Background: and Purpose The benefit regarding co-treatment with intravenous (IV) thrombolysis before mechanical thrombectomy in acute ischemic stroke with large vessel occlusion remains unclear. To test the hypothesis that clinical outcome of ischemic stroke patients with intracranial internal carotid artery, middle cerebral artery or basilar artery occlusion treated with direct endovascular thrombectomy within 4.5 hours will be non-inferior compared with that of standard bridging IV thrombolysis followed by endovascular thrombectomy. Methods: To randomize 780 patients 1:1 to direct thrombectomy or bridging IV thrombolysis with thrombectomy. An international-multicenter prospective randomized open label blinded endpoint trial (PROBE) (ClincalTrials.gov identifier: NCT03494920). Results: Primary endpoint is functional independence defined as modified Rankin Scale (mRS) 0–2 or return to baseline at 90 days. Secondary end points include ordinal mRS analysis, good angiographic reperfusion (modified Thrombolysis in Cerebral Infarction score [mTICI] 2b–3), safety endpoints include symptomatic intracerebral hemorrhage and death. Conclusions DIRECT-SAFE will provide unique information regarding the impact of direct thrombectomy in patients with large vessel occlusion, including patients with basilar artery occlusion, with comparison across different ethnic groups.

Combined latissimus dorsi transfer, subscapularis repair and Latarjet surgery is rare and has never been reported. A 35-year-old man with chronic shoulder pain had a long history of instability of his right shoulder. The first episode occurred during a game of touch rugby followed by multiple episodes of subluxation. MRI was done which showed complete tear of the subscapularis anteriorly which was retracted and atrophied indicating a longstanding tear. There was also significant mid substance supraspinatus tendon tear. Patient then underwent two surgeries. The initial surgery found the rotator cuff to be irreparable with glenoid bone loss and only acromioplasty with acromioclavicular joint resection were performed. He then had a single stage surgery consisting of latissimus dorsi transfer, Latarjet procedure and subscapularis repair. A two-stage surgery can be avoided, and good results can be obtained provided that the patient undergo correct rehabilitation regime after undergoing a single stage surgery.

Australia’s Indigenous peoples account for 3% of the country’s population yet continue to experience disproportionately higher rates of mortality and hospitalization for many infectious diseases.1 The 2009 influenza pandemic had an inequitable impact on Indigenous peoples in Australia,2 New Zealand,3 the Americas and the Pacific.4 Genuine and tangible actions that include Indigenous peoples in the planning and response for pandemic influenza is overdue. This paper will identify some of the strategies to incorporate the perspectives of Australia’s Indigenous peoples (hereafter Aboriginal) in planning and responding to infectious disease emergencies.

BACKGROUND:Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED), with primary electrical cardioversion (PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation (EDPS) for PEC differ from those requiring EDPS for other procedures:they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital. METHODS:This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression. RESULTS:A total of 4867 patients were included, 714 for PEC for AF and 4153 for other indications. PEC patients were more likely male (58.5％vs. 47.1％), older (59.5 years vs. 48.1 years), and less likely to be ASA I (46.6％ vs. 69.0％). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy (11.5％ vs. 78.2％). PEC patients were more likely to experience hypotension (27.6％vs. 16.5％) but respiratory AEs (apnea, hypoxia and airway intervention) were not different. CONCLUSION:EDPS for PEC differs from that conducted for other purposes:patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.

BACKGROUND:This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED). METHODS:The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction. RESULTS:Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48％ of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71％), cardioversion (12％) and abscess incision and drainage (12％) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO2<90％) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9％ vs. 9.3％,P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3％) patients in the ETC group and 7 (1.4％) in the control group (P=0.048). CONCLUSIONS:The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.

Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation and evaluation of public health practice. It can serve as an early warning system for impending public health emergencies; document the impact of an intervention, or track progress towards specified goals; and monitor and clarify the epidemiology of health problems, to allow priorities to be set and to inform public health policy and strategies.

Medical co-morbidities are very common in patients with psychiatric conditions. Although respecting one's autonomy to make treatment decisions is the ethical default position, the capacity to make such decisions may need to be assessed, especially when patients are in relapse of their psychiatric condition, and/or when the decisions made are high-risk and possibly fatal. This case report highlights the ethical issues of refusing potential life-saving treatment in a patient who is in relapse of her schizoaffective disorder. In particular, the assessment of decisional capacity and the role of the doctors (if the patient lacks capacity) are discussed. Recommendations are also made on how to better manage such situations.
Adult ; Female ; Humans ; Kidney Failure, Chronic ; therapy ; Mental Competency ; Patient Care ; ethics ; Patient Participation ; psychology ; Personal Autonomy ; Schizophrenia