Using a protocol to assess stroke patients in the emergency department (ED) enables rapid identification and reperfusion treatment of those who will benefit from it, say Batmanian et al (→ A protocol-driven model for the rapid initiation of stroke thrombolysis in the emergency department). Administered entirely in the ED, their protocol involved rapid assessment of all suspected stroke patients by an emergency physician, early computed tomography with involvement of a neurologist, assessment of appropriateness for thrombolysis using a checklist, and (where indicated) an infusion of tissue plasminogen activator (tPA). With this protocol, 15 of 40 patients who presented within 3 hours of symptom onset received thrombolysis (14% of all stroke admissions; a favourable proportion compared with studies elsewhere). According to Davis et al, the “number needed to treat” for benefit from tPA is very low — as few as three (→ Tissue plasminogen activator for ischaemic stroke: highly effective, reasonably safe and grossly underused). And all Australian hospitals should strive to deliver timely reperfusion therapy for stroke.
Beware . . .
How does an itinerant kitesurfer’s occupation relate to his multiple liver lesions? Our Diagnostic Dilemma (Buchholz and Rudan, “A professional kitesurfer with multiple liver lesions”) recalls an old aphorism.
Buruli ulcer: more awareness needed
Victorians living in communities where Mycobacterium ulcerans is known to be endemic present for medical attention earlier, and are diagnosed and treated more rapidly, than those living outside these areas. Sixty-one of 85 patients with Buruli ulcer (BU) identified by Quek et al lived in communities on the Bellarine Peninsula, where BU is endemic (→ Mycobacterium ulcerans infection: factors influencing diagnostic delay). These patients consulted a doctor in a median time of 3 weeks and BU was diagnosed a week later, while the corresponding figures for out-of-area patients were 5 and 5.3 weeks, respectively. While lesser awareness of an uncommon condition in non-endemic than endemic areas is understandable, the authors call for measures to raise the profile of BU outside the Bellarine Peninsula, as a third of cases occur in people who have visited the region.
Epilim levels overused
According to Rathmalgoda et al, most requests for measurement of serum sodium valproate (SVP) levels are not warranted when judged against evidence-based criteria (→ Serum sodium valproate testing: is it appropriate?). A retrospective audit of SVP tests ordered at Canberra Hospital over 3 months in 2005 found that only 15% of tests were done for an appropriate indication (to assess toxicity or compliance, or adjust dosage in patients on multiple medications) and only 29% were taken at an appropriate time (at least 8 hours after the most recent dose). Commenting on the audit, Vajda reminds us that we should treat patients, not levels, and that, with a few exceptions, serum monitoring of antiepileptic therapy should be based on clear indications, rather than done routinely (→ Monitoring antiepileptic drug therapy with serum level measurements).
In the mail
It is likely that herpes simplex virus can be transmitted by tattooing needles, say Marshall et al in Letters (→ Herpes compunctorum: cutaneous herpes simplex virus infection complicating tattooing). After making a fairly convincing case for this occurrence, they propose a new diagnostic term — “herpes compunctorum”. In other letters, Lee et al have been talking to Indigenous community members about the continuing high rates of cannabis use in Arnhem Land (→ High levels of cannabis use persist in Aboriginal communities in Arnhem Land, Northern Territory); Graham writes on behalf of the Therapeutic Goods Administration on the problems with approved product information (→ MIMS is not a stand-alone resource); and Byard and Matthews urge parents to heed safety messages about three-wheel strollers (→ Drowning and three-wheel strollers).
Ice users far from chilled
About one in 100 patients presenting to the emergency department of St Vincent’s Hospital in Sydney attend for problems relating to crystalline methamphetamine (“ice”) use, and these patients are more likely than patients attending with other drug-related problems to be violent and aggressive, say Bunting et al (→ Comparison of crystalline methamphetamine (“ice”) users and other patients with toxicology-related problems presenting to a hospital emergency department). In just 3 months in late 2006, 449 patients were seen at St Vincent’s ED for drug-related problems, 100 of whom had used ice. Compared with people attending for other drug-related problems, ice users were much more likely to be agitated (6% v 20%) or aggressive (2% v 18%) and to be brought to hospital by the police (9% v 24%).
Another time . . . another place
[I] waked and sat up . . . when I felt a confusion and indistinctness in my head which lasted, I suppose about half a minute . . . Soon after I perceived that I had suffered a paralytick stroke, and that my Speech was taken from me.
Samuel Johnson, Letter to Mrs Thrale, 1783