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Archive for January, 2012

Tuesday, January 31st 2012

Pineal Tumors

What is the most common germ cell tumor in the pineal region?

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Tuesday, January 31st 2012

Impact of Admission Month & Hospital Teaching Status on Outcomes In Subarachnoid Hemorrhage

Background
It is common knowledge to avoid major teaching hospitals in July. Such is when new residents, fresh from medical school, begin as physicians. In some studies the month has been associated with more errors, including notably fatal medication errors. However, the effect continues to be questioned and debated. Even a short review of the surgical literature finds that a preponderence of studies show no worse outcomes with surgical procedures in July as compared to other months. The most notable of these studies is likely this large retrospective review of all Medicare patients undergoing CABG, CEA, AAA repair, colectomy, pnacreatectomy, esophagectomy or hip ORIF between 2003 and 2006. They found no increased mortality or reported morbidity in those three Julys as compared to the other 33 months of the study. Other studies looking just at patients undergoing CABG or patients undergoing emergent appendectomy back up those results.

Add a recent study in the Journal of Neurosurgery to the pile of evidence that new resident physicians in July don’t endanger patients.

McDonald, Robert J., Harry J. Cloft, and David F. Kallmes. “Impact of Admission Month and Hospital Teaching Status on Outcomes in Subarrachnoid Hemorrhage: Evidence against the July Effect.” Journal of Neurosurgery 116 (2012): 157-63.

Design
The study by a group out of the Mayo Clinic is a retrospective analysis of a huge proportion of all hospital admissions between 2001-2008 for non-traumatic subarachnoid hemorrhage. The study pulled all admissions with ICD codes associated with SAH from the National Inpatient Sample. This is an AHRQ national database contributed to by all hospitals in 44 states.

The admissions and their outcomes were studied with two linear regression models for both teaching and non-teaching hospitals. One looked solely at inpatient mortality. The other looked at “unfavorable” discharged; those patients with SAH being discharged to skill care.

Results
There were 52,879 admissions for non-traumatic SAH in the NIS database between 2001-2008. 36,914 were admitted to teaching hospitals and 15,965 were admitted to non-teaching hospitals. There was no monthly variation, in either teaching or non-teaching hospitals, in either model. The authors failed to find any evidence of a “July effect.”

Of note however, there was a discrepancy in outcomes in terms of hospital teaching status. The probability of in-hospital mortality for patients presenting to a teaching hospital with non-traumatic SAH was 11% lower than that or patients presenting to a non-teaching hospital. The probability of “unfavorable” discharge, likewise, was 12% lower.

Discussion

The results of this retrospective review of SAH hos -pital admissions within the 2001–2008 NIS failed to demonstrate significant month-to-month variation among outcomes including in-hospital deaths and/or discharges requiring skilled care. This pattern was observed in both teaching and nonteaching hospitals and suggests that a July effect is absent among SAH hospitalizations.

Also, for life threatening problems, such as subarachnoid hemorrhage, tertiary centers (more often than not teaching facilities) appear to be the place to go for care. At least in terms of outcome.

Monday, January 30th 2012

Dural AVM

What is the most common location for dural arteriovenous malformations?

    A. Transverse sinus/sigmoid sinus junction
    B. Inferior sagittal sinus
    C. Cavernous sinus
    D. Superior sagittal sinus

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Tuesday, January 24th 2012

Orbital Tumors

Name the most common intraorbital tumors in children.

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Monday, January 23rd 2012

Senator Suffers Large Stroke

Senator Mark Kirk is the junior Senator from Illinois. He currently holds President Obama’s old seat which he won in a special election in 2010 to replace Roland Burris.

He has apparently suffered a large right sided, non-dominant hemisphere middle cerebral artery stroke, potentially after a carotid artery dissection on that side. And he’s now undergone a decompressive craniectomy on the right from the late edema suffered with such a large stroke.

Dr. Fessler said the stroke “will affect his ability to move his left arm, possibly his left leg and possibly will involve some facial paralysis. Fortunately, the stroke was not on the left side of his brain, in which case it would affect his ability to speak, understand and think.”

Chances for a full mental recovery were “good” but chances for a full physical recovery were “not great,” Fessler said.

The doctor said he was hopeful that, after rehabilitation at an acute care facility, Kirk would regain the use of his left leg, but said prospects for regaining the full use of his left arm were “very difficult.”

He said recovery is a matter of weeks or months — “it’s not going to be days.” Kirk’s relative youth and good physical shape are positives, Fessler said, and he expects Kirk could return to “a very vibrant life.”

I’m sure they’ve been aggressive considering his age and functional status, not to mention his stature. But to feel the need to go ahead with a craniectomy following a stroke implies a large area of ischemia. Decompressive craniectomy for large middle cerebral artery strokes is not terribly uncommon and the popularity for it has probably grown over the decades. As one, admittedly international paper, describes it.

Decompressive craniotomy in the setting of acute brain swelling from massive MCA infarct is a life saving procedure. It should be considered in patients with initial good GCS, who are deteriorating in neurological status. With the team effort of neurologist and neurosurgeons these cases have good outcome contrary to the natural history of disease…Thus an ideal candidate for decompressive craniotomy is the victim who is young, with no risk factors, who presents early and has nondominant, middle cerebral artery territory infarct, with a reasonable Glasgow Coma Scale with no (or) early signs of herniation. The key for success of these cases of large MCA infarcts is early detection. Clinicians should concentrate on formulating newer clinical, radiological and technical protocols to detect the suitable patients at an early stage.

Certainly from what we know Senator Kirk appears to be an ideal candidate. From the description of his possible long term deficits he appears to have had a large non-dominant hemisphere middle cerebral artery stroke. He is relatively young and fit. And, as The Chicago Tribune describes it, he presented with a relatively good exam and deteriorated quickly.

My thoughts and prayers are with him and his family. He has a long road ahead of him.

Monday, January 23rd 2012

Atlas Fractures

How are C1 vertebrae fractures classified?

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Thursday, January 19th 2012

Dentate Gyrus Cell Layers

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Name the layer labeled #2 in this cross section of the dentate gyrus of the hippocampus.

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Tuesday, January 17th 2012

Unusual Risk Factors For Thrombotic Stroke

What risk factors should be considered in unusual cases of thrombotic stroke?

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Tuesday, January 17th 2012

It Is Cheating But Should It Be?

This has been up and around. I’m sure within the radiology community the CNN “exclusive” was hardly news at all.

The gist of the accusation is that,

For years, doctors around the country taking an exam to become board certified in radiology have cheated by memorizing test questions, creating sophisticated banks of what are known as “recalls,” a CNN investigation has found.

No doubt what was going on constituted cheating. There were specific prohibitions against reproducing questions that test takers agreed to before the privilege of being able to take the written portions of the radiology boards.

But, I guess controversially, should it be that way?

True, it would be hardly a point of confidence if the board self published the questions on their tests and then told the resident candidates to memorize all the answers before they showed up. But the recalls are hardly that. I imagine them more as a study tool. I also imagine that studying them and getting the questions right on the board exam means the radiology residents have learned the material. And that seems the whole point of standardized testing as a method for certifying physicians for various specialties; to make sure they have a baseline, basic set of knowledge. In once sense, how does it matter how that knowledge is memorized?

Saturday, January 14th 2012

Arachnoid Cysts

What are the most common presentations of arachnoid cysts?

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