Utility of point of care assessment of platelet reactivity (using the PFA-100®) to aid in diagnosis of stroke.

BACKGROUND: Rapid and accurate diagnosis of patients presenting with symptoms of stroke is needed to facilitate the timely delivery of proven effective treatment for patients with acute ischemic stroke (AIS). The aim of this study was to determine whether early assessment of platelet reactivity in patients presenting with symptoms of AIS was associated with a diagnosis of AIS, transient ischemic attack (TIA), or stroke mimic. METHODS: This prospective study included patients with symptoms of AIS treated at an inner-city emergency department (ED). Blood samples were obtained and assayed for platelet reactivity (quantified by closure time). Patients were grouped by discharge diagnosis into: AIS, TIA, or stroke mimic. Binary logistic regression model was used to predict the association of closure time with the final diagnosis of 1) either AIS or TIA or, 2) stroke mimic. RESULTS: Of 114 patients enrolled, 32 were diagnosed with AIS, 33 TIA, and 49 were diagnosed as a stroke mimic. There was no significant difference in closure times among patients with a diagnosis of AIS or TIA versus stroke mimic. A history of migraines and history of seizures were independently associated with lower odds of an AIS or TIA diagnosis (OR 0.31, 95% CI 0.10 to 0.94 and OR 0.08, 95% CI 0.01 to 0.88, respectively). CONCLUSION: Closure time was not found to be a clinically reliable differentiator of patients with a diagnosis of AIS, TIA, or stroke mimic in the ED.

Comparison of quantitative EEG to current clinical decision rules for head CT use in acute mild traumatic brain injury in the ED.

STUDY OBJECTIVE: We compared the performance of a handheld quantitative electroencephalogram (QEEG) acquisition device to New Orleans Criteria (NOC), Canadian CT Head Rule (CCHR), and National Emergency X-Radiography Utilization Study II (NEXUS II) Rule in predicting intracranial lesions on head computed tomography (CT) in acute mild traumatic brain injury in the emergency department (ED). METHODS: Patients between 18 and 80 years of age who presented to the ED with acute blunt head trauma were enrolled in this prospective observational study at 2 urban academic EDs in Detroit, MI. Data were collected for 10 minutes from frontal leads to determine a QEEG discriminant score that could maximally classify intracranial lesions on head CT. RESULTS: One hundred fifty-two patients were enrolled from July 2012 to February 2013. A total 17.1% had acute traumatic intracranial lesions on head CT. Quantitative electroencephalogram discriminant score of greater than or equal to 31 was found to be a good cutoff (area under receiver operating characteristic curve = 0.84; 95% confidence interval [CI], 0.76-0.93) to classify patients with positive head CT. The sensitivity of QEEG discriminant score was 92.3 (95% CI, 73.4-98.6), whereas the specificity was 57.1 (95% CI, 48.0-65.8). The sensitivity and specificity of the decision rules were as follows: NOC 96.1 (95% CI, 78.4-99.7) and 15.8 (95% CI, 10.1-23.6); CCHR 46.1 (95% CI, 27.1-66.2) and 86.5 (95% CI, 78.9-91.7); NEXUS II 96.1 (95% CI, 78.4-99.7) and 31.7 (95% CI, 23.9-40.7). CONCLUSION: At a sensitivity of greater than 90%, QEEG discriminant score had better specificity than NOC and NEXUS II. Only CCHR had better specificity than QEEG discriminant score but at the cost of low (<50%) sensitivity.

Efficacy and safety of quinine loading dose in patients with severe falciparum malaria at a tertiary care hospital in Pakistan.

OBJECTIVE: To compare the clinical outcomes of a loading dose regimen of quinine with a uniform dose regimen in patients with severe falciparum malaria. METHODS: A retrospective chart review of 315 patients admitted with severe falciparum malaria and treated with quinine at a tertiary care teaching hospital of Karachi, Pakistan during 1999-2006 was conducted. Group A with 103 patients (32.7%) was given an initial loading dose of quinine while group B with 212 patients (67.3%) did not receive the loading dose. The two groups were compared in terms of reduction of parasite load, resolution of fever, recovery of consciousness and incidence of adverse effects. Outcome parameters were measured on the third day of therapy. RESULTS: More individuals in group A (62.1%) were afebrile as compared to group B (54.7%) at day 3 of therapy. Patients in group B showed greater reduction in parasitaemia (47.2% at baseline to 4.7% on day 3) as compared to group A (56.3 % at baseline to 9.7% on day 3). Following therapy, fewer patients in group B had altered consciousness (7.1% at baseline to 4.7% on day 3) as compared to patients in group A (7.8% at baseline to 5.8% on day 3). However, these associations were not statistically significant. The incidence of thrombocytopenia was higher in Group A (5.8%) as compared to Group B (0.9%). CONCLUSION: Although quinine loading dose may be more effective than uniform dose in rapid fever clearance; it also appears to be associated with higher toxicity. Uniform dose of quinine may be prescribed in severe falciparum malaria in view of its better safety profile.

Career goals of trainee physicians in internal medicine.

OBJECTIVE: To survey Internal Medicine trainees' future career choices and factors influencing their decision-making. DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from November 2006 to January 2007. SUBJECTS AND METHODS: A standard questionnaire was administered to the residents and Interns working in the Department of Internal Medicine of The Aga Khan University Hospital. The questionnaire covered demographic details, specialty choice, work-time distribution and factors influencing career choice. Descriptive statistics were applied. RESULTS: A total of 49 doctors participated with 57% females; and 43% males, having 33% interns and 67% residents. A minority (22%) opted for internal medicine, while 78% selected sub-specialties with cardiology (20%) being the most sought- after sub-specialty. Majority (69%) wanted to spend more time in clinical activities compared to administration (18%) or research (13%). Majority (92%) wanted to work in an academic setting. Availability of a structured training program (61%), ability to practice broad area of medicine (41%) and prestige of the specialty (41%) highly influenced their career choices. Forty one (82%) wanted to proceed abroad for further training and 80% wanted to eventually practice in Pakistan. CONCLUSION: Most of the interviewed under-training physicians wanted to pursue sub-specialty. Clinical work was more attractive compared to research. A structured training program was detrimental in affecting their choices. Majority wanted further training abroad but eventual settlement in Pakistan. The study results can help us create the basis for reforming the current training programs.

Drug overdose: a wake up call! Experience at a tertiary care centre in Karachi, Pakistan.

OBJECTIVE: To study the characteristics of patients admitted with drug overdose caused either by accidental overdose of the prescribed medications or as an act of deliberate self harm (DSH) at a tertiary care hospital in Karachi, Pakistan. METHODS: A retrospective case series review was conducted at the Aga Khan University Hospital from January 2002 to October 2006. Three hundred and twenty four adult patients admitted with drug overdose were included in the study. RESULTS: Our sample group revealed mean age of 36.2 +/- 17.0 years, more females (59%), housewives (34%), and students (20%). Fifty six percent of patients committing DSH were married (p = 0.001), 81% needed in-patient psychiatric services (p = 0.016) of whom a significantly high number (38%) refused it. Domestic and social issues were rated highest among DSH group (p = 0.003), depression among females was common (p = 0.028) and Benzodiazepines (41%) was the most frequently used drug (p = 0.021). Sub-group analysis of accidental overdoses revealed mean age of 45.6 +/- 19.6 years, single (75.4%) and males (54.1%). Drugs used were mainly Benzodiazepines (18%) followed by Opioids (11%), Antiepileptics (10%) and Warfarin (10%). CONCLUSION: Our study showed that depressed housewives are at greater risk for DSH. Domestic and social issues were rated highest and Benzodiazepines were the most commonly used agents. Most of our patients refused inpatient psychiatric treatment leading us to believe that general awareness of psychiatric illnesses is imperative in our community. High number of accidental overdoses is alarming in older, single males convincing us to believe that existing pharmacy system needs further evaluation and modification.

Design and rationale of the high-sensitivity Troponin T Rules Out Acute Cardiac Insufficiency Trial.

BACKGROUND: Acute heart failure (AHF) is a common presentation in the Emergency Department (ED), and most patients are admitted to the hospital. Identification of patients with AHF who have a low risk of adverse events and are suitable for discharge from the ED is difficult, and an objective tool would be useful. METHODS: The highly sensitive Troponin T Rules Out Acute Cardiac Insufficiency Trial (TACIT) will enroll ED patients being treated for AHF. Patients will undergo standard ED evaluation and treatment. High-sensitivity troponin T (hsTnT) will be drawn at the time of enrollment and 3 hours after the initial draw. The initial hsTnT draw will be no more than 3 hours after initiation of therapy for AHF (vasodilator, loop diuretic, noninvasive ventilation). Treating clinicians will be blinded to hsTnT results. We will assess whether hsTnT, as a single measurement or in series, can accurately predict patients at low risk of short-term adverse events. CONCLUSION: TACIT will explore the value of hsTnT measurements in isolation, or in combination with other markers of disease severity, for the identification of ED patients with AHF who are at low risk of short-term adverse events.

Intravenous enalaprilat for treatment of acute hypertensive heart failure in the emergency department.

BACKGROUND: Afterload reduction with bolus enalaprilat is used by some for management of acute hypertensive heart failure (HF) but existing data on the safety and effectiveness of this practice are limited. The purpose of this study was to evaluate the clinical effects of bolus enalaprilat when administered to patients with acute hypertensive heart failure. FINDINGS: We performed an IRB-approved retrospective cohort study of patients who presented to the emergency department of a large urban academic hospital. Patients were identified by pharmacy record and included if they received enalaprilat intravenous (IV) bolus in the setting of acute hypertensive HF. A total of 103 patients were included. Patients were hypertensive on presentation (systolic blood pressure [SBP] = 195.2 [SD ± 32.3] mmHg) with significantly elevated mean NT-proBNP levels (3797.8 [SD ± 6523.2] pg/ml). The mean dose of enalaprilat was 1.3 [SD ± 0.7] mg, with most patients (76.7%) receiving a single 1.25 mg bolus. By 3 h post-enalaprilat, SBP had decreased substantially (-30.5 mmHg) with only 2 patients (1.9%) developing hypotension. Renal function was unaffected, with no significant change in serum creatinine by 72 h. In the 30 days post-admission, patients spent an average of 23 [SD ± 7.5] days alive and out of hospital. CONCLUSIONS: In this retrospective cohort of acute hypertensive HF patients, bolus IV enalaprilat resulted in a substantial reduction in systolic BP without adverse effect.

Connectome-scale assessment of structural and functional connectivity in mild traumatic brain injury at the acute stage.

Mild traumatic brain injury (mTBI) accounts for over one million emergency visits each year in the United States. The large-scale structural and functional network connectivity changes of mTBI are still unknown. This study was designed to determine the connectome-scale brain network connectivity changes in mTBI at both structural and functional levels. 40 mTBI patients at the acute stage and 50 healthy controls were recruited. A novel approach called Dense Individualized and Common Connectivity-based Cortical Landmarks (DICCCOLs) was applied for connectome-scale analysis of both diffusion tensor imaging and resting state functional MRI data. Among 358 networks identified on DICCCOL analysis, 41 networks were identified as structurally discrepant between patient and control groups. The involved major white matter tracts include the corpus callosum, and superior and inferior longitudinal fasciculi. Functional connectivity analysis identified 60 connectomic signatures that differentiate patients from controls with 93.75% sensitivity and 100% specificity. Analysis of functional domains showed decreased intra-network connectivity within the emotion network and among emotion-cognition interactions, and increased interactions among action-emotion and action-cognition as well as within perception networks. This work suggests that mTBI may result in changes of structural and functional connectivity on a connectome scale at the acute stage.

Resting State Functional Connectivity in Mild Traumatic Brain Injury at the Acute Stage: Independent Component and Seed-Based Analyses.

Mild traumatic brain injury (mTBI) accounts for more than 1 million emergency visits each year. Most of the injured stay in the emergency department for a few hours and are discharged home without a specific follow-up plan because of their negative clinical structural imaging. Advanced magnetic resonance imaging (MRI), particularly functional MRI (fMRI), has been reported as being sensitive to functional disturbances after brain injury. In this study, a cohort of 12 patients with mTBI were prospectively recruited from the emergency department of our local Level-1 trauma center for an advanced MRI scan at the acute stage. Sixteen age- and sex-matched controls were also recruited for comparison. Both group-based and individual-based independent component analysis of resting-state fMRI (rsfMRI) demonstrated reduced functional connectivity in both posterior cingulate cortex (PCC) and precuneus regions in comparison with controls, which is part of the default mode network (DMN). Further seed-based analysis confirmed reduced functional connectivity in these two regions and also demonstrated increased connectivity between these regions and other regions of the brain in mTBI. Seed-based analysis using the thalamus, hippocampus, and amygdala regions further demonstrated increased functional connectivity between these regions and other regions of the brain, particularly in the frontal lobe, in mTBI. Our data demonstrate alterations of multiple brain networks at the resting state, particularly increased functional connectivity in the frontal lobe, in response to brain concussion at the acute stage. Resting-state functional connectivity of the DMN could serve as a potential biomarker for improved detection of mTBI in the acute setting.

Nursing home-acquired pneumonia: course and management in the emergency department.

BACKGROUND: Pneumonia is among the foremost causes of hospitalization and mortality in patients residing in extended care facilities. Despite its prevalence, there is currently little literature focusing on the course and management of nursing home-acquired pneumonia (NHAP) in the emergency department (ED). Our objective was to investigate the ED presentation, course, management and outcomes in patients admitted through the ED with NHAP. METHODS: A retrospective chart review of nursing home patients with a presumptive or final diagnosis of pneumonia admitted through the ED was performed at two large hospitals in Detroit, Michigan. RESULTS: A total of 296 patients were included in the study from 2002 to 2007 with a mean age of 81.1 years (SD ± 10.95) and 55.4% females. Blood cultures were performed on 90.8% of patients in the ED; 17.8% of these revealed growths, but half of these were considered contaminants. Initial chest x-ray in the ED was read as possible pneumonia in 18.2% of patients; 73.9% were started on antibiotics (ABX) in the ED. Mean hospital length of stay (LOS) was 10.75 days (SD ± 9.35) and in-hospital mortality was 16.2%. Time until first ABX in univariate analysis was nearly significant (p = 0.053) for mortality prediction, and the appropriate versus inappropriate ABX (per the Infectious Diseases Society of America and American Thoracic Society guidelines) did not affect mortality. Patients treated with a single ABX had significantly increased LOS (p = 0.0089). There was poor correlation between LOS and time until first ABX as well as LOS and time until appropriate ABX with a correlation coefficient of -0.048 (p = 0.42) and -0.08 (p = 0.43), respectively. CONCLUSIONS: In this data set of NHAP patients admitted through the ED, we found a surprisingly low prevalence of true-positive blood cultures, high incidence of antibiotic pre-treatment at nursing homes prior to admission, high hospital mortality and low immunization rates. There was a wide spectrum of pathogens grown in blood culture. Only two thirds of the patients had dyspnea at presentation, and less than half had either cough or fever. On physical examination, about one fourth had no clinical findings consistent with pneumonia. Further, less than one fifth of chest x-rays were interpreted as possible pneumonia.

Combining biochemical and imaging markers to improve diagnosis and characterization of mild traumatic brain injury in the acute setting: results from a pilot study.

BACKGROUND: Mild traumatic brain injury (mTBI) is a significant healthcare burden and its diagnosis remains a challenge in the emergency department. Serum biomarkers and advanced magnetic resonance imaging (MRI) techniques have already demonstrated their potential to improve the detection of brain injury even in patients with negative computed tomography (CT) findings. The objective of this study was to determine the clinical value of a combinational use of both blood biomarkers and MRI in mTBI detection and their characterization in the acute setting (within 24 hours after injury). METHODS: Nine patients with mTBI were prospectively recruited from the emergency department. Serum samples were collected at the time of hospital admission and every 6 hours up to 24 hours post injury. Neuronal (Ubiquitin C-terminal Hydrolase-L1 [UCH-L1]) and glial (glial fibrillary acidic protein [GFAP]) biomarker levels were analyzed. Advanced MRI data were acquired at 9 ± 6.91 hours after injury. Patients' neurocognitive status was assessed by using the Standard Assessment of Concussion (SAC) instrument. RESULTS: The median serum levels of UCH-L1 and GFAP on admission were increased 4.9 folds and 10.6 folds, respectively, compared to reference values. Three patients were found to have intracranial hemorrhages on SWI, all of whom had very high GFAP levels. Total volume of brain white matter (WM) with abnormal fractional anisotropy (FA) measures of diffusion tensor imaging (DTI) were negatively correlated with patients' SAC scores, including delayed recall. Both increased and decreased DTI-FA values were observed in the same subjects. Serum biomarker level was not correlated with patients' DTI data nor SAC score. CONCLUSIONS: Blood biomarkers and advanced MRI may correlate or complement each other in different aspects of mTBI detection and characterization. GFAP might have potential to serve as a clinical screening tool for intracranial bleeding. UCH-L1 complements MRI in injury detection. Impairment at WM tracts may account for the patients' neurocognitive symptoms.

Syncope: experience at a tertiary care hospital in Karachi, Pakistan.

INTRODUCTION: Our aim was to determine the characteristics of patients presenting with syncope at a tertiary care hospital in Karachi, Pakistan. METHODS: A review of medical records was conducted retrospectively at the Department of Medicine, Aga Khan University Hospital, Karachi. Patients aged 16 and above, admitted from January 2000 to December 2005 with the diagnosis of syncope made by the attending physician were included. RESULTS: A total of 269 patients were included (75% males, mean age: 57.4 years). Neurogenic (vasovagal) syncope was the most common cause (47%), followed by cardiogenic syncope (18%) and orthostatic syncope (9%). A total of 24% were discharged undiagnosed. Twenty patients (7.4%) did not have any prodrome. Common prodromal symptoms included dizziness (61%), sweating (25%), palpitations (19%), nausea/vomiting (19%) and visual symptoms (17%). The distribution of symptoms according to cause of syncope revealed only breathlessness to be significantly associated with cardiogenic syncope (p = 0.002). Most patients with cardiogenic syncope were aged above 40 (98%, p < 0.001), had coronary artery disease (72%, p < 0.001) and abnormal electrocardiogram at presentation (92%, p < 0.001). CONCLUSION: Despite differences in burden of diseases, our findings were similar to those of published syncope literature. Further studies are needed to develop a protocol to expedite the evaluation and limit the work-up and admission in low-risk patients.