Prospective, Multicenter, Controlled Trial of Mobile Stroke Units.

BACKGROUND: Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard management by emergency medical services (EMS). Whether and how much MSUs alter outcomes has not been extensively studied. METHODS: In an observational, prospective, multicenter, alternating-week trial, we assessed outcomes from MSU or EMS management within 4.5 hours after onset of acute stroke symptoms. The primary outcome was the score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes according to a patient value system, derived from scores on the modified Rankin scale of 0 to 6, with higher scores indicating more disability). The main analysis involved dichotomized scores on the utility-weighted modified Rankin scale (≥0.91 or <0.91, approximating scores on the modified Rankin scale of ≤1 or >1) at 90 days in patients eligible for t-PA. Analyses were also performed in all enrolled patients. RESULTS: We enrolled 1515 patients, of whom 1047 were eligible to receive t-PA; 617 received care by MSU and 430 by EMS. The median time from onset of stroke to administration of t-PA was 72 minutes in the MSU group and 108 minutes in the EMS group. Of patients eligible for t-PA, 97.1% in the MSU group received t-PA, as compared with 79.5% in the EMS group. The mean score on the utility-weighted modified Rankin scale at 90 days in patients eligible for t-PA was 0.72 in the MSU group and 0.66 in the EMS group (adjusted odds ratio for a score of ≥0.91, 2.43; 95% confidence interval [CI], 1.75 to 3.36; P<0.001). Among the patients eligible for t-PA, 55.0% in the MSU group and 44.4% in the EMS group had a score of 0 or 1 on the modified Rankin scale at 90 days. Among all enrolled patients, the mean score on the utility-weighted modified Rankin scale at discharge was 0.57 in the MSU group and 0.51 in the EMS group (adjusted odds ratio for a score of ≥0.91, 1.82; 95% CI, 1.39 to 2.37; P<0.001). Secondary clinical outcomes generally favored MSUs. Mortality at 90 days was 8.9% in the MSU group and 11.9% in the EMS group. CONCLUSIONS: In patients with acute stroke who were eligible for t-PA, utility-weighted disability outcomes at 90 days were better with MSUs than with EMS. (Funded by the Patient-Centered Outcomes Research Institute; BEST-MSU ClinicalTrials.gov number, NCT02190500.).

Planning a new emergency department: from design to occupancy.

Planning, designing, and occupying a new emergency department requires the collective input and hard work of many individuals, A case study of Memorial Hermann Hospital in Houston, Tex examines what it takes to design an emergency department that is planned for future growth, and then seamlessly occupy a new facility that is triple the size of the old one. Planning strategies are described, including workload analysis, staff input, staff training, mock patient runs, and a move-in plan. An analysis of the 5-year old facility concludes that there is very little that could have been done differently in terms of facility design and operations.

Radial pulse character relationships to systolic blood pressure and trauma outcomes.

BACKGROUND: Patient measurements that do not require monitoring equipment may be the only way to evaluate casualties in austere conditions to determine treatment and transport priority. Objective. To test the hypothesis that palpable pulse characteristics in the radial artery would estimate systolic blood pressure (SBP) and predict outcome in trauma patients. METHODS: Data were analyzed from the medical records of 342 trauma patients ranging from 18 to 50 years of age. Prehospital data were collected by helicopter emergency medical personnel at the scene of the injury. Based on radial pulse character, patients were divided into normal (n = 313) and weak (n = 29) groups. Those whose medical records did not describe pulse characters were not considered. Differences in SBP, mortality, and medical interventions between the radial-pulse-character groups were evaluated. RESULTS: The SBP taken at the scene was a mean of 26 mm Hg lower in those patients with weak radial pulse characters (102 mm Hg versus 128 mm Hg). Similarly, the lowest mean SBPs recorded in the field between the normal- and weak-pulse-character groups were 112 mm Hg and 99 mm Hg, respectively. Patient mortality increased with weak pulse character such that the mortality rats were 3% for the normal-pulse-character group and 29% for the weak-pulse-character-group (odds ratio = 15.2). CONCLUSIONS: These preliminary data suggest that a weak radial pulse may be an acceptable method for initial rapid evaluation of trauma patients. This simple and rapid method of pulse evaluation should be considered for the triage of trauma patients in field conditions with limited instrumentation.

TRANSPLANTATION OF POLYMER ENCAPSULATED PC12 CELLS: USE OF CHITOSAN AS AN IMMOBILIZATION MATRIX.

Polymer capsules were fabricated to encapsulate PC12 cells within a semipermeable and immunoprotective barrier. The inclusion of precipitated chitosan as an immobilization matrix within the polymer capsules increased the survival and physiological functioning of the PC12 cells. In an initial study, HPLC analysis revealed that the inclusion of a chitosan matrix resulted in an increased output of catecholamines from the encapsulated PC12 cells under both basal conditions, and following high potassium depolarization at 2 and 4 wk following encapsulation in vitro. Furthermore, implantation of cohort PC12 cell-loaded capsules into guinea pig striata revealed that chitosan enhanced PC 12 cell survival after 6 wk. A second study determined that 12 wk after implantation into guinea pig striatum, abundant tyrosine hydroxylase-positive PC12 cells were evenly distributed within capsules containing chitosan. The long-term biocompatibility of these implants was good as determined by the absence of inflammatory or immune cells, and minimal GFAP reactivity surrounding the implant site. In contrast, implantation of unencapsulated PC12 cells resulted in a marked host tissue reaction, and destruction of the implanted cells within 4 wk. It is concluded that the inclusion of precipitated chitosan as an immobilization matrix enhanced the viability of encapsulated PC12 cells, and that altering the internal milieu of polymeric capsules may represent an effective transplant strategy for ameliorating human diseases characterized by secretory cell dysfunction.