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Jonathan A Edlow

Publications and source records attributed to Jonathan A Edlow.

18 recordsLinked to original sources
PubMed2007

Pitfalls in the diagnosis of cerebellar infarction.

BACKGROUND: Cerebellar infarctions are an important cause of neurologic disease. Failure to recognize and rapidly diagnose cerebellar infarction may lead to serious morbidity and mortality due to hydrocephalus and brain stem infarction. OBJECTIVES: To identify sources of preventable medical errors, the authors obtained pilot data on cerebellar ischemic strokes that were initially misdiagnosed in the emergency department. METHODS: Fifteen cases of misdiagnosed cerebellar infarctions were collected, all seen, or reviewed by the authors during a five-year period. For each patient, they report the presenting symptoms, the findings on neurologic examination performed in the emergency department, specific areas of the examination not performed or documented, diagnostic testing, the follow-up course after misdiagnosis, and outcome. The different types of errors leading to misdiagnosis are categorized. RESULTS: Half of the patients were younger than 50 years and presented with headache and dizziness. All patients had either incomplete or poorly documented neurologic examinations. Almost all patients had a computed tomographic scan of the head interpreted as normal, and most of these patients underwent subsequent magnetic resonance imaging showing cerebellar infarction. The initial incorrect diagnoses included migraine, toxic encephalopathy, gastritis, meningitis, myocardial infarction, and polyneuropathy. The overall mortality in this patient cohort was 40%. Among the survivors, about 50% had disabling deficits. Pitfalls leading to misdiagnosis involved the clinical evaluation, diagnostic testing, and establishing a diagnosis and disposition. CONCLUSIONS: This study demonstrates how the diagnosis of cerebellar infarction can be missed or delayed in patients presenting to the emergency department.

Adult↗
PubMed2006

National study on emergency department visits for transient ischemic attack, 1992-2001.

OBJECTIVES: To describe the epidemiology of U.S. emergency department (ED) visits for transient ischemic attack (TIA) and to measure rates of antiplatelet medication use, neuroimaging, and hospitalization during a ten-year time period. METHODS: The authors obtained data from the 1992-2001 National Hospital Ambulatory Medical Care Survey. TIA cases were identified by having ICD-9 code 435. RESULTS: From 1992 to 2001, there were 769 cases, representing 2,969,000 ED visits for TIA. The population rate of 1.1 ED visits per 1,000 U.S. population (95% CI = 0.92 to 1.30) was stable over time. TIA was diagnosed in 0.3% of all ED visits. Physicians administered aspirin and other antiplatelet agents to a small percentage of patients, and 42% of TIA patients (95% CI = 29% to 55%) received no medications at all in the ED. Too few data points existed to measure a statistically valid trend over time. Physicians performed computed tomography scanning in 56% (95% CI = 45% to 66%) of cases and performed magnetic resonance imaging (MRI) in < 5% of cases, and there was a trend toward increased imaging over time. Admission rates did not increase during the ten-year period, with 54% (95% CI = 42% to 67%) admitted. Regional differences were noted, however, with the highest admission rate found in the Northeast (68%). CONCLUSIONS: Between 1992 and 2001, the population rate of ED visits for TIA was stable, as were admission rates (54%). Antiplatelet medications appear to be underutilized and to be discordant with published guidelines. Neuroimaging increased significantly. These findings may reflect the limited evidence base for the guidelines, educational deficits, or other barriers to guideline implementation.

Adolescent↗
PubMed2006

Geriatric neurologic emergencies.

Geriatrics is an important subspecialty within the field of emergency medicine and represents a burgeoning area of practice. The special vulnerability of elderly patients to neurologic disease and injury and the comparative subtlety of clinical presentation mean that physicians should have a lower threshold for laboratory studies, radiologic imaging, consultation, and admission. Transferring appropriate patients to tertiary centers that offer specialized trauma and neurologic and neurosurgical care greatly enhances survival and functional outcomes.

Aged↗
PubMed2006

MDCT angiography of acute chest pain: evaluation of ECG-gated and nongated techniques.

OBJECTIVE: The objective of our study was to compare MDCT angiography protocols used in patients with acute chest pain caused by vascular, nonvascular, and cardiac abnormalities. SUBJECTS AND METHODS: In four groups of 20 patients with chest pain each, four MDCT protocols were used based on monitoring vascular attenuation: pulmonary embolism (150 H at pulmonary artery), aortic dissection (200 H at aortic arch), chest pain (200 H at pulmonary artery), and chest pain with ECG gating (150 H at pulmonary artery). Vascular enhancement was assessed by attenuation measurements taken from locations in the pulmonary artery (n = 3) and thoracic aorta (n = 4). The appearance of the coronary artery in regard to opacification and motion was assessed on a scale of 1 to 5 (best). RESULTS: The mean pulmonary artery and aorta attenuation (372 H and 352 H, respectively) was significantly higher (p < 0.005, Student's t test) and the number of vessel attenuation points measuring less than 200 H (1/140) was significantly smaller (p < 0.001, chi-square test) in the chest pain compared with the dissection (318 H, 310 H; 16/140), gated chest pain (304 H, 286 H; 17/14), and pulmonary embolism (302 H, 220 H; 28/140) groups. The median coronary artery visualization score was 4; the proximal regions received a significantly (p < 0.005, Mann-Whitney test) higher grade compared with the middle and distal regions (medians, 5, 4, and 2, respectively). Artifacts were noted on the gated scans. CONCLUSION: The chest pain protocol can be used to assess both the pulmonary arteries and the thoracic aorta, whereas the ECG-gating protocol appears to be a promising adjunct for a comprehensive single chest pain protocol.

Acute Disease↗
PubMed2005

Barriers to the use of outpatient enoxaparin therapy in patients with deep venous thrombosis.

OBJECTIVE: To establish a clinical pathway for outpatient enoxaparin therapy in deep venous thrombosis (DVT) and then characterize its implementation and barriers to use. PROCEDURE: Single institution, prospective, observational study of consecutive adult emergency department patients (age > or =18 years) who had a diagnosis of DVT. A clinical pathway was created to facilitate outpatient therapy with enoxaparin, and then all patients with DVT were enrolled and studied. RESULTS: A total of 97/98 (99%) eligible patients were enrolled. Among 97 patients, 29 (30%) were successfully started on the outpatient enoxaparin therapy approach. Of the 68 (70%) patients not started on the outpatient therapy, 19 (20%) patients had contraindications to anticoagulant therapy, 33 (34%) had other indications for hospitalization, 6 (6%) were unable to reliably self-inject, and 10 (10%) patients had a primary care physician or emergency physician who rejected the outpatient approach. CONCLUSIONS: The establishment of an organized DVT pathway for outpatient enoxaparin may facilitate home therapy; however, there will remain reasons that make hospital admission unavoidable in some patients.

Ambulatory Care↗
PubMed2005

Emergency department presentations of transverse myelitis: two case reports.

Transverse myelitis, a diagnosis that may be made in the emergency department (ED) by emergency physicians, can be difficult to diagnose because of its variable signs and symptoms and its poorly understood pathogenesis. In this article, we recount 2 cases of transverse myelitis to demonstrate its presentation, diagnosis, and management in the ED.

Abdominal Pain↗
PubMed2005

Myasthenia gravis: lessons for the emergency physician.

We describe three patients with myasthenia gravis who presented to the emergency department - one with a previously established diagnosis and two others who were newly diagnosed as a result of workup initiated in the emergency department. Differential diagnosis of conditions causing neuromuscular weakness is broad; however, a key aspect of myasthenia gravis is fluctuating muscle weakness that increases with repeated use and improves with rest. Both newly diagnosed patients presented with ocular complaints, a common finding in myasthenia gravis. The third patient presented with a potentially life-threatening myasthenic crisis. Key points of discussion include: bedside tests to diagnose myasthenia gravis; distinction between cholinergic versus myasthenic crisis; and emergency department considerations when intubating a myasthenia gravis patient becomes necessary.

Aged↗
PubMed2005

Diagnosis of subarachnoid hemorrhage.

The ideal therapy and neurocritical care for patients with aneurysmal subarachnoid hemorrhage (SAH) follows from an early and accurate diagnosis. However, approximately 30% of patients with SAH are misdiagnosed at their initial visit to a physician. This article explores the reasons for this alarming error rate: failure to understand the full spectrum of presentation of SAH and failure to know the limitations of the major diagnostic tests (computed tomography of the brain and lumbar puncture [LP]). I suggest a strategy for selecting which patients with headache require evaluation beyond history and physical examination and how that evaluation should proceed. Other diagnostic issues are also discussed, such as use of magnetic resonance scanning and angiography for diagnosis, distinguishing the traumatic LP from true SAH, the concept of warning bleeds, and the LP-first diagnostic strategy.

Cerebral Angiography↗
PubMed2004

Transient ischemic attack: review for the emergency physician.

In the past few years, the approach to patients with transient ischemic attacks has undergone a transformation. To care for these patients, emergency physicians must understand these changes. They must be comfortable with the diagnosis and treatment of transient ischemic attacks in their emergency department. To this end, we ask and answer the following 6 important questions in this up-to-date review of transient ischemic attacks: (1) How is a transient ischemic attack defined? (2) Does this patient have a transient ischemic attack? (3) Once diagnosed, what diagnostic evaluation should be done (and when)? (4) What treatment should be instituted (and when)? (5) What is the correct disposition? and (6) What are the current medical guidelines?

Anticoagulants↗
PubMed2004

Ultrasound diagnosis of deep venous thrombosis.

The ultrasound diagnosis of deep venous thrombosis by an emergency physician is occurring with increased frequency. The examination is simple to perform and, when combined with a clinical pretest probability or D-dimer, can aid in the rapid disposition ofa patient with lower extremity pain and swelling. The technique and findings of the limited lower extremity ultrasound and the data to support its use in the emergency department are discussed.

Algorithms↗
PubMed2003

Diagnosis of subarachnoid hemorrhage in the emergency department.

To decide which patients with headache ought to be evaluated for SAH, physicians should focus on specific elements of the patient history, such as onset, severity, and quality of the headache and associated symptoms. These questions should be asked and the responses documented for every patient with a headache. The physical examination should be compulsive with regard to vital signs, HEENT. and neurologic signs. Then, the physician should form an explicit differential diagnosis and have reasons for diagnosing migraine, tension, or sinus headache and other benign causes. If there is no clear-cut alternative hypothesis, the patient should be evaluated by CT and LP (if the CT is negative, equivocal, or technically inadequate). Physicians should understand the limitations of this diagnostic algorithm. In addition, the CSF should be carefully analyzed, including measuring the opening pressure. In patients whose CT scans and CSF analyses are normal, further testing is rarely indicated.

Diagnosis, Differential↗
PubMed2003

Benign exertional headache.

We describe 4 patients with benign exertional headache presenting to the emergency department. Consideration of this uncommon cause of headache might facilitate an accurate diagnosis of those patients with headache caused by strenuous exercise.

Acetaminophen↗
PubMed2003

Incidence of traumatic lumbar puncture.

OBJECTIVE: To determine the incidence of traumatic lumbar puncture (LP). METHODS: A retrospective study was conducted at an urban, university tertiary care referral center with 50000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. RESULTS: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01). CONCLUSIONS: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital.

Cerebrospinal Fluid↗
PubMed2002

Erythema migrans.

EM is the most common manifestation of early Lyme disease, occurring in a high percentage of cases. Because this phase of infection with B. burgdorferi offers an excellent opportunity to treat this potentially systemic infection, front-line physicians must be familiar with its diagnosis. Although much attention has been paid to the classic form--the target lesion or bull's eye--there are variations that are more common. These include uniform coloration, lesions with necrotic or vesicular centers, and lesions with shapes that are not circular or oval. These findings must be interpreted in epidemiologic context. Serologic testing at this phase of the illness should not be done. It is unnecessary and potentially misleading; false-positive and false-negative tests can occur. Diagnosis is clinical. Prompt initiation of appropriate antibiotic therapy for 3 weeks cures most patients at this early stage of the disease. Clinicians should be aware that 15% of patients may be coinfected with a second tick-borne pathogen, which could alter the usual clinical manifestations and the response to treatment.

Anti-Bacterial Agents↗
PubMed2002

Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage.

The lumbar puncture (LP) is a relatively simple diagnostic test. However, significant diagnostic ambiguity can arise when trauma from the needle causes bleeding into the subarachnoid space, especially when trying to make the diagnosis of subarachnoid hemorrhage (SAH). The purpose of this article is to assist emergency physicians in distinguishing traumatic LPs from SAH. To correctly interpret the findings of a traumatic tap, a few concepts must be understood. Timing of the LP in relation to the onset of the SAH affects the results of the cerebrospinal fluid (CFS) analysis; the typical findings will change with time. With a few caveats, xanthochromia, the yellow discoloration of the CSF resulting from hemoglobin catabolism, is often critical in making a diagnosis of SAH. A few of the most essential methods for distinguishing traumatic LP from true SAH include: the "three tube test," opening pressure, and inspection for visual xanthochromia.

Algorithms↗
PubMed2002

Xanthochromia.

CONTEXT: Diagnosis of subarachnoid hemorrhage is usually established by computed tomographic scanning; however, in a few patients, lumbar puncture to examine the cerebrospinal fluid for erythrocytes and xanthochromia is necessary. Some authorities recommend delaying lumbar puncture by 12 hours following onset of symptoms to ensure sufficient time has elapsed for xanthochromia to develop. This recommendation is based on measuring xanthochromia by spectrophotometry. Our hypothesis was that very few hospital laboratories in the United States use this method. OBJECTIVE: To determine the percentage of hospital clinical laboratories that measure for xanthochromia using spectrophotometry. DESIGN, SETTING, AND PARTICIPANTS: Mail survey to 3500 hospital clinical laboratory directors (in collaboration with the College of American Pathologists). Surveys were mailed in January 2001 and the results tabulated 1 month later. Participation was voluntary. MAIN OUTCOME MEASURES: Percentage of hospital clinical laboratories that use spectrophotometry versus visual inspection. RESULTS: Of the 3500 laboratories surveyed, 2551 (72.9%) responded. Of these, 1944 (76.2%) indicated that they evaluated for xanthochromia. Of the 1952 laboratories that answered the question "How do you report your results?" 1947 (99.7%) reported using visual inspection. CONCLUSIONS: When evaluating for xanthochromia in cerebrospinal fluid, nearly all hospital clinical laboratories in the United States use visual inspection. Given this current reality, the recommendation of delaying lumbar puncture by 12 hours needs to be reassessed.

Clinical Laboratory Techniques↗