPAP in inpatient settings. A single prior "data mining" study using diagnostic and procedural codes concluded that 6% of people with sleep apnea receive CPAP when in the hospital. The purpose of this study is to reexamine the frequency with which people who have an established diagnosis of sleep apnea receive therapy for it when they are admitted to the hospital for other reasons. METHODS: A retrospective cohort study of 195 people with an existing diagnosis of obstructive sleep apnea admitted to a tertiary medical center from March 2009-July 2009. A logistic regression analysis was used to determine relative risk for provision of CPAP therapy controlling for the following variables: admission diagnosis, unit of admission (medical/surgical/psychiatric/pediatrics), length of stay, comorbidities, and patient characteristics (age/ race/ gender). RESULTS: Twenty-six percent of people with an established diagnosis of OSA received CPAP therapy during their hospitalization. In an additional 10%, therapy was offered but not implemented. Of the variables considered, only admission diagnosis of obesity (n = 3) was associated with an increased likelihood of receiving CPAP. CONCLUSIONS: This rate of provision of CPAP to hospitalized patients, while low at 26%, is much higher than a previous study on this topic that estimated frequency of use of CPAP strictly linking diagnostic codes for OSA and procedural codes for CPAP.