A survey of precision diagnosis and management capacity of pulmonary embolism in 90 hospitals of China.

OBJECTIVE: To conduct a survey of diagnostic facility and therapeutic capability of Pulmonary thromboembolism (PE) in 90 hospitals throughout China. METHOD: It was a cross-sectional study among the participating hospitals of the National Key Research & Development Program of China-the Precision Research of Standardized Management and Application of Pulmonary Thromboembolism to obtain the equipment and application of radiological facility to diagnose PE, laboratory tests for thrombophilia, coagulation function and the availability of anticoagulants and thrombolysis agents. RESULTS: CT pulmonary arteriography is capable in all 90 hospitals, 71.11% of the hospitals could perform ventilation/perfusion scintigraphy, 24.44% of the hospitals do not routinely perform right heart evaluation by echocardiography. Protein C and protein S activity can be detected in half of the hospitals and warfarin pharmacogenomics tests can be conducted in 40 hospitals. Immune turbidimetry was used as the detection method of D-dimer in 72.37% hospitals. About 81.11% of participating hospitals were equipped with new novel oral anticoagulants, all of which were equipped with Rivaroxaban. CONCLUSION: The hospitals are capable for standardized diagnosis and management PE, while the capability of precise stratification, coagulation function tests, thrombophilia screening and pharmacogenomics requires further improvement.

Emergency medicine in the Veterans Health Administration-results from a nationwide survey.

STUDY OBJECTIVE: We describe emergency physician staffing, capabilities, and academic practices in US Veterans Health Administration (VHA) emergency departments (EDs). METHODS: As part of an ongoing process improvement effort for the VHA emergency care system, VHA-wide surveys are conducted among ED medical directors every 3 years. Web-based surveys of VHA ED directors were conducted in 2013 on clinical operations and academic program development. We describe the results from the 2013 survey. When available, we compare responses with the previously administered survey from 2010. RESULTS: A total of 118 of 118 ED directors filled out the survey in 2013 (100% response rate). Respondents reported that 45.5% of VHA emergency physicians are board certified in emergency medicine, and 95% spend most their time in direct patient care. Clinical care is also provided by part-time (<0.5 full-time employee equivalent) emergency physicians in 59.3% of EDs. More than half of EDs (57%) provide on-site tissue plasminogen activator for acute ischemic stroke patients, and only 39% can administer tissue plasminogen activator 24 hours per day, 7 days per week. Less than half (48.3%) of EDs have emergency Obstetrics and Gynecology consultation availability. Most VHA EDs (78.8%) have a university affiliation, but only 21.5% participated in the respective academic emergency medicine program. CONCLUSIONS: Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having university affiliations, traditional academic activities (eg, teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women's health.

Techniques for improving efficiency in the emergency department for patients with acute ischemic stroke.

The past 15 years have witnessed significant strides in the management of acute stroke. The most significant advance, reperfusion therapy, has changed relatively little, but the integrated healthcare systems-stroke systems-established to effectively and safely administer stroke treatments have evolved greatly. Driving change is the understanding that "time is brain." Data are compelling that the likelihood of improvement is directly tied to time of reperfusion. Regional stroke systems of care ensure patients arrive at the most appropriate stroke-capable hospital in which intrahospital systems have been created to process the potential stroke patient as quickly as possible. The hospital-based systems are comprised of prehospital care providers, emergency department physicians and nurses, stroke team members, and critical ancillary services such as neuroimaging and laboratory. Given their complexity, these systems of care require maintenance. Through teamwork and ownership of the process, more patients will be saved from potential death and long-term disability.

[Advancement on thrombolytic characteristic, function and clinical application of different fibrinolytic enzymes].

Cardio-cerebral vascular diseases endanger people's health very seriously. Thrombolytic therapy is effective in curing thrombotic diseases at present. Microorganism is an important source of thrombolytic drug. Plasminogen activators are widely used as thrombolytic drugs clinically, while they are still exists some defects. This article analyzed research and development status of kinds of thrombolytic drugs from microorganisms, and evaluated their clinical efficacy and safety, aiming at showing the direction to search new and effective thrombolytic drugs and prevent and treat thromboembolic disease.

[Infrastructure of emergency medical services. Comparison of physician-staffed ambulance equipment in the state of Baden-Wuerttemberg in 2001 and 2005]. / Strukturqualität im Notarztdienst. Vergleich der Ausstattung arztbesetzter Rettungsmittel in Baden-Württemberg in den Jahren 2001 und 2005.

BACKGROUND: A survey amongst emergency physician bases in the federal state of Baden-Wuerttemberg in 2001 concerning equipment available for airway management and the treatment of acute coronary syndromes showed striking differences with respect to implementation of European norms and international recommendations. The survey was repeated in 2005 to evaluate the development of the equipment in physician-staffed ambulance systems. METHODS: A questionnaire was sent to all emergency physician bases (ground ambulance and helicopter) registered with the Ministry of Health in Baden-Wuerttemberg. Questions encompassed availability of options to verify correct tracheal tube position (e.g. capnometry), supraglottic airway devices as alternatives to mask ventilation and tracheal intubation, 12-lead ECG and fibrinolytic agents. RESULTS: In 2001, 116 out of 127 bases (91.3%) participated and in 2005, 107 out of 120 bases (89.2%) returned the questionnaire. With availability in 97.2% of bases, prevalence of supraglottic airway devices is almost state-wide (2001: 54.3%, p<0.001, Fisher's exact test). The topics verification of tracheal tube position (2005: 73.8%, 2001: 26.7%, p<0.001), 12-lead ECG (2005: 89.7%, 2001: 52.6%, p<0.001) and fibrinolytic therapy (2005: 59.8%, 2001: 12.9%, p<0.001) showed noticeable increases in the corresponding availability, however, distinct regional structural deficits were still present in 2005. CONCLUSIONS: A favourable trend could be found concerning the equipment of physician-staffed ambulances state-wide. Further efforts must be undertaken to ensure the complete implementation of legal requirements and international recommendations concerning provision of medical equipment.

Techniques in dosing for thrombolysis of occluded central venous catheters.

Dosing of thrombolytic agents for restoration of flow to thrombotically occluded central venous catheters has been empiric. The lowest effective dose of any agent is not known. Given that none of the dosing regimens in current use has ever been found to be toxic, this is probably not a major clinical problem as long as the regimen is highly effective. Thrombolytic regimens differ in the type of drug, dose of drug, method of administration (injection versus prolonged infusion), and duration of administration. All of these variables are important in determining the efficacy, and possibly the toxicity, of a regimen. Active research is being conducted to determine the most effective ways of using the expanding number of thrombolytic medications that are now, or soon may be, on the market.

Reduced in-hospital mortality from acute myocardial infarction with general adoption of thrombolytic treatment in the North West Thames health region 1979-1991.

OBJECTIVE: To determine the impact of studies of thrombolytic treatment in acute myocardial infarction on inhospital mortality. DESIGN: Retrospective study. SETTING: All 21 major hospitals in the North West Thames health region. PATIENTS: 63,903 patients with acute myocardial infarction. STUDY PERIOD: 1979-1991. MAIN OUTCOME MEASURES: in-hospital mortality. RESULTS: Overall mortality decreased by 5.2% from 25.4% to 20.2% (P < 0.0001) (95% confidence interval (CI) 3.4 to 6.6). Male mortality decreased by 6.5% from 22.3% to 15.8% (P < 0.0001) (95% CI 4.8 to 8.4); female mortality decreased by 4.3% from 32.6% to 28.3% (P < 0.01) (95% CI 1.3 to 7.4). Reductions in mortality occurred in all age and sex groups but were greater in younger patients. Logistic regression analysis of death rates showed that the odds ratio of death in 1991 compared with that in 1979 was 0.75 (95% CI 0.69 to 0.82). After allowing for the effects of age and sex, this odds ratio became 0.54 (95% CI 0.49 to 0.59), as more elderly patients were treated in 1991. Purchase of streptokinase increased 31-fold from 116 doses in 1983 to 3554 doses in 1991. There was a pronounced negative association between annual purchases of streptokinase and mortality (Kendall's rank correlation = -0.86, P = 0.003). Changes in clinical practice resulted in the saving of the lives of an estimated 600 patients with acute myocardial infarction in 1991. This extrapolates to an annual saving of 10,500 lives in the United Kingdom. CONCLUSIONS: In the past few years thrombolytic treatment has been widely adopted for the management of acute myocardial infarction. This has been paralleled by a substantial reduction in in-hospital mortality.