Evaluation of Post-thrombolytic Events to Determine Appropriate ICU Monitoring Duration for Patients with Ischemic Stroke.

BACKGROUND: Standard treatment for eligible patients presenting with acute ischemic stroke (AIS) is thrombolysis with tissue plasminogen activators alteplase or tenecteplase. Current guidelines recommend monitoring patients in an intensive care unit (ICU) for 24 h after thrombolytic therapy. However, recent studies have questioned the need for prolonged ICU monitoring. This retrospective cohort study aims to identify potential candidates for early transition to a lower level of care by assessing risk factors for neurological deterioration, symptomatic intracranial hemorrhage (sICH), or need for ICU intervention within 24 h post-thrombolysis. METHODS: This retrospective cohort study included adult patients 18 years and older with AIS who received thrombolysis. Patients were excluded if they were transferred to another facility, if they were transitioned to comfort care or hospice care within 24 h, or if they lacked imaging and National Institutes of Health Stroke Scale (NIHSS) score data. The primary end point was incidence of sICH between 0-12 and 12-24 h. Secondary end points included the need for ICU intervention and rates of neurological deterioration. RESULTS: The analysis included 204 patients who received the full dose of alteplase. Among them, ten patients (4.9%) developed sICH, with the majority (n = 7) occurring within 12 h post-thrombolysis. Sixty-two patients required ICU interventions within 12 h compared with four patients after 12 h. Twenty-four patients had neurological deterioration within 12 h, and seven patients had neurological deterioration after 12 h. Multivariable analysis identified mechanical thrombectomy and increased blood pressure at presentation as predictors of ICU need beyond 12 h post-thrombolysis. CONCLUSIONS: Our study demonstrates that sICH, neurological deterioration, and need for ICU intervention rarely occur beyond 12 h after thrombolytic administration. Patients presenting with blood pressures < 140/90 mm Hg, NIHSS scores < 10, and not undergoing mechanical thrombectomy may be best candidates for early de-escalation. Larger prospective studies are needed to more fully evaluate the safety, feasibility, and financial impact of early transition out of the ICU.

Safety and Effect on Intracranial Pressure of 3% Hypertonic Saline Bolus Via Peripheral Intravenous Catheter for Neurological Emergencies.

BACKGROUND: Elevated intracranial pressure (ICP) is a neurological emergency in patients with acute brain injuries. Such a state requires immediate and effective interventions to prevent potential neurological deterioration. Current clinical guidelines recommend hypertonic saline (HTS) and mannitol as first-line therapeutic agents. Notably, HTS is conventionally administered through central venous catheters (CVCs), which may introduce delays in treatment due to the complexities associated with CVC placement. These delays can critically affect patient outcomes, necessitating the exploration of more rapid therapeutic avenues. This study aimed to investigate the safety and effect on ICP of administering rapid boluses of 3% HTS via peripheral intravenous (PIV) catheters. METHODS: A retrospective cohort study was performed on patients admitted to Sisters of Saint Mary Health Saint Louis University Hospital from March 2019 to September 2022 who received at least one 3% HTS bolus via PIV at a rate of 999 mL/hour for neurological emergencies. Outcomes assessed included complications related to 3% HTS bolus and its effect on ICP. RESULTS: Of 216 3% HTS boluses administered in 124 patients, complications occurred in 8 administrations (3.7%). Pain at the injection site (4 administrations; 1.9%) and thrombophlebitis (3 administrations; 1.4%) were most common. The median ICP reduced by 6 mm Hg after 3% HTS bolus administration (p < 0.001). CONCLUSIONS: Rapid bolus administration of 3% HTS via PIV catheters presents itself as a relatively safe approach to treat neurological emergencies. Its implementation could provide an invaluable alternative to the traditional CVC-based administration, potentially minimizing CVC-associated complications and expediting life-saving interventions for patients with neurological emergencies, especially in the field and emergency department settings.

Manipulating polymer composition to create low-cost, high-fidelity sensors for indoor CO2 monitoring.

Carbon dioxide (CO2) has been linked to many deleterious health effects, and it has also been used as a proxy for building occupancy measurements. These applications have created a need for low-cost and low-power CO2 sensors that can be seamlessly incorporated into existing buildings. We report a resonant mass sensor coated with a solution-processable polymer blend of poly(ethylene oxide) (PEO) and poly(ethyleneimine) (PEI) for the detection of CO2 across multiple use conditions. Controlling the polymer blend composition and nanostructure enabled better transport of the analyte gas into the sensing layer, which allowed for significantly enhanced CO2 sensing relative to the state of the art. Moreover, the hydrophilic nature of PEO resulted in water uptake, which provided for higher sensing sensitivity at elevated humidity conditions. Therefore, this key integration of materials and resonant sensor platform could be a potential solution in the future for CO2 monitoring in smart infrastructure.

Prehospital hypoxemia, measured by pulse oximetry, predicts hospital outcomes during the New York City COVID-19 pandemic.

OBJECTIVE: To determine if oxygen saturation (out-of-hospital SpO2), measured by New York City (NYC) 9-1-1 Emergency Medical Services (EMS), was an independent predictor of coronavirus disease 2019 (COVID-19) in-hospital mortality and length of stay, after controlling for the competing risk of death. If so, out-of-hospital SpO2 could be useful for initial triage. METHODS: A population-based longitudinal study of adult patients transported by EMS to emergency departments (ED) between March 5 and April 30, 2020 (the NYC COVID-19 peak period). Inclusion required EMS prehospital SpO2 measurement while breathing room air, transport to emergency department, and a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription polymerase chain reaction test. Multivariable logistic regression modeled mortality as a function of prehospital SpO2, controlling for covariates (age, sex, race/ethnicity, and comorbidities). A competing risk model also was performed to estimate the absolute risks of out-of-hospital SpO2 on the cumulative incidence of being discharged from the hospital alive. RESULTS: In 1673 patients, out-of-hospital SpO2 and age were independent predictors of in-hospital mortality and length of stay, after controlling for the competing risk of death. Among patients ≥66 years old, the probability of death was 26% with an out-of-hospital SpO2 >90% versus 54% with an out-of-hospital SpO2 ≤90%. Among patients <66 years old, the probability of death was 11.5% with an out-of-hospital SpO2 >90% versus 31% with an out-of-hospital SpO2 ≤ 90%. An out-of-hospital SpO2 level ≤90% was associated with over 50% decreased likelihood of being discharged alive, regardless of age. CONCLUSIONS: Out-of-hospital SpO2 and age predicted in-hospital mortality and length of stay: An out-of-hospital SpO2 ≤90% strongly supports a triage decision for immediate hospital admission. For out-of-hospital SpO2 >90%, the decision to admit depends on multiple factors, including age, resource availability (outpatient vs inpatient), and the potential impact of new treatments.

System impacts of the COVID-19 pandemic on New York City's emergency medical services.

OBJECTIVES: To describe the impact of the COVID-19 pandemic on New York City's (NYC) 9-1-1 emergency medical services (EMS) system and assess the efficacy of pandemic planning to meet increased demands. METHODS: Longitudinal analysis of NYC 9-1-1 EMS system call volumes, call-types, and response times during the COVID-19 peak-period (March 16-April 15, 2020) and post-surge period (April 16-May 31, 2020) compared with the same 2019 periods. RESULTS: EMS system received 30,469 more calls from March 16-April 15, 2020 compared with March 16-April 15, 2019 (161,815 vs 127,962; P < 0.001). On March 30, 2020, call volume increased 60% compared with the same 2019 date. The majority were for respiratory (relative risk [RR] = 2.50; 95% confidence interval [CI] = 2.44-2.56) and cardiovascular (RR = 1.85; 95% CI = 1.82-1.89) call-types. The proportion of high-acuity, life-threatening call-types increased compared with 2019 (42.3% vs 36.4%). Planned interventions to prioritize high-acuity calls resulted in the average response time increasing by 3 minutes compared with an 11-minute increase for low low-acuity calls. Post-surge, EMS system received fewer calls compared with 2019 (154,310 vs 193,786; P < 0.001). CONCLUSIONS: COVID-19-associated NYC 9-1-1 EMS volume surge was primarily due to respiratory and cardiovascular call-types. As the pandemic stabilized, call volume declined to below pre-pandemic levels. Our results highlight the importance of EMS system-wide pandemic crisis planning.

Acute myeloid leukemia induction with cladribine: Outcomes by age and leukemia risk.

Acute myeloid leukemia (AML) induction traditionally includes seven days of cytarabine and three days of an anthracycline (7 + 3). Because of evidence of increased efficacy of cladribine combined with this regimen, we conducted a retrospective analysis of 107 AML patients treated with idarubicin, cytarabine and cladribine (IAC) at our institution. Complete remission (CR) occurred in 71%, with overall response of 79%. One-year survival overall was 59%, with 47% (27/57) among patients ≥60 years old and 72% (36/50) in those <60 (Relative Risk [RR] 1.9, 95% CI 1.2-3.2). Median overall survival was 17.3 months in all patients and Cox proportional hazard ratio (HR) for death was 2.2 (95% CI 1.3-3.6) for age ≥60 years compared to <60 years. One year survival was 100% among favorable NCCN risk patients versus 64% in intermediate-risk and 35% in poor-risk patients (p < 0.001). HR for death in intermediate- risk (4.2, 95% CI 1.5-12) and poor-risk (8.4, 95% CI 3.0-24) compared to favorable risk AML was higher than that associated with age ≥60 years (HR 2.2). We conclude that IAC is an effective AML induction regimen, NCCN leukemia risk predicts survival better than age in our population, and high intensity regimens can be justified in selected older patients.

Impact of non-guideline-based treatment of status epilepticus.

BACKGROUND: This retrospective study analyzed benzodiazepine usage patterns in relation to guideline recommendations for the treatment of generalized convulsive status epilepticus (GCSE) as practiced by emergency medical services (EMS) and the emergency department (ED) of an inner-city hospital. Secondary outcomes of interest were adverse events and admission/discharge outcomes. METHODS: Records of all patients≥18years old diagnosed with GCSE between June 2012 and September 2015 and transported by EMS to our hospital ED were reviewed. RESULTS: Of 44 patients analyzed, 43 (98%) had a history of epilepsy. Benzodiazepine utilization varied; EMS preferred midazolam (69% of cases) while the ED utilized lorazepam (91% of cases). Benzodiazepine dosages used were lower than guideline recommendations. Seizure activity was aborted with benzodiazepines alone in 22 (50%) patients. Twelve patients (27%) experienced seizure recurrence following SE treatment and achievement of seizure cessation. Twenty-three (52%) patients required intubation after arrival to ED. All 44 patients were admitted; 30 (68%) required admission to the intensive care unit. CONCLUSIONS: There was consistent underdosing of benzodiazepines in treatment of GCSE in both EMS and ED settings likely resulting in underachievement of seizure cessation, while intubation rates were higher than reported when compared to previous studies. Prospective studies are needed to identify barriers to optimal benzodiazepine usage in GCSE patients.

Efficacy and Toxicity of Induction Therapy with Cladribine, Idarubicin, and Cytarabine (IAC) for Acute Myeloid Leukemia.

We report our single-center experience with cytarabine and idarubicin for induction therapy for acute myeloid leukemia (AML) with an additional 5 days of cladribine (IAC therapy). From July 2012 to September 2014, 38 patients completed a full course of IAC induction. Median patient age was 61 years, 61% of patients were ≥60 years old, and 71% were male. The complete remission (CR) rate was 63% following a single induction course, three patients (8%) required a second induction course to achieve CR, for an overall response rate of 71%. The median duration of severe neutropenia was 30.5 days. Thirty-two percent of patients developed mucositis, 76% experienced diarrhea, and 61% developed a rash. Incidence of CR following IAC induction therapy for AML was comparable to historical data, but with frequent diarrhea, rash, and fungal infections. This study found IAC efficacy and toxicity was similar irrespective of age.

Prehospital Indicators for Disaster Preparedness and Response: New York City Emergency Medical Services in Hurricane Sandy.

OBJECTIVE: We aimed to evaluate emergency medical services (EMS) data as disaster metrics and to assess stress in surrounding hospitals and a municipal network after the closure of Bellevue Hospital during Hurricane Sandy in 2012. METHODS: We retrospectively reviewed EMS activity and call types within New York City's 911 computer-assisted dispatch database from January 1, 2011, to December 31, 2013. We evaluated EMS ambulance transports to individual hospitals during Bellevue's closure and incremental recovery from urgent care capacity, to freestanding emergency department (ED) capability, freestanding ED with 911-receiving designation, and return of inpatient services. RESULTS: A total of 2,877,087 patient transports were available for analysis; a total of 707,593 involved Manhattan hospitals. The 911 ambulance transports disproportionately increased at the 3 closest hospitals by 63.6%, 60.7%, and 37.2%. When Bellevue closed, transports to specific hospitals increased by 45% or more for the following call types: blunt traumatic injury, drugs and alcohol, cardiac conditions, difficulty breathing, "pedestrian struck," unconsciousness, altered mental status, and emotionally disturbed persons. CONCLUSIONS: EMS data identified hospitals with disproportionately increased patient loads after Hurricane Sandy. Loss of Bellevue, a public, safety net medical center, produced statistically significant increases in specific types of medical and trauma transports at surrounding hospitals. Focused redeployment of human, economic, and social capital across hospital systems may be required to expedite regional health care systems recovery. (Disaster Med Public Health Preparedness. 2016;10:333-343).

Utilization of emergency medical services in a large urban area: description of call types and temporal trends.

BACKGROUND: Emergency medical services (EMS) systems are used by the public for a range of medically related problems. OBJECTIVE: To understand and analyze the patterns of EMS utilization and trends over time in a large urban EMS system so that we may better direct efforts toward improving those services. METHODS: The 63 call type designations from all New York City (NYC) 9-1-1 EMS calls between 1999 and 2007 were obtained and grouped into 10 broad and 30 specific medical categories. Aggregated numbers of total EMS calls and individual categories were divided by NYC resident population estimates to determine utilization rates. Temporal trends were evaluated for statistical significance with Spearman's rho (ρ). RESULTS: There were 9,916,904 EMS calls between 1999 and 2007, with an average of 1,101,878 calls/year. Utilization rates increased from 129.5 to 141.9 calls/1,000 residents/year over the study period (average annual rise of 1.16%). Among all medical/surgical call types (excluding trauma), there was an average annual increase of 1.8%/year. The most substantial increases were among "psychiatric/drug related" (+5.6%/year), "generalized illness" (+3.2%/year), and "environmental related" calls (+2.9%/year). The largest decrease was among "respiratory" calls (-1.2%/year), specifically for "asthma" (-5.0%/year). For trauma call types, there was an annual average decrease of 0.4%/year, with the category of "violence related" calls having the greatest decline (-3.3%/year). CONCLUSION: There was an increase in overall EMS utilization rates, though not all call types rose uniformly. Rather, a number of significant trends were identified reflecting either changing medical needs or changing patterns of EMS utilization in NYC's population.

Association of ambient fine particles with out-of-hospital cardiac arrests in New York City.

Cardiovascular morbidity has been associated with particulate matter (PM) air pollution, although the relation between pollutants and sudden death from cardiac arrest has not been established. This study examined associations between out-of-hospital cardiac arrests and fine PM (of aerodynamic diameter ≤2.5 µm, or PM(2.5)), ozone, nitrogen dioxide, sulfur dioxide, and carbon monoxide in New York City. The authors analyzed 8,216 out-of-hospital cardiac arrests of primary cardiac etiology during the years 2002-2006. Time-series and case-crossover analyses were conducted, controlling for season, day-of-week, same-day, and delayed/apparent temperature. An increased risk of cardiac arrest in time-series (relative risk (RR) = 1.06, 95% confidence interval (CI): 1.02, 1.10) and case-crossover (RR = 1.04, 95% CI: 0.99, 1.08) analysis for a PM(2.5) increase of 10 µg/m³ in the average of 0- and 1-day lags was found. The association was significant in the warm season (RR = 1.09, 95% CI: 1.03, 1.15) but not the cold season (RR = 1.01, 95% CI: 0.95, 1.07). Associations of cardiac arrest with other pollutants were weaker. These findings, consistent with studies implicating acute cardiovascular effects of PM, support a link between PM(2.5) and out-of-hospital cardiac arrests. Since few individuals survive an arrest, air pollution control may help prevent future cardiovascular mortality.

Triage accuracy at a multiple casualty incident disaster drill: the Emergency Medical Service, Fire Department of New York City experience.

We sought to evaluate the accuracy and speed for the triage of multiple patients during a disaster drill by Emergency Medical Service (EMS) personnel. During a disaster drill (train collision with blast injury and chemical release), the accuracy and speed of triage of 130 patient-actors by the Fire Department of New York City (FDNY) EMS personnel was evaluated using the Simple Triage and Rapid Treatment (START) triage system. All EMS personnel had been previously trained in START, but refresher training was not administered before the drill. Overall triage accuracy was 78%. In patients that had additional changes in their status during the triage process (injects), 62% were retriaged appropriately. Because of security and decontamination procedures, triage at the triage/treatment area began 40 minutes after the drill commenced. It took 2 hours and 38 minutes to completely clear the scene of all patients. On average, the time from the start of triage to transport was 1 hour and 2 minutes. Despite the fact that triage is a skill practiced by every EMS system in the country on a daily basis, few studies regarding triage accuracy are available. Limited data suggest that the triage accuracy rates using different triage strategy algorithms are approximately 45% to 55%. During this drill, FDNY-EMS triage accuracy using the START system exceeded these expectations. This study provides insight as to the triage experience of a large urban EMS system operating at a disaster drill.

Predictors of retention in an alcohol, tobacco, and other drug prevention study.

This article explored retention patterns, as well as factors that predicted these patterns, in the evaluation of a relationship-based substance abuse prevention intervention study that targeted inner-city African American youth. A total of 851 contacts were made to retain 82% (n = 104) of the baseline sample (N = 127) in the evaluation. Results from multinomial regression analyses indicated that participants who were retained in the evaluation were more likely to perceive alcohol, tobacco, and other drug use as less risky and were more likely to report higher levels of family supervision than were evaluation attrits. Those who were easy to retain reported lower family conflict and fewer family relocations during the past year than those who were difficult to retain. Implications of these findings for developing retention strategies, as well as future research, are discussed.

Impact of a citywide blackout on an urban emergency medical services system.

INTRODUCTION: On 14 August 2003, New York City and a large portion of the northeastern United States experienced the largest blackout in the history of the country. An analysis of such a widespread disaster on emergency medical service (EMS) operations may assist in planning for and managing such disasters in the future. METHODS: A retrospective review of all EMS activity within New York City's 9-1-1 emergency telephone system during the 29 hours during which all or parts of the city were without power (16:11 hours (h) on 14 August 2003 until 21:03 h on 15 August 2003) was performed. Control periods were established utilizing identical time periods during the five weeks preceding the blackout. RESULTS: Significant increases were identified in the overall EMS demand (7,844 incidents vs. 3,860 incidents; p < 0.001) as well as in 20 of the 62 call-types of the system, including cardiac arrests (119 vs. 76, p = 0.043). Significant decreases were found only among calls related to psychological emergencies (114 vs. 221; p = 0.006) and drug- or alcohol-related emergencies (78 vs. 146; p = 0.009). Though median response times increased by only 60 seconds, median call-processing times within the 9-1-1 emergency telephone system EMS dispatch center of the city increased from 1.1 to 5.5 minutes. CONCLUSIONS: The citywide blackout resulted in dramatic changes in the demands upon the EMS system of New York City, the types of patients for whom EMS providers were assigned to provide care, and the dispositions for those assignments. During this time of increased, system-wide demand, the use of cross-trained firefighter and first-responder engine companies resulted in improved response times to cardiac arrest patients. Finally, the ability of the EMS dispatch center to process the increased requests for EMS assistance proved to be the rate-limiting step in responding to these emergencies. These findings will prove useful in planning for future blackouts or any disaster that may broadly impact the infrastructure of a city.

A method for estimating the parameters of electrodynamic drivers in thermoacoustic coolers.

The electroacoustic efficiency of high-power actuators used in thermoacoustic coolers may be estimated using a linear model involving a combination of six parameters. A method to identify these equivalent driver parameters from measured total electrical impedance and velocity-voltage transfer function data was developed. A commercially available, moving-magnet driver coupled to a functional thermoacoustic cooler was used to demonstrate the procedure experimentally. The method, based on linear electrical circuit theory, allowed for the possible frequency and amplitude dependence of the driver parameters to be estimated. The results demonstrated that driver parameters measured in vacuo using this method can be used to predict the driver efficiency and performance for operating conditions which may be encountered under load.