Acute neurological care in north-east Germany with telemedicine support (ANNOTeM): protocol of a multi-center, controlled, open-label, two-arm intervention study.

BACKGROUND: Both diagnosis and treatment of neurological emergencies require neurological expertise and are time-sensitive. The lack of fast neurological expertise in regions with underserved infrastructure poses a major barrier for state-of-the-art care of patients with acute neurological diseases and leads to disparity in provision of health care. The main purpose of ANNOTeM (acute neurological care in North East Germany with telemedicine support) is to establish effective and sustainable support structures for evidence based treatments for stroke and other neurological emergencies and to improve outcome for acute neurological diseases in these rural regions. METHODS: A "hub-and-spoke" network structure was implemented connecting three academic neurological centres ("hubs") and rural hospitals ("spokes") caring for neurological emergencies. The network structure includes (1) the establishment of a 24/7 telemedicine consultation service, (2) the implementation of standardized operating procedures (SOPs) in the network hospitals, (3) a multiprofessional training scheme, and (4) a quality management program. Data from three major health insurance companies as well as data from the quality management program are being collected and evaluated. Primary outcome is the composite of first time of receiving paid outpatient nursing care, first time of receiving care in a nursing home, or death within 90 days after hospital admission. DISCUSSION: Beyond stroke only few studies have assessed the effects of telemedically supported networks on diagnosis and outcome of neurological emergencies. ANNOTeM will provide information whether this approach leads to improved outcome. In addition, a health economic analysis will be performed. STUDY REGISTRATION: German Clinical Trials Register DRKS00013067, date of registration: November 16 th, 2017, URL: http://www.drks.de/DRKS00013068.

[Appropriate treatment of acute stroke at all times and in all places : Organizational concepts and new approaches]. / Richtige Therapie des akuten Schlaganfalls zu jeder Zeit und an jedem Ort : Organisationskonzepte und neue Ansätze.

Stroke is one of the most common neurological diseases in acute care. The introduction of new organizational concepts in the rescue chain and in acute inpatient services can significantly reduce time to treatment and patients can receive specific therapeutic options that have been shown to improve acute stroke prognosis. This review provides an overview of organizational structures that lead to improved medical care and outlines the evidence-based therapeutic options. This is intended to give the reader a decision support on provision of specific treatment in acute ischemic stroke. The almost simultaneous proof of effectiveness of mechanical thrombectomy for targeted patient populations in five randomized trials has challenged the organization of stroke care. This provides a good example of how an optimized interplay within the rescue chain from emergency services via community hospitals to referral centers with intervention facilities can ensure access to this novel treatment for as many patients as possible. For the limited time span between onset of symptoms and start of treatment, creative but nevertheless well-standardized concepts have emerged that lead to measurable therapeutic success. It has become an urgent challenge to create sustainable regional infrastructures that allow access to appropriate treatment for all patients.

[Mobile CT: technical aspects of prehospital stroke imaging before intravenous thrombolysis]. / CT im Notarztwagen: technische Aspekte der prähospitalen radiologischen Schlaganfalldiagnostik vor systemischer Thrombolyse.

PURPOSE: To reduce the time from symptom onset to treatment with tissue plasminogen activator (tPA) in ischemic stroke, an ambulance was equipped with a CT scanner. We analyzed process and image quality of CT scanning during the pilot study regarding image quality and safety issues. MATERIALS AND METHODS: The pilot study of a stroke emergency mobile unit (STEMO) ran over a period of 12 weeks on 5 weekdays from 7a.m. to 6:30 p.m. A teleradiological service for the justifying indication and reporting was established. The radiographer was responsible for the performance of the CT scan on the ambulance. 64 cranial CT scans and 1 intracranial CT angiography were performed. We compared times from ambulance alarm to treatment decision (time of last brain scan) with a cohort of 50 consecutive tPA treatments before implementation of STEMO. RESULTS: 62 (95%) of the 65 scans performed had sufficient quality for reading. Technical quality was not optimal in 45 cases (69%) mainly caused by suboptimal positioning of patient or eye lens protection. Motion artefacts were observed in 8 exams (12%). No safety issues occurred for team or patients. 23 patients were treated with thrombolysis. Time from alarm to last CT scan was 18 minutes shorter than in the tPA cohort before STEMO implementation. CONCLUSION: A teleradiological support for primary stroke imaging by CT on-site is feasible, quality-wise of diagnostic value and has not raised safety issues.

The utility of PEG3350 without electrolytes for 2-day colonoscopy preparation in children.

OBJECTIVES: Successful colonoscopy preparation requires a method which is easy to administer. Simplifying this technique would be useful for adult and pediatric gastroenterologists. Most cleanout agents are not well tolerated by children. Polyethylene glycol without electrolytes (PEG3350 without electrolytes) has been used for constipation and bowel cleanout, but has not been studied as 2-day preparation for colonoscopy in children. This study evaluates the dosing, effectiveness and satisfaction with PEG3350 without electrolytes as a 2-day cleanout for colonoscopy preparation in children. METHODS: Parents of patients aged 5 years or older undergoing colonoscopies were approached for participation. All caretakers received standard instructions with a suggested food handout and a diary to track the doses of PEG3350 administered and to document other adjunct measures (suppository, enema). On the procedure day, parents and children completed appropriate satisfaction questionnaires. Post procedure, the physician rated the visualization of the mucosa. A pediatric gastroenterologist investigator and a second blinded pediatric gastroenterologist assessed the effectiveness using standard procedure photos. RESULTS: 30 patients aged 5-16 years were recruited (15 males, 15 females). The majority of parents and children reported being "very satisfied" or "satisfied" with the preparation. The preparation was rated by the principal investigator and independent pediatric gastroenterologist as effective in all cases. The mean number of doses was 4.7 on Day 1 and 4.9 on Day 2. The average dose given was 1.90 g/kg/day. CONCLUSION: PEG3350 without electrolytes appears to be safe, effective, and well tolerated as a 2-day clean out for colonoscopy preparation in children with an average dose of 1.90 g/kg/day.

Raman spectroscopy on surfacted ferrofluids in a magnetic field.

We investigated the effect of an external magnetic field up to 0.25 T on the Raman spectra of surfacted ferrofluids with various magnetic-particle concentrations. With increasing magnetic field the Raman spectra, which display the characteristic broad bands associated with vibrations of surfactant and water molecules, show a pronounced decrease in intensity in the range up to 50 mT. We interpret this behavior as due to an increase of the local particle concentration in the magnetic fluid. At larger fields a magnetic excitation with an intensity growing in proportion to the magnetization of the ferrofluid becomes apparent at around 4400 cm(-1). We consider both effects as evidence for the formation of a solid structure by the magnetic nanoparticles in the presence of a magnetic field.

A randomized comparison of helium-oxygen mixture (Heliox) and racemic epinephrine for the treatment of moderate to severe croup.

OBJECTIVE: To compare the additive effect of a helium-oxygen mixture (Heliox) or racemic epinephrine (RE) on croup scores (CSs) in children with moderate to severe croup treated with humidified oxygen and steroids. Design. A prospective, randomized, double-blind trial. SETTING: Emergency department and pediatric intensive care unit of an urban level I trauma center. PARTICIPANTS: Randomly assigned, consecutive children ages 6 months to 3 years presenting with moderate to severe croup (CS: >/=5). Interventions. After cool humidified oxygen and 0.6 mg/kg of intramuscular dexamethasone, patients were randomized to receive either Heliox or RE. Vital signs, oxygen saturation, and CSs were recorded at regular intervals. OUTCOME/ANALYSIS: Reductions in CSs were compared using repeated-measures analysis of variance. RESULTS: Thirty-three patients were enrolled. Three were excluded because of protocol violations, and 1 was excluded because of lack of documentation, leaving 29 patients for final analysis. The average age was 24.2 months, 20 were male (68.8%). Both Heliox and RE were associated with improvement in CSs over time. There were no significant differences in mean CS, oxygen saturation, respiratory rate, or heart rate between groups at baseline or at the end of the treatment period. CONCLUSION: In patients with moderate to severe croup, the administration of Heliox resulted in similar improvements in CS compared with patients given RE.

Cocaine-associated chest pain: how common is myocardial infarction?

OBJECTIVE: Prior studies addressing the incidence of acute myocardial infarction (AMI) in patients with cocaine-associated chest pain have found divergent results. Previous prospective studies, which found approximately a 6% incidence of AMI, have been criticized for selection bias. This study sought to determine the rate of AMI in patients with cocaine-associated chest pain. METHODS: All patients seen in an urban university-affiliated hospital between July 1996 and February 1998 were identified by ICD-9 medical records search for cocaine use and chest pain/ acute coronary syndromes. In this system, all faculty admit all patients with cocaine-associated chest pain for at least 23-hour observation periods. Data collected included demographics, medical and cocaine use history, presenting characteristics, hospital course, cardiovascular complications, and diagnostic tests using a 119-item closed-question data instrument with high interrater reliability. The main outcome measure was AMI according to World Health Organization (WHO) criteria. RESULTS: There were 250 patients identified with a mean age of 33.5 +/- 8.5 years; 77% were male; 84% were African American. Of 196 patients tested, 185 had cocaine or cocaine metabolites in the urine (94%). The incidence of cardiac risk factors were: hypercholesterolemia, 8%; diabetes, 6%; family history, 34%; hypertension, 26%; tobacco use, 77%; prior MI, 6%; and prior chest pain, 40%. Seventy-seven percent admitted to cocaine use in the preceding 24 hours: crack, 85%; IV, 2%; nasal, 6%. Twenty-five patients (10%) had electrocardiographic evidence of ischemia. A total of 15 patients experienced an AMI (6%; 95% CI = 4.1% to 8.9%) using WHO criteria. Complications were infrequent: bradydysrrhythmias, 0.4%; congestive heart failure, 0.4%; supraventricular tachycardia, 1.2%; sustained ventricular tachycardia, 0.8%. CONCLUSION: The incidence of AMI was 6% in patients with cocaine-associated chest pain. This result is identical to that found in prior prospective studies.

Rectal methohexital sedation for computed tomography imaging of stable pediatric emergency department patients.

OBJECTIVE: Rapid onset of sleep, brief duration of action, and ease of administration are properties that make rectal methohexital (MXT) an attractive choice for sedating stable pediatric emergency department (ED) patients for computed tomography (CT) imaging. METHODOLOGY: One hundred stable patients between 3 and 60 months of age who presented to any of 3 participating EDs and required sedation to undergo CT scanning were given 25 mg/kg of rectal MXT approximately 15 minutes before their imaging. Vital signs and oxygen saturation were recorded at regular intervals. Data collected included indication for CT imaging, time to achieve sleep, time to reach discharge criteria, adequacy of sedation, adverse effects, and parental satisfaction. RESULTS: Ninety-five percent of the patients were adequately sedated with rectal MXT. It took an average of 8 minutes to achieve full sedation and the duration of action averaged 79.3 minutes. Ten percent had transient side effects, but all recovered completely. None required intubation. Parental satisfaction was 90%. CONCLUSION: Rectal MXT compares favorably to other methods of nonintravenous sedation for CT scanning of stable pediatric ED patients in terms of rapidity of onset and reliability but does cause a significant amount of transient respiratory depression. Its use requires careful monitoring of oxygen saturation and should be used only in a setting where physicians skilled in airway management are present. If these requirements are met, it may be a good choice for the relatively noninvasive sedation of pediatric ED patients undergoing painless but anxiety-provoking procedures.methohexital, pediatric procedure sedation, rectal administration, computerized tomography imaging.

A combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department patients.

OBJECTIVE: To describe the clinical characteristics of a combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department (ED) patients. METHODS: This was a prospective, observational trial, conducted in the ED of an urban level II trauma center. Patients > or = 18 years of age requiring procedural sedation and analgesia were eligible, and enrolled patients received 0.07 mg/kg of intravenous midazolam followed by 2 mg/kg of intravenous ketamine. Vital signs were recorded at regular intervals. The adequacy of sedation, adverse effects, patient satisfaction, and time to reach discharge alertness were determined. Descriptive statistics were calculated using statistical analysis software. RESULTS: Seventy-seven patients were enrolled. Three were excluded due to protocol violations, three due to lack of documentation, and one due to subcutaneous infiltration of ketamine, leaving 70 patients for analysis. The average age was 31 years, and 41 (59%) were female. Indications for procedural sedation and analgesia included abscess incision and drainage (66%), fracture/joint reduction (26%), and other (8%). The mean dose of midazolam was 5.6 +/- 1.4 mg and the mean dose of ketamine was 159 +/- 42 mg. The mean time to achieve discharge criteria was 64 +/- 24 minutes. Five patients experienced mild emergence reactions, but there were no episodes of hallucinations, delirium, or other serious emergence reactions. Eighteen (25%) patients recalled dreaming while sedated; twelve (17%) were described as pleasant, two (3%) unpleasant, three (4%) both pleasant and unpleasant, and one (1%) neither pleasant nor unpleasant. There were four (6%) cases of respiratory compromise, two (3%) episodes of emesis, and one (1%) case of myoclonia. All of these were transient and did not result in a change in the patient's disposition. Only one (1%) patient indicated that she was not satisfied with the sedation regimen. CONCLUSIONS: The combination of midazolam and ketamine provides effective procedural sedation and analgesia in adult ED patients, and appears to be safe.

Adolescent injury in the emergency department: opportunity for alcohol interventions?

STUDY OBJECTIVE: Alcohol, the most commonly used substance among adolescents, is frequently associated with injury. Little is known regarding the drinking characteristics of injured adolescents. Such data are critical for developing emergency department interventions to decrease alcohol-related injury among adolescents. We sought to describe the drinking characteristics of injured adolescents and to describe the relationship of injury severity and mechanisms with drinking characteristics. METHODS: This study was a prospective cohort study performed in a university hospital (sampled May 1, 1995, to July 15, 1995) and a large urban teaching hospital (sampled May 1, 1996, to August 1, 1996). The participants were aged 12 to 20 years, presenting within 6 hours of an injury. We performed a saliva alcohol test and self-administered questionnaire. Age, sex, E-code, injury severity score (ISS), and ED disposition were recorded. An alcohol frequency/quantity index was calculated. Descriptive statistics and 95% confidence intervals were calculated. RESULTS: Two hundred sixty-three patients with a mean age of 17 years and a mean ISS of 2.1 (SD 3.5) were recruited. One hundred fifty-two (50%) were males, and 33 (13%) were admitted. Ten (4%) patients had a positive saliva alcohol test response. On average, within the last year, these adolescents had 1.7 adverse alcohol consequences. Sixty percent drank in unsupervised settings, and 36% reported drinking 5 or more drinks in a row. CONCLUSION: Alcohol use/misuse is a substantial problem among injured adolescents regardless of severity or mechanism of injury. ED physicians should consider screening/intervention or primary prevention of alcohol problems for all injured adolescents.

Conflicts of interest in emergency medicine.

Conflicts of interest have become prevalent in the daily practice of emergency medicine because physician relationships with patients, hospitals, insurers, and the medical industry have become increasingly complex. Conflict resolution requires both physician recognition and available resources to avoid engaging in a conflict that may jeopardize public confidence regarding patient advocacy. This article analyzes the essential characteristics of several conflicts of interest that apply to emergency physicians, and reviews rational ways to systematically avoid or curtail them.

Resource utilization in the emergency department: the duty of stewardship.

As the pool of available health care resources continues to evaporate, emergency physicians will be increasingly required to guard against the provision of expensive, unnecessary, and marginally beneficial care. This article proposes that emergency physicians embrace the ethic of prudent resource stewardship to ensure the continued availability of emergency services to all who need them. When making resource allocation decisions, emergency physicians must consider the likelihood, magnitude, and duration of benefits to patients, the urgency of the condition, and the cost and burdens of treatment to patients, payers, and society. These considerations go beyond professional duties to individual patients and suggest that ignoring the burdens of emergency department microallocation decisions is socially and morally irresponsible.

The work of the American emergency physician.

The organisation of the American emergency health care system has changed rapidly during recent years, but it remains very different to the system in the United Kingdom. American emergency departments are organised around an attending physician based service, rather than a consultant led service. As a result, the work of the American emergency physician differs considerably from that of the United Kingdom A&E consultant. The problems associated with working in an attending physician based service include antisocial hours of work, sleep deprivation, decreased job satisfaction, and "burn out," all in the context of a relatively hostile medicolegal climate. Although there appear to be no easy answers to some of these problems, the A&E specialist should be aware of the potential future difficulties for A&E medicine as it develops within the United Kingdom.

A transatlantic comparison of training in emergency medicine.

The system of training in accident and emergency (A&E) medicine in the United Kingdom is at a critical and much earlier stage of development than in the United States. Transatlantic comparison offers the opportunity to explore possible ways of improving training in the United Kingdom. Comparison revealed deficiencies in the UK training system in the following: prehospital care training, formal theoretical teaching, close supervision in a clinical setting, and in-service training examinations. Implementation of measures designed to address these deficiencies would enhance UK training in A&E medicine.

Quantitative study of ductal breast cancer--patient targeted prognosis: an exploration of case base reasoning.

Current analytic methodologies allow the extraction, even from small tumor masses, of extensive information on the biologic characteristics of malignant lesions, such as tumor aggressivity, metastatic potential, drug resistance, and host interactions. Clinical practice now offers a wide range of therapeutic strategies. Information technological advances offer the opportunity to refer to very large data bases of patient anamnestic data, response to treatment and clinical outcome. There is a need to formulate therapy and prognosis for each individual case. Case based reasoning is a knowledge based methodology where the outcome for complex situations can be predicted by referring to a large data base of cases of known outcomes. The preliminary data obtained from this study suggest that case based reasoning may offer a promising approach to individual targeted prognosis.

Giant urethral calculus: a rare cause of acute urinary retention.

We present a case of a 98-yr-old woman with acute urinary retention secondary to a large urethral calculus. This is a unique cause of obstructive uropathy for several reasons. First, urethral calculi are extremely rare in American-born Caucasian females. Second, urethral stones in females are nearly always associated with underlying genitourinary pathology; however, subsequent work up failed to reveal any strictures, diverticula, or related processes that may have predisposed this patient to urethral calculus formation. The epidemiology, pathogenesis, clinical presentation, and emergency management of large urethral calculi are reviewed.

Stereospecific Preparation of an Excitatory Amino Acid Antagonist with d-Hydantoinase from Agrobacterium tumefaciens as a Biocatalyst.

Extracts of Agrobacterium tumefaciens were used to mediate the stereospecific conversion of a racemic hydantoin to a carbamyl d-amino acid derivative, which is a precursor to (2R,4R,5S)-2-amino-4,5-(1,2-cyclohexyl)-7-phosphonoheptanoic acid (ACPA). ACPA has therapeutic value as an excitatory amino acid antagonist.