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To evaluate the risk and presence of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke, and examine the correlation of OSA with age, sex, ischemic stroke subtype, disability, and death, a prospective cohort study was conducted in all consecutive patients presenting with acute ischemic stroke between June 2007 and March 2008. Exclusion criteria were age18 years, refusal of consent for the study, and incomplete questionnaire. The Berlin Sleep Questionnaire was used to identify patients at high risk for OSA. A total of 174 patients with acute ischemic stroke were included; 130 (74.7%) had a modified Rankin Scale (mRS) score ≥ 3 at dismissal, and 11 patients (6.3%) died within 1 month. The Berlin Sleep Questionnaire identified 105 patients (60.4%) at high risk for OSA, along with 7 patients (4%) with a previous diagnosis of OSA. Those with a previous diagnosis of OSA were more likely to die within the first month after stroke (relative risk, 5.3; 95% confidence interval, 1.4-20.1) compared with those without OSA. Patients at high risk for OSA did not demonstrate increased mortality at 30 days (P = 1.0). In multivariate analysis, after adjusting for age and National Institutes of Health Stroke Scale score, previous diagnosis of OSA was an independent predictor of worse functional outcome, that is, worse mRS score at hospital discharge (P = .004). The mRS score was 1.2 points higher (adjusted R², 40%) in those with OSA. Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke.

The physical and emotional stress of pregnancy can precipitate new-onset seizures in a woman. In these cases, emergency department evaluations must rule out underlying pathology. Careful consideration of antiepileptic drug use must be considered in the first trimester as all antiepileptic drugs have been linked to some teratogenic effect. Eclampsia must always be considered in the pregnant woman who is more than 20 weeks gestation; 25% of eclamptic seizures occur in the postpartum period. Magnesium is the recommended treatment for eclamptic seizures when delivery is not possible.

We sought to examine the relationship of the QTc interval with mortality and functional outcome after acute ischemic stroke, and determine whether a threshold cutoff is present beyond which risk of death increases.The QTc interval was measured for all patients presenting to the emergency department. The outcomes were mortality at 90 days and functional outcome at hospital discharge. The cutoffs were determined plotting martingale residuals.Patients with a prolonged QTc interval were more likely to die within 90 days compared with patients without a prolonged interval (relative risk [RR] 2.5; 95% confidence interval [CI] 1.5-4.1; P.001). The estimated survival at 90 days was 70.5% and 87.1%, respectively. This association retained statistical significance after adjusting for age and National Institutes of Health Stroke Scale score (RR 1.7; 95% CI 1.0-2.9; P = .043). Patients with a prolonged QTc interval were also more likely to have poor functional status compared with patients without a prolonged interval (odds ratio 1.8; 95% CI 1.2-3.0; P = .006). This association was not statistically significant after adjusting for age and National Institutes of Health Stroke Scale score (odds ratio 1.2; 95% CI 0.7-2.4). The identified threshold cutoffs for increased risk of death at 90 days were 440 milliseconds for women and 438 milliseconds for men.There appears to be an increased risk of early death in patients with acute ischemic stroke and a prolonged QTc interval at the time of emergency department presentation. Prognosis appears to be worse with QTc intervals longer than 440 milliseconds in women and longer than 438 milliseconds in men.

Background Statins have been shown to improve the functional outcome of patients after an ischemic stroke. We hypothesized that daily statin intake improves functional outcome after an acute ischemic stroke in patients with low-density lipoprotein (LDL) less than or equal to 100 mg/dL. Methods This was a prospective cohort study during a 22-month period of patients presenting with an acute ischemic stroke and lipid profiles measured. The functional disability was determined using modified Rankin scale score (0-2 good outcome, 3-6 bad outcome) at discharge. Chi-square test for binary data and nonparametric tests for nonnormally distributed variables were used for analysis. Results Of 508 patients, 207 presented with an LDL of 100 mg/dL or less and were included in the analysis. There was no significant difference in admission stroke severity (National Institutes of Health Stroke Scale [NIHSS]; P = .18), age ( P = .31), and sex ( P = .06) between those taking statins and not taking statins. Patients with LDL less than or equal to 100 mg/dL and taking statins (n = 100) were significantly more likely to have a good functional outcome (odds ratio 1.91; 95% confidence interval 1.05-3.47) when compared with those not on the medication. After adjusting for age, sex, and NIHSS, statin intake still predicted a better functional outcome ( P Conclusion Daily statin intake appears to result in a better functional outcome after an ischemic stroke in patients with ideal LDL levels (≤100 mg/dL) before and after adjusting for age and stroke severity. Pleiotropic effects of statins may play a role in this.

This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Ciccone A, Abraha I, Santilli I. Glycoprotein IIb-IIIa inhibitors for acute ischaemic stroke. Cochrane Review 2006; Issue 4. Chichester, UK: John Wiley and Sons. DOI:10.1002/14651858.CD005208.pub2. The Annals’ EBEM editors helped prepare the abstract of this Cochrane systematic review, as well as the Evidence-Based Medicine Teaching Points.

This is a systematic review abstract, a regular feature of the Annals’ Evidence-Based Emergency Medicine (EBEM) series. Each features an abstract of a systematic review from the Cochrane Database of Systematic Reviews and a commentary by an emergency physician knowledgeable in the subject area. The source for this systematic review abstract is: Gubitz G, Counsell C, Sandercock P, Signorini D. Anticoagulants for acute ischaemic stroke (Cochrane Review). In: The Cochrane Library. Issue 3. Oxford, United Kingdom: Update Software; 2004. The Annals’ EBEM editors helped prepare the abstract of this Cochrane systematic review as well as the EvidenceBased Medicine Teaching Points.

E B E M / S Y S T E M A T I C R E V I E W A B S T R A C T J U L Y 2 0 0 3 4 2 : 1 A N N A L S O F E M E R G E N C Y M E D I C I N E 1 5 1 authors meant that the researchers made some sort of effort to exclude hemorrhagic stroke, although only 1 of the 7 trials included actually used computed tomography (CT) to make the distinction. D A T A E X T R A C T I O N Two authors independently selected trials, extracted data, and assessed the quality of the trials. Odds of death, functional outcome, and adverse effects were assessed with 95% confidence intervals (CIs). M A I N R E S U L T S A total of 22 trials were identified, of which 7 fulfilled the inclusion criteria (n=453 patients) and were included in this updated review. Two of the 7 studies used betamethasone, whereas the remainder used dexamethasone. Corticosteroid treatment was associated with very variable change in odds of death (95% CI 0.68 to 1.72). No meaningful analysis could be derived for functional outcome, because the studies did not use common neurologic impairment scales or common time intervals for assessment, making it impossible to pool data for analysis. Similarly, only 1 of the 7 studies reported adverse effects in a systematic manner, thereby precluding meta-analysis. Overall, adverse effects were infrequent and consisted of gastrointestinal bleeding, infection, and hyperglycemia.

Study objectives: We determine whether standard ECG intervals, based largely on population data from middle-aged men, are applicable to the elderly, particularly those older than 90 years. Methods: The medical records of all patients aged 90 years and older presenting to our institution for health maintenance examinations in 2002 were examined. Data on rhythm, QTc, QRS, and PR intervals was collected. The presence of coronary artery disease, including history of myocardial infarction, valvulopathy, or presence of pacemaker, was also recorded. A prolonged QTc interval was defined as 440 ms or greater. A prolonged QRS interval was defined as 100 ms or greater. A prolonged PR interval was defined as 200 ms or greater. All patients in the mentioned cohort were captured; there were no missing records. Results: Of the 60 total patients, 35 had an ECG performed as part of their routine medical examination. Fourteen of the 35 patients had a history of coronary artery disease (CAD) as defined above, whereas 21 patients had no such history. The mean PR, QRS, and QTc intervals are summarized in Table 1. The presence of pronged intervals is summarized in Table 2 according to intervals defined in the methods. Conclusion: ECG intervals are prolonged in approximately one third of all patients older than 90 years who present for routine medical care. The presence of coronary artery disease does not appear to have much impact on the ECG intervals. However, mean and median values for the PR, QRS, and QTc intervals do not differ greatly from published normals. Table 1, abstract 230 . Mean Rate (SD; Range) Mean PR Interval, ms (SD; Range) Mean QRS Interval, ms (SD; Range) Mean QTc Interval, ms (SD; Range) Whole group 70 (11.85; 41–102) 199 (36; 148–282) 105 (28.6; 76–190) 436 (29.54; 385–505) CAD group 63 (10.29; 41–78) 207 (39; 124–282) 102 (22.8; 76–190) 429 (27.86; 385–503) Non-CAD group 68 (8.80; 53–103) 196 (35; 148–280) 112 (31.1; 76–102) 438 (31.32; 397–505) Table 2, abstract 230 . Frequency of Prolonged PR Interval Frequency of Prolonged QRS Interval Frequency of Prolonged QTc Interval Whole group 15 (43%) 14 (40%) 10 (29%) CAD group 4 (29%) 6 (43%) 3 (21%) Non-CAD group 11 (52%) 8 (38%) 7 (33%)

u t t b 45-year-old woman had a syncopal episode while reparing for some appointments. The episode was decribed as a gentle “easing down”; the patient’s husband aught her before she hit anything. She did not have any ead trauma. The past medical history was notable for ecently diagnosed carcinoma of the head of the panreas, for which she underwent biliary stent placement at nother instititution a few days before the syncopal episode. Physical examination revealed an extremely tiredppearing woman who was able to answer some quesions but had an altered level of consciousness. Her vital igns were within normal limits except for temperature, hich was 35.8°C. Extremities demonstrated pitting dema up to the knees. The rest of the physical examiation findings were normal. An electrocardiogram (EKG) was obtained immeditely and showed markedly peaked T waves, with a new eft bundle branch block (Figure 1). Because markedly levated T waves are consistent with hyperkalemia, elecrolyte levels were determined immediately and, simulaneously, treatment for hyperkalemia was instituted. he patient received 1 ampule of 10% calcium chloride nd 10 units of regular insulin intravenously, followed by ampule of D50 and 1 nebulizer treatment of 2.5 mg of lbuterol. After these measures, EKG was repeated and howed normalization of the T waves and disappearance f the left bundle branch block (Figure 2). The serum otassium level was 7.3 mEq/L. Arterial blood gas analysis revealed the following: pH .46; PCO2, 27 mm Hg; and bicarbonate, 16 mEq/L. The