Utilizing an emergency medicine stabilization team to provide critical care in a rural health system.

INTRODUCTION: Over the past decade, Emergency Department (ED) patient volumes have increased more than available hospital ICU capacity. This has led to increased boarding and crowding in EDs, requiring new methods of providing intensive care. Many hospitals nationwide have developed ICU boarding mitigation strategies at the hospital and ED level or implemented ED-based resuscitative care units to improve patient care and disposition. However, these have been described in the setting of larger medical centers without broader application to rural, community ED environments. The authors herein have created an ED model utilizing a physician and nurse on-call team to provide improved care to critically ill patients requiring resuscitation when an ICU bed is not immediately available. GOALS: The goal of this paper is to describe a novel approach to providing critical care in a rural health system. A community health system-based resuscitation team named Emergency Medicine Stabilization Team, or EMSTAT, was developed as a mobile team consisting of one emergency physician and one emergency or critical care nurse. The authors present data from the first 12 months of the program including diagnoses, procedures, temporal trends, and lengths of stay. RESULTS: Over the course of twelve months, EMSTAT was contacted for 195 patients and ultimately traveled to bedside for 131 cases. The three most common diagnoses seen were sepsis, respiratory failure, and diabetic emergencies. 99 documented procedures were performed; the most common were central venous catheters, arterial lines, and intubations. 104 patients were admitted to the intensive care unit, while the other 27 were either downgraded to a lower level of care, discharged, transitioned to palliative care, or died. DISCUSSION: Over a twelve-month period, the authors describe a novel rural community-based mobile critical care team. This team demonstrated the ability to quickly arrive at bedside, continue resuscitation, acquire a disposition, and provide individualized critical are. This model serves as a roadmap for developing similar community based-resuscitation programs.

Minimizing cortical disturbance to access ventricular subependymoma - A novel approach utilizing spinal minimally invasive tubular retractor system.

BACKGROUND: Subependymomas are rare benign tumors found primarily in the lateral and fourth ventricles. Patients become symptomatic when the tumor obstructs cerebrospinal fluid pathways. We present a novel minimally invasive technique for lateral ventricular subependymoma resection. CASE DESCRIPTION: A 57-year-old male presented after a period of progressive ataxia, right upper extremity tremor, and syncopal events. Emergent non-contrast computed tomography of the brain demonstrated a lobulated mass in the left lateral ventricle causing moderate-to-severe obstructive hydrocephalus. Emergent ventriculostomy was placed as a temporizing measure. Subsequent magnetic resonance imaging (MRI) illustrated a large benign appearing mass causing obstruction of the left foramen of Monroe. A small craniotomy was performed utilizing previous ventriculostomy twist hole. The left lateral ventricle was accessed through sequential dilation of ventriculostomy tract using a minimally invasive spine surgery tubular system. Tumor was resected en bloc under microscopic assistance. The patient had an excellent outcome with return to baseline mental status and was discharged from the hospital postoperative day 1. Follow-up MRI demonstrated gross total resection of the mass and decreasing lateral ventricle hydrocephalus with minimal cortical disturbance. CONCLUSION: A minimally invasive tubular system approach to ventricular tumors can be utilized to minimize cortical resection and brain retraction. Minimally invasive surgery also has the potential to decrease the length of stay and enhance postoperative recovery.

Stabilisation of a heptamethine cyanine dye by rotaxane encapsulation.

The crystal structure of a cyanine dye rotaxane shows that the cyclodextrin is tightly threaded round the polymethine bridge of the dye; encapsulation dramatically increases the kinetic chemical stability of the radicals formed on oxidation and reduction of the dye, making it possible to observe the rotaxane radical dication by ESR and UV-vis-NIR spectroscopy.

Homo- and hetero-[3]rotaxanes with two pi-systems clasped in a single macrocycle.

Here we present the first synthesis of a [3]rotaxane with two dumbbell components threaded through a single gamma-cyclodextrin macrocycle. This synthesis is carried out in two steps: first one dumbbell is synthesized threaded through the macrocycle to give a [2]rotaxane, then a second dumbbell is synthesized through the remaining cavity of the [2]rotaxane. We have synthesized a hetero- [3]rotaxane with one stilbene and one cyanine dye threaded through gamma-cyclodextrin, which exhibits quantitative energy transfer between the two encapsulated dyes. The stilbene [2]rotaxane intermediate in this synthesis has a remarkably high affinity for suitably shaped hydrophobic guests in aqueous solution, facilitating the synthesis of [3]rotaxanes and suggesting possible applications in sensors.