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Here you will find information regarding rotation schedules, academic resources, wellness and facts about our program and residents. Check out our bios and photos. Please also visit the Emergency Department's official residency website. This site is intended for Mount Sinai EM residency purposes only, and no information on these pages is intended or should be construed as medical advice. Read more.

Pittfalls in Dvt Management

You’re on your last patient of the day, starting to thinking about which type of sushi you’re going to order later, when the ultrasound comes back. Positive study, you were sure of it, after all, the patient had a hx of cancer and 3 days of progressive leg swelling and pain. He looked like this:

Red Leg Small

You start them on lovenox, admit and run off for sushi.

The next day, you get a call from the chairman, he says “remember that patient you admitted….” Oh Oh…

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Mr. Clean Trial is Here….a Quick Swipe at It.

Question:

-In acute stroke, does the addition of intra-arterial management improve outcomes compared to usual care?

Methodes: 

-Multicenter, randomized, open-label (but blinded end points) in the Netherlands. 502 patients in 16 centers.

-Comparing: (comparing intra-arterial intervention within 6 hours + usual care) vs. usual care.

-Required a radiologically proven intracranial occlusion for study eligibility

-Intervention was arterial catheterization and delivery of a thrombolytic agent, mechanical thrombectomy, or both, within 6 hours (method left up to the interventionist)

-Approx 90% in each group got TPA (considered usual care in this trial).

Results: 

-The primary outcome was distribution of modified Rankin scale at 90 days. These favored the intervention group in all categories except death.

-Regarding patient who were functionally independent with Rankin score of 0-2, the was 32.6% in the intervention group  vs. 19.1% in the control group.

Mr. Clean

 

-There were no differences in serious adverse events during 90 follow up period between groups.

-HOWEVER, there was a significant difference in the number of symptomatic new strokes in a different territory than the original stroke within 90 days in the intervention group (5.6% in intervention group vs. 0.4% control group)

-Also, some have noted that the TPA only group did very poorly in this trial compared to NINDS and IMS-3, which could make the intervention group look artificially superior.

———————————————–

Now, it always comes down to, would you want this for yourself or a loved one? I’m sure you’ll want to read more to decide.

Further Reading:

Original Article:http://www.nejm.org/doi/full/10.1056/NEJMoa1411587#t=articleTop

Opinions and Summaries:

http://www.emlitofnote.com/2014/12/mr-clean-new-golden-age.html

http://stemlynsblog.org/jc-intra-arterial-treatment-stroke/

http://www.neuroicudoc.com/2014/11/the-mr-clean-trial-improved-outcomes.html

Watch the 2 minute NEJM summary video here:

http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMoa1411587&aid=NEJMoa1411587_attach_1&area=aop

Complex Regional Pain Syndrome

@JoePinero

50 yo M hx of NIDDM, recent left shoulder surgery x 4 mo ago for rotator cuff tear, currently presenting with left arm pain from shoulder to hand with swelling and tightness of the left hand and fingers.

Exam:

Well-appearing male holding his left arm at his side with obvious swelling to the hand with tense skin as appears below.
Hand 1

 

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Don’t Forget About the Kids….

@JoePinero

Quick Case: 17 mo M child presenting with painless bright red rectal bleeding x 1 day. Benign physical exam. Afebrile, with stable vitals and normal labs.

Dx: Meckels Diverticulum
T99 scan for diagnosis (Sensitivity 85-97%, Specificity 97%)
Surgical treatment: Indicated in severe cases, significant blood loss, persistent abdominal pain, refractory to medical treatment. Most common procedure is the trans-umbilical laparoscopic-assisted (TULA) Meckel’s diverticulectomy, which allows the exteriorization of the diverticulum through the navel and the performance of the diverticulectomy outside of the abdomen with its repair in relationship to the enteric defect and morphology
Medical treatment: Indicated in the stable, non-severe cases, supportive care, high dose PPI, IV hydration

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Prisoners Can Refuse Care Too

@JoePinero Prisoners can often cause a lot of ethical dilemma’s when attempting to treat them in the hospital setting. Often times, physicians are reluctant to allow prisoners to sign-out AMA. However, there have been several supreme court cases in the past that have set a solid precedent for allowing this. In brief, here is an interesting, and relatively recent case that might help you the next time a sick prisoner is requesting to sign out AMA.

State vs Reid 2007  ( http://law.ubalt.edu/downloads/law_downloads/Stouffer%20v.%20Reid.pdf )
Reid, sentenced for 40 years, refusing dialysis during his first few years of sentencing with full knowledge that he will not survive without it. The medical doctors went to supreme court in effort to force care and were overruled. Reid was deemed of sound mind and was allowed to forgo dialysis. He would die later that year.

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