Novel partial anomalous pulmonary venous connection associated with brain abscess.

BACKGROUND: Right-to-left vascular shunts are associated with brain abscess. CASE REPORT: We present a 47-year-old female with a cryptogenic left thalamic abscess on which Streptococcus mitis grew upon aspiration. Computed tomography of the chest with contrast agent revealed an anomalous connection between the left superior pulmonary and brachiocephalic veins. A right-to-left shunt was confirmed in a transthoracic echocardiogram study in which bubbles were injected into the left arm; this shunt had not previously been noted upon right-arm injection. CONCLUSIONS: We recommend aggressive evaluation for right-to-left shunts in patients who present with cryptogenic brain abscesses. In addition to imaging, this should include a bubble-based study with left-arm saline injection

Cerebral Arteriovenous Malformations: Evaluation and Management.

There has been increased detection of incidental AVMs as result of the frequent use of advanced imaging techniques. The natural history of AVM is poorly understood and its management is controversial. This review provides an overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management of AVMs. The authors discussed the imaging techniques available for detecting AVMs with regard to the advantages and disadvantages of each imaging modality. Furthermore, this review paper discusses the factors that must be considered for the most appropriate management strategy (based on the current evidence in the literature) and the risks and benefits of each management option

Early Follow-Up Phone Calls to Reduce 30-Day Readmissions For Stroke Patients Discharged to Home

Patients admitted to the acute stroke unit with minor neurologic deficits are frequently discharged directly to home rather than to a rehabilitation center. Data from our tertiary care comprehensive stroke center has shown that in a 7-month period, 37% of patients admitted to the stroke unit were discharged home versus discharged to rehab or other location. Our average 30-day readmission rate for home discharges is 5.14%. More than 30% of these readmitted patients had been discharged on a Thursday or Friday on their index admission. When discharged home, patients typically are tasked with several responsibilities including but not limited to medication management, organizing follow-up appointments, monitoring blood pressure, and coordinating home services. In addition to recovering mentally and physically from stroke, these tasks can lead to additional burden particularly on weekends when access to care may be limited. We hypothesize that those who are discharged home on a Thursday or Friday are at higher risk for readmission and predict that scripted phone calls to these patients over the weekend could result in reduction in readmissions

Treatment for Mild Chronic Hypertension during Pregnancy.

BACKGROUND: The benefits and safety of the treatment of mild chronic hypertension (blood pressure, \u3c160/100 mm Hg) during pregnancy are uncertain. Data are needed on whether a strategy of targeting a blood pressure of less than 140/90 mm Hg reduces the incidence of adverse pregnancy outcomes without compromising fetal growth. METHODS: In this open-label, multicenter, randomized trial, we assigned pregnant women with mild chronic hypertension and singleton fetuses at a gestational age of less than 23 weeks to receive antihypertensive medications recommended for use in pregnancy (active-treatment group) or to receive no such treatment unless severe hypertension (systolic pressure, ≥160 mm Hg; or diastolic pressure, ≥105 mm Hg) developed (control group). The primary outcome was a composite of preeclampsia with severe features, medically indicated preterm birth at less than 35 weeks\u27 gestation, placental abruption, or fetal or neonatal death. The safety outcome was small-for-gestational-age birth weight below the 10th percentile for gestational age. Secondary outcomes included composites of serious neonatal or maternal complications, preeclampsia, and preterm birth. RESULTS: A total of 2408 women were enrolled in the trial. The incidence of a primary-outcome event was lower in the active-treatment group than in the control group (30.2% vs. 37.0%), for an adjusted risk ratio of 0.82 (95% confidence interval [CI], 0.74 to 0.92; P CONCLUSIONS: In pregnant women with mild chronic hypertension, a strategy of targeting a blood pressure of less than 140/90 mm Hg was associated with better pregnancy outcomes than a strategy of reserving treatment only for severe hypertension, with no increase in the risk of small-for-gestational-age birth weight. (Funded by the National Heart, Lung, and Blood Institute; CHAP ClinicalTrials.gov number, NCT02299414.)

The Prevalence of Cervico-Arterial Dissection in Sub-Arachnoid Hemorrhage in the United States

Objectives: In this study, we sought to determine the prevalence of cervico-arterial dissection in aubarachnoid hemorrhage (SAH) using a large administrative database

Improving Resident Confidence and Efficiency During Stroke Alerts Through Simulation Training

Objectives Teach incoming neurology residents how to respond efficiently and appropriately to stroke alerts Improve the confidence level of residents during stroke alertshttps://jdc.jefferson.edu/patientsafetyposters/1084/thumbnail.jp

Declaring Brain Death on ECMO

Purpose: Accumulating evidence suggests that organs from ECMO patients can be safely transplanted after a declaration of cardiac or brain death. However, making a diagnosis of brain death while a patient is on ECMO poses unique challenges and limited literature exists. We sought to describe the practice variations involved with declaring patients brain dead on ECMO by reviewing charts from our local organ procurement organization. Methods: After institutional review board approval, a retrospective chart review from our local organ procurement organization was performed to identify patients declared brain dead on ECMO who became organ donors. Between 1995 and 2014, we identified 26 patients on ECMO who donated organs after being diagnosed with brain death. Demographics, causes of death, clinical and ancillary studies used to pronounce brain death were recorded from charts. Results: All patients underwent one to two clinical exams as the initial step in the declaration of brain death. In addition to clinical examination, 15 (58%) of the patients underwent apnea testing, and of those, seven (47%) also had at least one ancillary test performed. Apnea testing was not utilized in 11 (42%) of the patients, and of those, nine (82%) had one or more ancillary tests performed to confirm brain death. Two (18%) patients underwent clinical examination only. Seventy-five percent of patients from 1995 - 2008 underwent apnea testing compared with only 50% of patients from 2009 to 2014. Conclusions: This study demonstrated the variability of practice patterns in the declaration of brain death for patients on ECMO over time and the lack of understanding of the CO2 physiology on ECMO. Additional studies are needed to devise a national standardized protocol to declare brain death on ECMO

The Prevalence and Risk Factors of Acute Myocardial Infarction (AMI) After Acute Ischemic Stroke (AIS) in the United States

Objectives: To determine the prevalence and risk factors for, and the association with in-hospital mortality of, AMI after AIS, and to study the effect of intravenous recombinant tissue plasminogen activator (r-tPA) in this setting. We hypothesized that AMI would be associated with lower survival rate at hospital discharge but that intravenous r-tPA would be associated with lower risk of AMI

Implementation of Attending-Supervised IPASS Handoff in the Neuro-ICU

Background Duty hour restrictions, cross coverage, and the growing number of mid-level practitioners has led to an increased number of handoffs across medical specialties These handoffs are well-known points of communication breakdown which can lead to patient safety issues Factors contributing to an effective handoff include standardization of communication, appropriate training and supervision, ample time, a quiet environment, and a supportive culture We hypothesize that attending supervision of handoffs is feasible and can improve practitioner perception of transitions of carehttps://jdc.jefferson.edu/patientsafetyposters/1077/thumbnail.jp

Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.

OBJECTIVE: Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis. METHODS: Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines. RESULTS: Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke. CONCLUSIONS: The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices