The American journal of emergency medicine
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Acute ischemic strokes account for 85% of all strokes and are the fifth leading cause of mortality in the United States. About one in five of all ischemic strokes occur during sleep and are not noticed until the patient wakes up with neurological deficits. There is growing evidence to support that a significantly higher number of stroke patients could benefit from more aggressive care, especially those patients who wake up with strokes. ⋯ Patients who are in the window for IV rtPA should receive it as soon as possible as well as be evaluated for mechanical thrombectomy. For those who are out of the window for IV rtPA, consider further imaging such as CTP and MR brain for diffusion-weighted sequences to evaluate for potential endovascular intervention. If a large vessel occlusion is present and imaging demonstrates a small infarct core and a large area of salvageable tissue, mechanical thrombectomy may be beneficial for the best possible functional outcome.
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Multicenter Study
Emergency department provider and facility variation in opioid prescriptions for discharged patients.
To study the variation in opioid prescribing among emergency physicians and facilities for discharged adult ED patients. ⋯ There was substantial physician and facility variation in opioid prescription for discharged adult ED patients. Emergency physicians were less likely to prescribe opioids when their workload was lower, and this effect diminished at high workload levels. Understanding situational and other factors that explain this variation is important given the rising U.S. opioid epidemic and the need for urgent intervention.
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Observational Study
On-demand synchronous audio video telemedicine visits are cost effective.
Claims data raises the possibility that on demand telemedicine programs might increase new utilization, offsetting the cost benefits described in some retrospective analyses. We prospectively evaluated the cost of a synchronous audio-video on-demand telemedicine taking into account both what patients would have done instead of the telemedicine visit as well as the care patients received after the visit. ⋯ In our on-demand telemedicine program, we found the majority of health concerns could be resolved in a single consultation and new utilization was infrequent. Synchronous audio-video telemedicine consults resulted in short-term cost savings by diverting patients from more expensive care settings.
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Skin flap-like wounds are common. These wound flaps are prone to avascular necrosis with simple debrided and sutured, and postoperative hyperplastic scarring and contracture of wound surfaces can adversely affect the patient's appearance. Here, we evaluate the data of cases with flap-like wounds to identify the causes of flap necrosis. ⋯ Injury reason, length-width ratio of wound, thickness of pedicle, operation time, injury site, direction of blood perfusion in the flap and operating methods, rather than age, sex and size of flap, were significant risk factors for necrosis of flap-like wounds.