Three to four percent of all patients with acute ischemic stroke (AIS) receive the only FDA-approved therapy, intravenous tissue plasminogen activator. We sought to assess the impact of a regional stroke program, the Stroke Center at Hartford Hospital, in facilitating various therapies for patients with AIS, and their early outcomes. For a 34-month period (May 2001 to February, 2004), 113 patients received either i.v. and/or intra-arterial thrombolysis, or an experimental protocol as a therapy for AIS. The Hartford Hospital and Stroke Center databases were queried for the diagnosis of AIS using ICD-9 codes, site of patient presentation, transportation modality, stroke severity, and clinical outcome. The percentage of patients with AIS treated has increased each of the past five fiscal years, to 15.4% for fiscal year 2004 to date. This growth is paralleled by increases in mean annual stroke severity of all stroke patients admitted to Hartford Hospital and in the numbers of patients transferred with AIS from other hospitals in southern New England. Symptomatic hemorrhage rate for the 113 patients was 5.3%. In-hospital mortality rate was 25.7%. Most patients (56.6%) were discharged from Hartford Hospital either to home or to acute rehabilitation. A regional stroke program greatly facilitated acute stroke treatment interventions. We attribute this growth to widespread educational programming, an Acute Stroke Team, catheter-based therapies with a dedicated Interventional Neuroradiology service, a 1800 Acute Stroke Hotline, and clinical trials.

Pseudo-atrial flutter is an EKG artifact that mimics a true atrial flutter. We report a case of pseudo-atrial flutter in a 67-year-old male with quadriplegia and ventilator dependence due to amyotrophic lateral sclerosis (ALS) who was hospitalized for respite care. Ihe pseudo-atrial flutterwas found to be due to percussions from a built-in chest wall percussion device in a hospital mattress used for chest physiotherapy.

Giant cell arteritis (GCA) is the most common form of primary vasculitis and it mainly involves large to medium sized vessels. It is also referred to as temporal arteritis as it primarily affects the temporal artery. Ocular involvement frequently occurs in GCA; if not promptly diagnosed, it can cause devastating ocular complications including complete vision loss and permanent blindness. In the majority of cases, it is unilateral; however, there are rare instances where bilateral ocular involvement is reported. In our report, we present the case of a patient presenting with bilateral sudden vision loss associated with GCA.

Acute care surgery (ACS) is a demanding profession that is by its na- ture unpredictable and requires practitioners to routinely deal with uncertainty and stress. We hy- pothesized that the field attracts people who are comfortable working in such an environment and that their comfort with uncertainty increases with experience. A surgeon's stress with uncertainty can be assessed usingthe previouslyvalidated Physician Reaction to Uncertainty Scale (PRU scale). After approval from our IRB and the Eastern Association for the Surgery of Trauma (EAST) Research and Scholarship Committee, an online-survey was sent to EAST members. The survey included demographic questions and the PRU scale. 'The PRU scale requires answering 15 questions on a scale of one to six (strongly disagree to strongly agree) with four subsections measuring anxiety to uncertainty, concern about outcomes, reluctance to disclose uncertainty to patients, and reluctance to disclose mistakes to physicians. A higher score represents greater discomfort. Survey requests were sent to 1707 members; 424 surveys were complete and used for analysis. Most respondents were surgeons (92.4%) and male (77.1%). Average total score was 40.4/90. Overall discomfort with uncertainty on the PRU scale did not vary with gender (p = .88), experience (P=.11), age (P=.21), or practice location (P=.26). With increased experience, there was decreased re- luctance to disclose uncertaintyto patients (P = .03) and a trend to decreased anxiety about outcomes (P=.09). Overall discomfort with uncertainty among ACS providers appears to be inherent in their personality and does not change over a career span.'Ihis factor may play a role in the development of occupational stress since discomfort with uncer- tainty appears to persist over time. Future studies looking at other surgical specialties for comparison and atlongitudinal studies may provide insight into the personality of the community.

Ihis article is a retrospective, sin- gle-center, single-surgeon review of all patients with Down syndrome (Trisomy 21) seen at a free- standing children's hospital between January 2000 and December 2011. The aim was to assess for un- recognized otologic pathology and hearing impair- ment in all new patients between six and 18 years old. Two-hundred-nine patients were seen during the study time frame. Fifty-one patients underwent ear tube surgery with eight patients undergoing surgery for at least three sets of ear tubes. Four patients underwent more advanced ear surgeries for perforation, severe retraction with conductive hearing loss, or acquired cholesteatoma.'Ihere were no cervical subluxations or dislocations periopera- tively. 'Ihirty-six of 47 patients between six and 18 years old had some degree of hearing impairment. 'he success rate of otologic surgery is similar to the non-Down syndrome population. A more compre- hensive database should be developed to ascertain the incidence ofhearingimpairmentin school-aged children with Down syndrome.

The impact of fluid ri suscitation on hematologic parameters and function has been well studied in hemorrhagic shock. Similar research has not been conducted in resuscitation of septic shock. In the absence of accompanying hemorrhage, resuscitation of patients with sepsis should be marked by hemodilution, followed by hemoconcentration during recovery. Records of patients with primary diagnoses of severe sepsis or septic shock treated in a community hospital intensive care unit (ICU) between 2009 and 2012 were extracted from an electronic d tabase for analysis. Demographic, physiologic, an laboratory values were recorded at daily intervals. 132 patients with an average age of 70. (SD 15.1) years and Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 15. (6.0) were studied. Patients spent an average of 10. (9.9) days in the ICU and 18.9 (12.0) days in hospita 19 (14.4%) did not survive hospitalization. Mean admission hematocrit was 34.8 (6.5%), and lo"m est hematocrit, adjusted for (average 0.2 U PRBC) transfusions, 25.3 (5.1)% (P < .001), occurred after an average of four days of treatment, and 7.2 (5.4 L of cumulative positive fluid balance. By day 10 adjusted hematocritincreased to 26.9(8.1) (P =.006' 'Ihere was a significant (P < .001) albeit loose correlation (R = .35) of cumulative positive fluid balance associated with lowest hematocrit. Fluid resuscitation of patients with severe sepsis or septic shock is marked by initial reductions of hematocrit followed by increases during recovery, as fluid is mobilized.

Brucellosis is the most common worldwide zoonosis which continues to remain a significant worldwide health problem and burden. Transmission usually occurs secondary to direct or indirect exposure to certain animals, but a major mode of transmission is the ingestion ofunpasteurized milk or milk products from infected animals. 'Ihe disease has a geographic distribution including the Mediterranean basin and Arabian Peninsula, India, Mexico, and parts of Central and South America. However, cases are seen in the United States in international travelers or due to ingestion ofusuallyimported, unpasteurized dairyproducts. Systemic infection with Brucella species can affect anyorgan, although focal forms ofbrucellosis do exist. We present a case of brucellar vertebral osteomyelitis.

As the need for comprehensive, affirmative health care for transgender and gender nonconforming youth has increased in recent years, clinical practice has struggled to catch up with evolving standards of care. The Yale Gender Center is an example of an interdisciplinary model of care that addresses not only clinical needs, but also ancillary needs for patients and training opportunities for students across several health disciplines. In this article, we discuss our clinical and training models, lessons learned, and our proposed directions to expand care. It is our hope to not only offer a model for interdisciplinary care among other health care centers, but to be able to learn from missteps and potentially collaborate with other centers in the future.