Alexis Newmark

Femoral artery cannulation for venoarterial extracorporeal membrane oxygenation (ECMO) can be associated with ischemic and neurologic complications. The subclavian artery offers an alternative cannulation site, which is helpful in patients with peripheral vascular disease, in those who have sustained pelvic trauma, or when ambulation is anticipated. This is a single-institution review of 20 adults who were placed on venoarterial ECMO using subclavian arterial cannulation over a 2 year period. Technical success with subclavian venoarterial ECMO was 100%. Median ECMO time was 168 hours (2.4-720 hours). Sufficient flows (median 4.24 L/min), oxygenation (median postcannulation PaO2 315 mm Hg), and ventricular unloading confirmed with intraoperative transesophageal echocardiogram were achieved in all patients. Seventy-five percent of patients were decannulated, 50% were extubated, and 45% were discharged. Seven patients (35%) had an entirely upper body ECMO configuration with the internal jugular vein serving as the venous drainage site. Complications included arterial cannula site hematoma and infection, as well as ipsilateral arm swelling. Each required conversion to femoral artery cannulation. There were no ischemic or neurologic complications. Patients with acute cardiopulmonary failure can safely be placed on subclavian venoarterial ECMO for prolonged periods with full flows, adequate oxygenation, and sufficient ventricular unloading.

BACKGROUND: Over the past 3 decades, a wide range of studies in the United States and the United Kingdom has reported that white individuals are more likely to be diagnosed with bipolar and affective disorders, whereas black individuals appear to be at higher risk for schizophrenia spectrum diagnoses. Despite the pressing need for strategies aimed at eliminating racial and cultural disparities in diagnosis and treatment of bipolar disorder, no systematic review of the existing literature in this area has been done. This study draws together the disparate strands of information in a comprehensive overview of the research base in this area. METHODS: An electronic literature search of the Medline and PsychINFO databases was conducted in October 2009, supplemented by a review of references in the identified articles, for a total of 51 articles included in this qualitative review. RESULTS: Black patients have consistently been found to be more likely than white patients to be diagnosed with schizophrenia rather than bipolar disorder. Four factors were identified as potential contributors to racial disparities in diagnostic rates: clinical presentation and expression of symptoms, access to care, help-seeking behaviors, and clinician judgment. CONCLUSION: Despite efforts to curtail the phenomenon, racial disparities in diagnosis of bipolar disorder persist. Racial and cultural elements may affect how patients manifest behaviors and symptoms and how these are interpreted and attributed by clinicians in the diagnostic process. As an appropriate diagnosis determines treatment options and is central to quality of care, incorrect diagnosis can potentially have a negative impact on treatment effectiveness and accuracy of prognosis.

OBJECTIVE: To perform a quality-improvement project to increase the rate at which expedited partner therapy is offered and prescribed at our clinic, in line with Connecticut Department of Public Health regulations. METHODS: We conducted quality-improvement interventions at an urban hospital-based outpatient clinic in Hartford, Connecticut, to improve prescribing of expedited partner therapy to at least 70% of eligible patients. We defined appropriate provision of expedited partner therapy by infection type (gonorrhea or chlamydia only per Centers for Disease Control and Prevention guidelines) and method of prescription per Connecticut Department of Public Health regulations (paper prescription or in-clinic dispensing). RESULTS: Rates of appropriate provision of expedited partner therapy improved with our interventions (21.6% vs 75.5%). We found an unexpected decrease in acceptance by patients after initiation of our interventions (81.3% vs 50.5%). CONCLUSION: We achieved our goal of improvement of rates of appropriate provision of expedited partner therapy to greater than 70% and have maintained this improvement over time. Future work should investigate potential barriers to expedited partner therapy acceptance, including type of infection, the effect of Department of Public Health regulation of prescribing options, and standard workflow in patient counseling.