The no smoking sign--insular infarction.

BACKGROUND: Cigarette smoking is the most common preventable cause of morbidity and mortality in developed countries. Smokers with brain damage involving the insula are 136 times more likely to stop smoking immediately after the injury than smokers with brain injuries elsewhere. METHODS: Case Report. RESULTS: A 58-year-old woman with a history of hypertension, coronary artery disease, and 40 pack-year history (1 pack per day for 40 years) of smoking presented with sudden confusion and word-finding difficulty. Initial neurological examination showed disorientation to time, difficulty following commands, and perseveration. No focal motor, sensory, or visual deficit was present. Noncontrast head CT showed a new insular ischemic stroke. Five months after discharge from the hospital, the patient reported that she had not resumed smoking cigarettes, had not used any smoking cessation aids, and had not intended to stop smoking. Her daughter reported that "it was as if she forgot that she used to smoke." CONCLUSION: Unintentional abrupt smoking cessation serves as a unique lesion localizer. Insular hypocretin transmission plays a permissive role in the motivational properties of nicotine in animals. Whether the mechanism of smoking cessation relates to hypocretin secretion has yet to be proven in humans.

Re-utilization outcomes and costs of minor acute illness treated at family physician offices, walk-in clinics, and emergency departments.

OBJECTIVE: To examine factors associated with re-utilization of health services and to estimate and compare costs of treatment for minor acute illnesses in family physicians' offices (FPOs), walk-in clinics (WICs), and emergency departments (EDs). DESIGN: Prospective cohort study using questionnaires, telephone follow up, medical chart data, and costs according to Ontario Health Insurance Plan (OHIP) schedules. SETTING: 16 FPOs, 12 WICs, and 13 EDs in three Ontario cities. PARTICIPANTS: Consecutive patients with one of eight predefined minor acute illnesses found in all three settings (upper respiratory infection, pharyngitis, acute bronchitis, acute otitis media, serous otitis media, low back pain, gastroenteritis, and urinary tract infection). MAIN OUTCOME MEASURES: "Early" (< 3 days) versus "later" (3 days to 2 weeks) re-utilization of health services after initial encounter and direct cost to OHIP. RESULTS: The overall rate of re-utilization of health services for the same episode of illness was 11.3% for early and 20.6% for later re-utilization. Factors associated with early re-utilization were initial evaluation in ED setting (odds ratio [OR] = 6.5, confidence interval [CI] = 2.2-19.2) and, regardless of setting, less satisfaction with patient-centred care (OR = 1.7 for each one-point decrease on a four-point scale; CI = 1.1-2.7). Factors associated with later re-utilization were ED setting (OR = 4.9; CI = 2.4-9.9) and diagnosis of urinary tract infection (OR = 2.4; CI = 1.1-5.2). Factors tested and found not signifcantly associated with rate of re-utilization were patients' age, sex, responses to a variety of questions assessing psychosocial factors (stress, social support, independence), and opinions on health care. Cost of care was similar for FPOs and WICs and higher for EDs for all diagnoses. The initial visit was the largest component of cost in all settings, and this component (as well as total cost) was consistently higher in EDs. CONCLUSION: Both re-utilization rates and costs are higher for those seeking care in EDs for minor acute illness. Patient-centred care, an important feature of health care encounters regardless of setting, can reduce re-utilization rates.