Code ICH: A Call to Action.

Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.

Ominous Causes of Headache.

PURPOSE OF REVIEW: While primary headaches like migraines or cluster headaches are prevalent and often debilitating, it's the secondary headaches-those resulting from underlying pathologies-that can be particularly ominous. This article delves into the sinister causes of headaches, underscoring the importance of a meticulous clinical approach, especially when presented with red flags. RECENT FINDINGS: Headaches, one of the most common complaints in clinical practice, span a spectrum from benign tension-type episodes to harbingers of life-threatening conditions. For the seasoned physician, differentiating between these extremes is paramount. Headache etiologies covered in this article will include subarachnoid hemorrhage (SAH), cervical artery dissection, cerebral venous thrombosis, meningitis, obstructive hydrocephalus, and brain tumor.

Prevalence of Craniofacial Injuries in the Elderly Population.

INTRODUCTION: Recognizing and understanding risk factors for craniofacial injury in the elderly is of paramount importance in prevention. This research aims to investigate the prevalence of craniofacial injuries in connection with extrinsic preventable factors, particularly identifying common household products that pose the greatest risk for such injuries. MATERIALS AND METHODS: This study was done with the utilization of the 2013 to 2022 National Electronic Injury Surveillance System (NEISS). Data gathered included patient age, injury type, cause of injury, and year of incidence. "Elderly" was defined as an individual of 65 years of age or older. RESULTS: There was a total of 9,703,688 estimated national cases of elderly craniofacial injury from 2013 to 2022. In all, 5,888,112 (60.68%) of these occurred in females. In descending order, the 5 most common items responsible for craniofacial injury in the elderly are floors/flooring Materials (3,741,706, 30.92%), beds/bed frames (1,250,396, 10.33%), stairs/steps (907,92, 7.50%), chairs (546,697, 4.52%), and tables (453,989, 3.75%). These top 5 account for roughly 57% of all cases. The 5 most common presenting diagnoses were internal injury (2,957,095, 40.21%), lacerations (1,435,926, 19.53%), ABR (1,191,008, 16.20%), fracture (568,842, 7.74%), and hematoma (355,871, 4.84%). CONCLUSIONS: Out of the roughly 10 million cases of craniofacial injury in the last decade, ~three-fifths have happened to women. The majority of injuries occur in a home setting. The overwhelming majority of cases were related to the product code 1807-floors or flooring materials, and the largest diagnosis was internal injury by a wide margin. Evidently, there is a large population of elderly patients who suffer from craniofacial injuries related to objects and items that permeate within their living residences. The elimination of excess elderly craniofacial injury can be achieved by reducing fall risk factors in the immediate vicinity of the elderly.

Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage.

Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.

Real-World Field Performance of the Los Angeles Motor Scale as a Large Vessel Occlusion Screen: A Prospective Muticentre Study.

BACKGROUND: The Los Angeles Motor Scale (LAMS) is a 3-item, 0-to-5-point motor stroke-deficit scale derived from the Los Angeles Prehospital Stroke Screen. We assessed the predictive validity (for interventions performed and discharge disposition) of the LAMS performed in the field by paramedics in a geographic region of over 5,200 km2, covering both rural and urban areas. METHODS: We analyzed data gathered from Phase I of the LIT-PASS study (Large Vessel Occlusion Identification Through Prehospital Administration of Stroke Scales) which included all patients with suspected acute cerebrovascular disease, as assessed by the Balance, Eyes, Face, Arm, Speech, Terrible Headache/Time to Call 911 (BE-FAST) test. RESULTS: Among 1,906 patients with median age 72 years (interquartile range [IQR] 60-81), 53% were female with a median on-scene time of 15 min (IQR 12-19). C statistics for the interventions of mechanical thrombectomy, alteplase administration, computed tomography angiography, and perfusion imaging were 0.681, 0.643, and 0.680, respectively. The cut point for predicting these 3 interventions was confirmed to be LAMS ≥ 4. LAMS ≥ 4 had sensitivity 0.730 (0.661-0.790) and specificity 0.570 (0.539-0.601) for mechanical intervention (endovascular thrombectomy, coiling, or clipping) and relative risk of 2.98 (2.19-4.07) for in-hospital death. CONCLUSIONS: This real-world field study validates the LAMS as an effective tool for prehospital assessment of suspected strokes in determining transport decisions, with predictive validity for interventions performed.

Is rhythm control better than rate control for new-onset atrial fibrillation in the emergency department?

In patients with new-onset atrial fibrillation and symptom onset within 48 hours, rhythm control is preferred over rate control if the patient is younger than 65 years. For patients with congestive heart failure, valvular heart disease, hypertension, or permanent atrial fibrillation, rate control remains the favored strategy.

Insulin for glycaemic control in acute ischaemic stroke.

BACKGROUND: People with hyperglycaemia concomitant with an acute stroke have greater mortality, stroke severity, and functional impairment when compared with those with normoglycaemia at stroke presentation. This is an update of a Cochrane Review first published in 2011. OBJECTIVES: To determine whether intensively monitoring insulin therapy aimed at maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (September 2013), CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to September 2013), EMBASE (1980 to September 2013), CINAHL (1982 to September 2013), Science Citation Index (1900 to September 2013), and Web of Science (ISI Web of Knowledge) (1993 to September 2013). We also searched ongoing trials registers and SCOPUS. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing intensively monitored insulin therapy versus usual care in adults with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS: We obtained a total of 1565 titles through the literature search. Two review authors independently selected the included articles and extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures. We resolved disagreements by discussion. MAIN RESULTS: We included 11 RCTs involving 1583 participants (791 participants in the intervention group and 792 in the control group). We found that there was no difference between the treatment and control groups in the outcomes of death or dependency (OR 0.99, 95% CI 0.79 to 1.23) or final neurological deficit (SMD -0.09, 95% CI -0.19 to 0.01). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 14.6, 95% CI 6.6 to 32.2). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and disability or neurological deficit. The number needed to treat was not significant for the outcomes of death and final neurological deficit. The number needed to harm was nine for symptomatic hypoglycaemia. AUTHORS' CONCLUSIONS: After updating the results of our previous review, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those people whose glucose levels were maintained within a tighter range with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those people in the control group.

History and Evolution of the Tuning Fork.

This paper is a summary of the evolution of the tuning fork, a crucial part of the cranial nerves and auditory examination. The tuning fork is a two-pronged fork that resonates at a specific pitch when struck against a surface and has been proven to be incredibly useful in diagnosing and detecting hearing disorders. The tuning fork, an unassuming device in modern medicine, traces its origins back to an era when scientific understanding and medical diagnostics were in their nascent stages. Since its inception, this unpretentious instrument has played a pivotal role in the hands of healthcare practitioners, aiding in the diagnosis and assessment of various medical conditions. This paper embarks on a captivating journey through time to explore the origin, evolution, and significant milestones in the development of the tuning fork. From the first suggestion of differentiating hearing disorders to present-day tuning forks, this paper maps the different stages that the tuning fork has gone through and how its use has changed over time. Along the way, we will discover how the tuning fork has harmonized with music, medicine, and various scientific pursuits, enriching our understanding of sound and resonance while leaving an indelible mark on the course of human history. Delving into the historical context of its creation, this review uncovers the ingenious minds that birthed this innovative device and the pivotal moments that brought it to the forefront of human endeavors.

Mastoiditis Now Affects Adults: A Case Report of an Occurrence of the Disease in an 82-Year-Old Male.

Mastoiditis is typically considered a suppurative complication of otitis media seen in children. Vaccines and therapeutics can change the demographics of diseases. Childhood vaccination against Haemophilus influenza, for example, has shifted the mean age for ear, nose, and throat infections caused by this bug to age 25, whereas this used to be most prevalent in the pediatric age group previously. The authors present the case of an 82-year-old man who had mastoiditis. This case serves as a reminder to avoid anchoring bias when seeing an undifferentiated patient in the emergency department.

Exploration of the Motivational Factors that Influence the Maintenance of Health.

Objective: This study aims to identify motivators influencing individuals' commitment to maintaining positive health trajectories across different demographics. The primary objective is to leverage this knowledge to enhance patient-physician relationships and improve the quality of care. Methods: A web-based survey collected data from 204 randomly selected participants aged 16 and older. The survey assessed participants' self-rated health, health-related habits, and motivators for a healthy lifestyle. Open-ended responses were included. Results: Participants had a mean self-rated health score of 6.24 (scale: one to ten). Motivation scores for health-related factors averaged 3.25 (scale: one to five), with caregiving responsibility scoring 3.07 (scale: one to five), mainly among women. Motivators related to personal productivity and values scored 3.44 (scale: one to five), while cultural or religious beliefs scored lowest at 2.89 (scale: one to five). Common themes from free responses included longevity, quality of life, personal well-being, family, independence, prevention of complications, health goals, finances, and faith, listed by frequency. Among participants, only 30% had chronic diseases, but 80% of those with chronic conditions were motivated to improve their health. Conclusion: This survey gathered valuable data on motivators for maintaining positive health trajectories. The findings have implications for improving patient-physician relationships and healthcare delivery. Understanding individuals' motivators can inform tailored interventions and personalized care approaches.

Bibliometric analysis of ChatGPT in medicine.

INTRODUCTION: The emergence of artificial intelligence (AI) chat programs has opened two distinct paths, one enhancing interaction and another potentially replacing personal understanding. Ethical and legal concerns arise due to the rapid development of these programs. This paper investigates academic discussions on AI in medicine, analyzing the context, frequency, and reasons behind these conversations. METHODS: The study collected data from the Web of Science database on articles containing the keyword "ChatGPT" published from January to September 2023, resulting in 786 medically related journal articles. The inclusion criteria were peer-reviewed articles in English related to medicine. RESULTS: The United States led in publications (38.1%), followed by India (15.5%) and China (7.0%). Keywords such as "patient" (16.7%), "research" (12%), and "performance" (10.6%) were prevalent. The Cureus Journal of Medical Science (11.8%) had the most publications, followed by the Annals of Biomedical Engineering (8.3%). August 2023 had the highest number of publications (29.3%), with significant growth between February to March and April to May. Medical General Internal (21.0%) was the most common category, followed by Surgery (15.4%) and Radiology (7.9%). DISCUSSION: The prominence of India in ChatGPT research, despite lower research funding, indicates the platform's popularity and highlights the importance of monitoring its use for potential medical misinformation. China's interest in ChatGPT research suggests a focus on Natural Language Processing (NLP) AI applications, despite public bans on the platform. Cureus' success in publishing ChatGPT articles can be attributed to its open-access, rapid publication model. The study identifies research trends in plastic surgery, radiology, and obstetric gynecology, emphasizing the need for ethical considerations and reliability assessments in the application of ChatGPT in medical practice. CONCLUSION: ChatGPT's presence in medical literature is growing rapidly across various specialties, but concerns related to safety, privacy, and accuracy persist. More research is needed to assess its suitability for patient care and implications for non-medical use. Skepticism and thorough review of research are essential, as current studies may face retraction as more information emerges.

Rectus Sheath Hematoma.

The authors report on the case of a 69-year-old female who presented to the emergency department due to exquisite abdominal pain she described as occurring after she coughed. Imaging revealed a rectus sheath hematoma (RSH). A RSH is an uncommon but significant cause of acute abdominal pain that occurs when blood accumulates in the sheath of the rectus abdominis muscle. It can be caused by a muscular tear or a ruptured epigastric artery and can happen spontaneously or after trauma. The etiology, presentation, diagnosis, and management are discussed.

Sex and employment status affect patients' perspectives regarding affordability of emergency department visits.

BACKGROUND: For many conditions, a timely visit to the Emergency Department (ED) can have a tremendous impact on the patient's outcome. However, the decision to visit the ED in a time of need can be stressful. Our study aims to understand whether cost was a factor for seeking ED care, and if any particular subgroups including race, ethnicity and sex were less likely to obtain such care. METHODS: A web-based survey of US adults was conducted to assess participants' ED access, estimates of the cost of visiting, and their overall levels of comfort in seeking emergency care. Statistical analyses performed in JMP 16.1 for the Mac. RESULTS: Multivariate regression modeling demonstrated that women (p = 0.0241), participants employed for wages (p = 0.0257), or self-employed (p = 0.0019) are less likely to visit the ED due to cost. Conversely, retired individuals are significantly less likely to encounter cost as a restriction (p = 0.0081). CONCLUSION: In a national survey sample that asked about whether cost was a factor in visiting the emergency department, women and people who worked for wages or were self-employed were most likely to think twice about cost.

A nationwide analysis of upper extremity injuries in martial arts.

Objective: Given the rise of martial arts within the fitness and recreational industry, it is important to study trends in injury and note that practicing martial arts comes with a risk of injury, particularly to the upper extremities. By studying consumer product-related injuries to the upper extremities and addressing the current gap in the literature, future martial arts equipment can come with increased safety features, better provide information to healthcare providers treating such injuries, and improve risk mitigation through the Consumer Product Safety Commission. Methods: The National Electronic Injury Surveillance System Database was analyzed to collect data on martial arts equipment-related injuries on the upper extremities within the last 10 years. Results: Over the most recent span of 10 years (2013-2022), there were approximately 78,680 injuries reported to the ED. The majority of them took place in 2013 (12.8%). Men were 2.4 times more likely to get injured than women. Injuries peaked in the age group 10-19-year-olds (33%) and particularly age 12 (4.8%). The upper extremity most commonly affected was the shoulder (29.1%), and the most common diagnosis group was a fracture (29.2%). Most injuries presented to the emergency department were not hospitalized (98.7%). Conclusions: This study highlights the occurrence of upper extremity injuries due to martial arts within the last 10 years and provides new information on the prevalence of such injuries. The results highlight that these injuries are usually non-severe and most commonly affect adolescent males; however, future research should explore performance-based recovery post-injury and long-term pain.

Factors Influencing Patient Satisfaction with Total Joint Replacement Surgery.

Background: Replacement arthroplasty surgery is a surgical procedure that is needed to restore the activity of a joint. Patient satisfaction regarding arthroplasty surgery is influenced by post-operative complication rate, ability to afford care, and quality of interaction. In this study, we assessed patients' postoperative complications, mobility, and pain management as proxies for their overall satisfaction with total joint replacement (TJR). Methods: An anonymous web-based survey was conducted for patients who had undergone any total joint replacement surgery in the US. Respondents were adults living in the United States. Results: 180 individuals met the inclusion criteria and responded to the survey. Age, education, gender, and race were fitted against the patient satisfaction level with the surgeon. While education [P=0.4720], gender [P=0.5097 ], and race [P=0.8183] were not significant, age in years [P=0.02340] was predictive of overall satisfaction levels [R2=0.0213]. When controlling for BMI, infection [P=0.0164], nerve damage [P=0.0250], delayed healing [P=0.0024], hematoma [P=0.0497], were more likely to occur in participants who have had a knee replacement, as compared to shoulder and hip replacement surgery. When controlling for mobility before surgery vs. mobility after surgery [P=0.0114], patients who selected the highest level of mobility before surgery were likely to select the highest level of mobility after surgery. Medicaid, Medicare, private insurance, employer-based insurance, and no insurance were fitted against the patient's self-reported difficulty in paying for their treatment/care. Although employer-based insurance [P=0.0790] was not significant in predicting difficulty in paying for the surgery, patients with Medicaid [P=0.0280], Medicare [P=0.0200], or private insurance [P=0.0343] did. Conclusion: In this cohort, older patients were associated with having improved satisfaction with the surgeon who performed their joint replacement. Complications were higher in patients who underwent a knee arthroplasty compared to a shoulder or hip arthroplasty.

Cancer caregivers are primarily motivated by love and sense of duty.

Cancer is a debilitating disease for which patients often need caretakers to help them live their lives and complete basic activities. This study aims to characterize the burden of the caretaker. A 14-question survey was sent out to randomly selected United States cancer caretakers to analyze the social, emotional, and physical burden of their caretaking. The results show that a majority of caretakers are direct family to the patient (69.5%). The patients' cancers are often in early stages with about 54.5% having stage 1 cancer and 22.5% having stage 2 cancer while only 8.5% had stage 3 cancer and 17.8% had stage 4 cancer. When asked about their motivation, caretakers most often do it because of love (58.82%) with family responsibilities/duty being the second highest reason (35.56%). When asked about their biggest burden, many caretakers said that grief was the biggest issue (30.50%) with mental health issues also being troublesome (28%). 75.6% of respondents said that being a cancer caretaker has negatively impacted their mental health from either anxiety (37.29%), depression (33.9%), or other conditions (4.41%). When asked about the negative impacts of being a caregiver, 43.5% stated they faced high financial costs to give care, and 35% stated they met a lack of social support or lost friends. In comparison, 33% stated they had negative physical impacts. The number of participants who face overwhelming or high stress nearly quintupled from baseline, from 13% to 59.5%. This cross-sectional survey of US adults demonstrates that there are clear negative impacts on cancer caregivers on their physical, financial, social, and mental health. These data underscore the importance of taking care of patients' caregivers.