Ultrasound of Optic Nerve Sheath Diameter and Stroke Outcomes.

We aimed at utilizing ocular ultrasound to determine its utility in predicting outcomes among stroke patients. DESIGN: Single-center prospective observational study. SETTING: Emergency department and ICUs. PATIENTS: Patients suspected of stroke. INTERVENTIONS: None. MEASURES AND MAIN RESULTS: Bilateral optic nerve sheath diameter was measured on arrival and within the first 2 days of admission. Outcomes were inpatient survival, Cerebral Performance Category, and modified Rankin Scale at 3 and 6 months. Analysis was conducted using descriptive statistics, paired t test, chi-square test. Eighty-six patients were enrolled with ischemic or hemorrhagic stroke. Mean age was 67.2 years (± 15 yr), and 54.7% of patients were male. There was no difference between left and right eye measurements (p = 0.467 and p = 0.903, respectively) or between longitudinal and transverse measurements (transverse p = 0.163 and longitudinal p = 0.270). Mean optic nerve sheath diameter differed in patients who survived versus died prior to discharge in both ischemic (0.53 vs 0.58 cm; p = 0.009) or hemorrhagic stroke (0.57 vs 0.62 cm; p = 0.019). For every 0.1 cm increase in optic nerve sheath diameter, odds ratio for death were 4.2 among ischemic stroke (95% CI, 1.32-13.64; p = 0.015), and odds ratio 6.2 among ischemic or hemorrhagic patients (95% CI, 1.160-33.382; p = 0.033). Increased optic nerve sheath diameter correlated (r = 0.44; p < 0.0001) with poor functional outcomes measured as modified Rankin Scale scores of 3-6 at 6 months. CONCLUSIONS: Elevations in optic nerve sheath diameter were associated with increased inhospital mortality and poor functional outcome at 6 months. Optic nerve sheath diameter may serve as a noninvasive marker of inhospital mortality and functional outcome. Further multicenter prospective trials for evaluating and treating optic nerve sheath diameter in ischemic and hemorrhagic strokes are warranted.

Comparison of 3 Symptom Classification Methods to Standardize the History Component of the HEART Score.

OBJECTIVES: The History, Electrocardiography, Age, Risk factors, Troponin (HEART) score enables rapid risk stratification of emergency department patients presenting with chest pain. However, the subjectivity in scoring introduced by the history component has been criticized by some clinicians. We examined the association of 3 objective scoring models with the results of noninvasive cardiac testing. METHODS: Medical records for all patients evaluated in the chest pain center of an academic medical center during a 1-year period were reviewed retrospectively. Each patient's history component score was calculated using 3 models developed by the authors. Differences in the distribution of HEART scores for each model, as well as their degree of agreement with one another, as well as the results of cardiac testing were analyzed. RESULTS: Seven hundred forty nine patients were studied, 58 of which had an abnormal stress test or computed tomography coronary angiography. The mean HEART scores for models 1, 2, and 3 were 2.97 (SD 1.17), 2.57 (SD 1.25), and 3.30 (SD 1.35), respectively, and were significantly different (P < 0.001). However, for each model, the likelihood of an abnormal cardiovascular test did not correlate with higher scores on the symptom component of the HEART score (P = 0.09, 0.41, and 0.86, respectively). CONCLUSIONS: While the objective scoring models produced different distributions of HEART scores, no model performed well with regards to identifying patients with abnormal advanced cardiac studies in this relatively low-risk cohort. Further studies in a broader cohort of patients, as well as comparison with the performance of subjective history scoring, is warranted before adoption of any of these objective models.

The incidence and significance of acute kidney injury following emergent contrast administration in patients with STEMI and stroke.

The authors have investigated the incidence of acute kidney injury (AKI) and short-term mortality following an activated STEMI and stroke alert at a tertiary referral and academic center. A single center, retrospective chart review of STEMI and stroke activation patients from January 2010 to March 2012. Data was collected and reviewed from an institutional database following IRB-approval. Inclusion criteria were STEMI patients taken for cardiac catheterization, excluding patients receiving hemodialysis due to end-stage renal disease (ESRD). Primary outcome measures were the incidence of AKI using the RIFLE criteria and short-term mortality. 745 patients were included (488 stroke, 257 STEMI). The median age was 65, and 39 % were female. Overall inpatient mortality was 7.0 %. 5.4 % (40/745) of patients experienced some degree of AKI (8.6 % of STEMI, 3.7 % of stroke patients). Overall, 30 % of patients with AKI died during their hospitalization. AKI was associated with a 7.1-fold (95 % CI 3.4-15.1) increase in mortality in the entire cohort. Among STEMI patients, AKI was associated with a 66.6-fold (95 % CI 12.9-343.4) increase in mortality. These findings follow similar trends published among critically ill patients with AKI. The risk of death with concomitant AKI in this hospital population is significant and deserves future study. Early recognition and awareness in the emergency department is paramount to the patient's survival. Future studies should focus on modalities to improve early recognition and preventative therapies.

An outbreak of acute delirium from exposure to the synthetic cannabinoid AB-CHMINACA.

BACKGROUND: Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement. RESULTS: Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product. DISCUSSION: The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life-threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak. CONCLUSION: A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures.

Evaluation of healthcare use trends of high-risk female intimate partner violence victims.

INTRODUCTION: Practitioners need more information about intimate partner violence (IPV) victims' healthcare use trends. We used a novel data-linkage method and complaint categorization allowing us to evaluate IPV victims healthcare use trends compared to the date of their victimization. METHODS: This was a retrospective case series using data-linking techniques cross-referencing databases of Medicaid-eligible women between the ages of 16 and 55 years, an IPV Case Database for 2007 and the Florida State Agency for Healthcare Administration, which tracks hospital inpatient, ambulatory and emergency department (ED) use within the State of Florida. We analyzed resulting healthcare visits 1.5 years before and 1.5 years after the women's reported IPV offense. Using all available claims data a 'complaint category' representing categories of presenting chief complaints was assigned to each healthcare visit. Analysis included descriptive statistics, correlation coefficients between time of offense and visits, and a logistic regression analysis. RESULTS: The 695 victims were linked with 4,344 healthcare visits in the four-year study period. The victims were young (46% in the 16-25 age group and 79% were younger than 35). Healthcare visits were in the ED (83%) rather than other healthcare sites. In the ED, IPV victims mostly had complaint categories of obstetrics and gynaecology-related visits (28.7%), infection-related visits (18.9%), and trauma-related visits (16.3%). ED use escalated approaching the victim's date of offense (r=0.59, p<0.0001) compared to use of non-ED sites of healthcare use (r=0.07, p=0.5817). ED use deescalated significantly after date of reported offense for ED visits (r=0.50, p<0.0001) versus non-ED use (r=0.00, p=0.9958). The victims' age group more likely to use the ED than any other age group was the 36-45 age group (OR 4.67, CI [3.26-6.68]). CONCLUSION: IPV victims use the ED increasingly approaching their date of offense. Presenting complaints were varied and did not reveal unique identifiers of IPV victims. This novel method of database matching between claims data and government records has been shown to be a valid way to evaluate healthcare utilization of at-risk populations.

The value of validated vulnerability data for conservation planning in rapidly changing landscapes.

Data needed for informed conservation prioritization are generally greater than the data available, and surrogates are often used. Although the need to anticipate threats is recognized, the effectiveness of surrogates for predicting habitat loss (or vulnerability) to land-use change is seldom tested. Here, we compared properties of two different vulnerability surrogates to validated vulnerability-validated prediction of habitat conversion based on a recent assessment of land-use change. We found that neither surrogate was a particularly effective predictor of vulnerability. Importantly, both surrogates performed poorly in places most imminently threatened with habitat conversion. We also show that the majority of areas protected over the last two decades have low vulnerability to the most active threatening process in this biome (habitat conversion). The contrary patterns of vulnerability and protection suggest that use of validated vulnerability would help to clarify protection needs, which might lead to the improvement of conservation decisions. Our study suggests the integration of validated vulnerability into conservation planning tools may be an important requirement for effective conservation planning in rapidly changing landscapes. We apply our results to discuss the practical considerations and potential value of incorporating validated vulnerability into conservation planning tools both generally and in the context of New Zealand's indigenous grasslands.