Abstract TMP70: The Emergency Department Screen is Associated with Lower Rates of Pneumonia in Acute Hemorrhagic Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jon Schrock ◽  
Benjamin Ball
Keyword(s):  
Emergency Department ◽  
Hemorrhagic Stroke ◽  
Pulmonary Infiltrate ◽  
Stroke Severity ◽  
Group 13 ◽  
Before And After ◽  
Poor Outcomes ◽  
Subarachnoid Hemorrhages ◽  
Acute Hemorrhagic Stroke ◽  
Very High

Introduction: Dysphagia is a common problem in acute hemorrhagic stroke (AHS) patients, predisposing them to pneumonia and leading to poor outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation, which for most patients with AHS is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia. Hypothesis: We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AHS patients. Methods: We performed a pre-post cohort study evaluating the rates of pneumonia in AHS patients presenting to our ED before and after instituting dysphagia screening in 2010. Our pre group were AHS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test. Results: We evaluated 469 pre screen and 462 post screen AHS patients. Both groups were 53% male. The rates of parenchymal bleed in the pre and post groups were 78% and 82%, respectively, with the remainder comprising subarachnoid hemorrhages or combination bleeds. Mean ICH scores were similar, pre 2.0 (SD 1.5) post 1.7 (SD 1.4). Dysphagia was present in 65% of the pre group and 63% of the post group. Incidence of pneumonia in the post group (13%) was significantly lower than the pre group (19%, P<0.001). Conclusion: The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AHS patients. This study was not designed to prove causation. Other factors not measured may have contributed to the reduction in rates of pneumonia. With the very high rates of dysphagia seen in this population, early dysphagia screening at ED presentation seems appropriate.

scholarly journals Subarachnoid hemorrhage in the emergency department

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Sima Patel ◽  
Amay Parikh ◽  
Okorie Nduka Okorie
Keyword(s):  
Emergency Department ◽  
Emergency Medicine ◽  
Subarachnoid Hemorrhage ◽  
Early Management ◽  
Vast Number ◽  
Emergency Medicine Physician ◽  
Medicine Physician ◽  
Diagnostic Modalities ◽  
Poor Outcomes ◽  
Subarachnoid Hemorrhages

Abstract Background Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician. Discussion The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest. Conclusion Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.

scholarly journals Association of Plasma Levels of Nitric Oxide Oxidative Metabolites with Acute Stroke in Patients Presenting to the Emergency Department of a Low-Middle Income Country

2019 ◽  
Vol 2019 ◽  
pp. 1-6
Author(s):  
Shahan Waheed ◽  
Ayaz Ghouse Kalsekar ◽  
Ayeesha Kamran Kamal ◽  
Nathan S. Bryan ◽  
Asad I. Mian
Keyword(s):  
Nitric Oxide ◽  
Emergency Department ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Hemorrhagic Stroke ◽  
Nonparametric Tests ◽  
University Hospital ◽  
Stroke Severity ◽  
Oxidative Metabolites ◽  
Significant Difference

Introduction. Acute stroke incites an inflammatory reaction in the brain’s microvasculature, activating formation of nitric oxide oxidative metabolites, nitrate and nitrite (NOx, collectively), measurable in plasma. Our objectives were to investigate plasma NOx in patients with acute stroke presenting to the Emergency Department (ED) and to determine if it could (i) differentiate between ischemic and hemorrhagic stroke; (ii) predict clinical outcomes. Methods. A cross-sectional study was conducted in the ED of Aga Khan University Hospital, from January 1 to December 31, 2016. Participants were enrolled if they had clinical acute stroke with confirmatory brain imaging to differentiate between ischemia and hemorrhage. Clinical demographic information, ancillary blood, and diagnostic specimens were collected as per standard of care since the center follows stroke algorithmic guidelines. Plasma NOx analysis was performed using high performance liquid chromatography. Clinical outcomes were assessed using Barthel Index and Modified Rankin Score. Data was analyzed using SPSS 19 and expressed in medians with interquartile ranges. Nonparametric tests were applied for comparing among groups. Pearson’s correlation was used to determine associations with aforementioned stroke severity and disability scales. Results. Seventy-five patients were enrolled, with median age of 57 years (IQR 47-66 years), 53 (71%) were males, and 46 (61%) had ischemic stroke. Overall, median NOx was 20.8 μM (IQR 13.4-35.3); there was no statistically significant difference between NOx in ischemic versus hemorrhagic stroke (21.2 μM vs. 17.9 μM; p=0.2). However, there was a significant positive correlation between NOx levels and aforementioned acute stroke scales [r(73)=0.417, p=0.0001], for both. Conclusion. Although plasma NOx could not differentiate between ischemia and hemorrhage, higher levels of the biomarker did show associations with poststroke disability scales. Further study with more patients in a multicenter trial is warranted to establish the real biomarker potential of plasma NOx in acute stroke.

Abstract TP255: The Emergency Department Dysphagia Screen is Associated With Lower Rates of Pneumonia in Acute Ischemic Stroke Patients

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Jon W Schrock ◽  
Linda Lou
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Data ◽  
Pulmonary Infiltrate ◽  
T Test ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Early Screening

Introduction: Dysphagia is a common problem in acute ischemic stroke (AIS) patients predisposing them to pneumonia and leading to worse outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation which for most patients with AIS, is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia. Hypothesis: We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AIS patients. Methods: We performed a pre-post cohort study evaluating the rates of pneumonia in AIS patients presenting to our ED. Our pre group were AIS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test. Results: We evaluated 419 pre screen and 1022 post screen AIS patients. Both groups were 50% female. The use of thombolytics in the pre group was 10% and post group was 11%. The median ages and ED NIHSS scores for the pre and post population were 63 years (IQR 53-73), 6 (IQR 3-10) and 64 years (IQR 56-76), 4 (IQR 2-8). Rates of dysphagia during hospitalization were 20% and 31% for the pre-post groups respectively. Rates of pneumonia for the pre-post groups were 13.8% and 8.0% respectively which was significantly different P=0.0007. Conclusion: The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AIS patients. This study was not designed to prove causation so other factors also may have influenced the lower rate of pneumonia including possibly slightly less severe strokes. The rates of diagnosed dysphagia were higher in the post group suggesting ED screening may heighten awareness resulting in increased diagnoses of dysphagia. Given the rates of dysphagia and pneumonia early screening of AIS patients in the ED seems prudent.

scholarly journals Endovascular Management of Hemorrhagic Stroke

Biomedicines ◽  
2022 ◽  
Vol 10 (1) ◽  
pp. 100
Author(s):  
Basel Musmar ◽  
Nimer Adeeb ◽  
Junaid Ansari ◽  
Pankaj Sharma ◽  
Hugo H. Cuellar
Keyword(s):  
Endovascular Treatment ◽  
Hemorrhagic Stroke ◽  
Vascular Malformations ◽  
Guglielmi Detachable Coils ◽  
Common Causes ◽  
Detachable Coils ◽  
Subarachnoid Hemorrhages ◽  
Acute Hemorrhagic Stroke ◽  
Flow Diverters

Significant advances in endovascular neurosurgery tools, devices, and techniques are changing the approach to the management of acute hemorrhagic stroke. The endovascular treatment of intracranial aneurysms emerged in the early 1990s with Guglielmi detachable coils, and since then, it gained rapid popularity that surpassed open surgery. Stent-assisted coiling and balloon remodeling techniques have made the treatment of wide-necked aneurysms more durable. With the introduction of flow diverters and flow disrupters, many aneurysms with complex geometrics can now be reliably managed. Arteriovenous malformations and fistulae can also benefit from endovascular therapy by embolization using n-butyl cyanoacrylate (NBCA), Onyx, polyvinyl alcohol (PVA), and coils. In this article, we describe the role of endovascular treatment for the most common causes of intracerebral and subarachnoid hemorrhages, particularly ruptured aneurysms and vascular malformations.

Abstract WP344: Total Healthcare Costs Before and After Stroke in Non-Valvular Atrial Fibrillation (NVAF) Patients Who Initiated Treatment With Rivaroxaban or Warfarin

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jennifer H Lin ◽  
Dejan Milentijevic ◽  
Shubham Shrivastava ◽  
Emily Kogan ◽  
Erik Sjoeland ◽  
...  
Keyword(s):  
Anticoagulation Therapy ◽  
Fold Increase ◽  
Cost Of Care ◽  
Stroke Severity ◽  
Cost Increase ◽  
Post Stroke ◽  
Before And After ◽  
History Of ◽  
Poor Outcomes ◽  
The Cost

Introduction: Healthcare expenditures remain unclear in NVAF patients initiating anticoagulation therapy. Objective: To compare total healthcare cost in pre- and post-stroke periods between rivaroxaban- and warfarin-treated NVAF patients. Methods: This retrospective study using de-identified IBM MarketScan Commercial and Medicare databases (2011-2019) included patients initiating rivaroxaban or warfarin within 30 days after a 1 st observed NVAF diagnosis who later developed ischemic or hemorrhage stroke. Patients had ≥6 months continuous health plan enrollment, CHA 2 DS 2 -VASc score ≥2 and no history of stroke or anticoagulation therapy. Inpatient stroke diagnosis was identified by ICD-9/-10 code, and stroke severity status was defined by National Institutes of Health Stroke Scale (NIHSS) score, imputed by a random forest method. Total per-patient per-year (PPPY) cost of care was calculated pre- and post-stroke (from treatment initiation to time of stroke and from stroke until end of study enrollment, respectively). Cost increases pre-/post-stroke were compared within each treatment cohort. Results: During a mean follow up of 25 and 30 months for rivaroxaban and warfarin respectively, 272 (2.0%) and 1,303 (3.3%) patients, respectively, developed stroke. For the rivaroxaban cohort, the pre-/post-stroke cost increase was lower than that for warfarin (1.79-fold vs 3.08-fold, respectively); for more severe stroke (NIHSS ≥6), the cost increase for rivaroxaban was half that of warfarin (3.19-fold increase vs 6.37-fold increase, respectively). Conclusions: The study showed a substantial increase in total cost of care following stroke, especially among patients with severe strokes. Warfarin patients had a much higher increase in post-stroke costs relative to rivaroxaban patients, suggesting a benefit of rivaroxaban in preventing strokes with poor outcomes that are costly.

Deformation Replication

1970 ◽  
Vol 28 ◽  
pp. 280-281
Author(s):  
J. Temple Black
Keyword(s):  
Cutting Speed ◽  
Machining Process ◽  
Depth Of Cut ◽  
Rake Face ◽  
Orthogonal Machining ◽  
Aluminum Chips ◽  
Before And After ◽  
Materials Used ◽  
Glass Knife ◽  
Very High

Tool materials used in ultramicrotomy are glass, developed by Latta and Hartmann (1) and diamond, introduced by Fernandez-Moran (2). While diamonds produce more good sections per knife edge than glass, they are expensive; require careful mounting and handling; and are time consuming to clean before and after usage, purchase from vendors (3-6 months waiting time), and regrind. Glass offers an easily accessible, inexpensive material ($0.04 per knife) with very high compressive strength (3) that can be employed in microtomy of metals (4) as well as biological materials. When the orthogonal machining process is being studied, glass offers additional advantages. Sections of metal or plastic can be dried down on the rake face, coated with Au-Pd, and examined directly in the SEM with no additional handling (5). Figure 1 shows aluminum chips microtomed with a 75° glass knife at a cutting speed of 1 mm/sec with a depth of cut of 1000 Å lying on the rake face of the knife.

scholarly journals Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

2021 ◽  
pp. neurintsurg-2020-017155
Author(s):  
Alexander M Kollikowski ◽  
Franziska Cattus ◽  
Julia Haag ◽  
Jörn Feick ◽  
Alexander G März ◽  
...  
Keyword(s):  
Patient Characteristics ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Vessel Occlusion ◽  
Before And After ◽  
Transferred Patients ◽  
Stroke Center

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

Use of Ophthalmic Sonography to Evaluate for Intraocular Foreign Body in Both Outpatient and Emergency Department/Urgent Care Patients

2021 ◽  
pp. 875647932110332
Author(s):  
Patrick J. Fish
Keyword(s):  
Emergency Department ◽  
Foreign Body ◽  
Foreign Bodies ◽  
Outpatient Setting ◽  
Intraocular Foreign Body ◽  
Urgent Care ◽  
Posterior Chamber ◽  
Emergency Department Setting ◽  
Before And After ◽  
Glass Metal

Intraocular foreign bodies (IOFB) present differently depending on the type of material (wood, glass, metal) for the IOFB, extent of the injury, and location of the injury. IOFB and the injury can cause a perforation or penetration of the globe which can require more extensive treatment including surgery. Proper evaluation of the IOFB and injury can help to determine extent of the injury, the prognosis of the vision, and health of the eye before and after treatment but may be difficult for the physician depending on the view of the posterior chamber being compromised by media or simply by patient sensitivity. The extent of the injury may also prevent proper evaluation due to swelling, lacerations on the lids, or pain. Proper ophthalmic sonography can provide a quick evaluation of the globe for any IOFB in both the outpatient setting as well as emergency department setting. Evaluation via sonography may allow the physician to accurately diagnose and properly treat the patient to help restore and prevent further loss of vision.

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