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Concept: Boston

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In November 2015, a neurologist in the Boston, Massachusetts, area reported four cases of an uncommon amnestic syndrome involving acute and complete ischemia of both hippocampi, as identified by magnetic resonance imaging (MRI), to the Massachusetts Department of Public Health (MDPH) (1). A subsequent e-mail alert, generated by the Massachusetts Board of Registration in Medicine and sent to relevant medical specialists (including neurologists, neuroradiologists, and emergency physicians), resulted in the identification of 10 additional cases that had occurred during 2012-2016. All 14 patients (mean and median age = 35 years) had been evaluated at hospitals in eastern Massachusetts. Thirteen of the 14 patients underwent routine clinical toxicology screening at the time of initial evaluation; eight tested positive for opioids, two for cocaine, and two for benzodiazepines. Apart from sporadic cases (2-6), this combination of clinical and imaging findings has been reported rarely. The apparent temporospatial clustering, relatively young age at onset (19-52 years), and associated substance use among these patients should stimulate further case identification to determine whether these observations represent an emerging syndrome related to substance use or other causes (e.g., a toxic exposure).

Concepts: Medicine, Brain, Hospital, Medical imaging, Nuclear magnetic resonance, Physician, Magnetic resonance imaging, Boston

15

Health care consumers won a significant victory when Massachusetts Suffolk County Superior Court Judge Janet Sanders blocked a settlement that would have allowed Partners HealthCare, the system that dominates the Boston area, to acquire three additional health care providers in eastern Massachusetts. Sanders concluded that the acquisitions “would cement Partners' already strong position in the health care market and give it the ability, because of this market muscle, to exact higher prices from insurers for the services its providers render.” If this decision is not overturned on appeal, consumers will now be spared those projected price increases. But there is . . .

Concepts: Health care, Health care provider, Healthcare, Health, Massachusetts, Boston, New York, Greater Boston

10

Many patients even those with health insurance pay out-of-pocket for medicines. We investigated the availability and prices of essential medicines in the Boston area.

Concepts: Health care, Health insurance, Pharmacy, Price, Massachusetts, New England, Boston, Greater Boston

6

Our aim was to identify the factors influencing the selection of a model of acute stroke service centralization to create fewer high-volume specialist units in two metropolitan areas of England (London and Greater Manchester). It considers the reasons why services were more fully centralized in London than in Greater Manchester.

Concepts: England, New York City, London, Boston, Manchester United F.C., Greater Manchester, Manchester, Metropolitan county

6

We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions.

Concepts: Marathon, Boston, Atomic bombings of Hiroshima and Nagasaki, Bomb, Boston Marathon, Robert Kipkoech Cheruiyot, World Marathon Majors, Bobbi Gibb

4

The Boston Marathon bombing was the first major, modern US terrorist event with multiple, severe lower extremity injuries. First responders, including trained professionals and civilian bystanders, rushed to aid the injured. The purpose of this review was to determine how severely bleeding extremity injuries were treated in the prehospital setting in the aftermath of the Boston Marathon bombing.

Concepts: Massachusetts, Marathon, Boston, Boston Marathon, Robert Kipkoech Cheruiyot, World Marathon Majors, Bobbi Gibb

4

Earlier this year, Boston Children’s Hospital was targeted in a sustained cyberattack purportedly instigated by the hacker group known as Anonymous - an event that may carry lessons for other health care organizations that now rely heavily on electronic systems.

Concepts: Health care, Health insurance, Electronics, Massachusetts, Boston, Children's Hospital Boston, The Hacker

3

The role of repeated exposure to collective trauma in explaining response to subsequent community-wide trauma is poorly understood. We examined the relationship between acute stress response to the 2013 Boston Marathon bombings and prior direct and indirect media-based exposure to three collective traumatic events: the September 11, 2001 (9/11) terrorist attacks, Superstorm Sandy, and the Sandy Hook Elementary School shooting. Representative samples of residents of metropolitan Boston (n = 846) and New York City (n = 941) completed Internet-based surveys shortly after the Boston Marathon bombings. Cumulative direct exposure and indirect exposure to prior community trauma and acute stress symptoms were assessed. Acute stress levels did not differ between Boston and New York metropolitan residents. Cumulative direct and indirect, live-media-based exposure to 9/11, Superstorm Sandy, and the Sandy Hook shooting were positively associated with acute stress responses in the covariate-adjusted model. People who experience multiple community-based traumas may be sensitized to the negative impact of subsequent events, especially in communities previously exposed to similar disasters.

Concepts: New York City, Massachusetts, Boston, Metropolitan area, New York, Philadelphia, World Trade Center, Acute stress reaction

3

Purpose To analyze imaging utilization and emergency radiology process turnaround times in response to the April 15, 2013, Boston Marathon bombing in order to identify opportunities for improvement in the Brigham and Women’s Hospital (BWH) emergency operations plan. Materials and Methods Institutional review board approval was obtained with waivers of informed consent. Patient demographics, injuries, and outcomes were gathered, along with measures of emergency department (ED) imaging utilization and turnaround times, which were compared with operations from the preceding year by using the Wilcoxon rank sum test. Multivariate linear regression was used to assess contributors to examination cancellations. Results Forty patients presented to BWH after the bombing; 16 were admitted and 24 were discharged home. There were no fatalities. Ten patients required emergent surgery. Blast injury types included 13 (33%) primary, 20 (51%) secondary, three (8%) tertiary, and 19 (49%) quaternary. Thirty-one patients (78%) underwent imaging in the ED; 57 radiographic examinations in 30 patients and 16 computed tomographic (CT) examinations in seven patients. Sixty-two radiographic and 14 CT orders were cancelled. Median time from blast to patient arrival was 97 minutes (interquartile range [IQR], 43-139 minutes), patient arrival to ED examination order, 24 minutes (IQR, 12-50 minutes), order to examination completion, 49 minutes (IQR, 26-70 minutes), and examination completion to available dictated text report, 75 minutes (IQR, 19-147 minutes). Examination completion turnaround times were significantly increased for radiography (52 minutes [IQR, 26-73 minutes] vs annual median, 31 minutes [IQR, 19-48 minutes]; P = .001) and decreased for CT (37 minutes [IQR, 26-50 minutes] vs annual median, 72 minutes [IQR, 40-129 minutes]; P = .001). There were no significant differences in report availability turnaround time (75 minutes [IQR, 19-147 minutes] vs annual median, 74 minutes [IQR, 35-127 minutes]; P = .34). Conclusion The surge in imaging utilization after the Boston Marathon bombing stressed emergency radiology operations. Process analysis enabled identification of successes and opportunities for improvement in ongoing emergency operations planning. © RSNA, 2014.

Concepts: X-ray, Hospital, Medical imaging, Median, Interquartile range, Wilcoxon signed-rank test, Quartile, Boston

2

BACKGROUND AND OBJECTIVES:Chest pain is a complaint for which children are frequently evaluated. Cardiac causes are rarely found despite expenditure of considerable time and resources. We describe validation throughout New England of a clinical guideline for cost-effective evaluation of pediatric patients first seen by a cardiologist for chest pain using a unique methodology termed the Standardized Clinical Assessment and Management Plans (SCAMPs).METHODS:A total of 1016 ambulatory patients, ages 7 to 21 years initially seen for chest pain at Boston Children’s Hospital (BCH) or the New England Congenital Cardiology Association (NECCA) practices, were evaluated by using a SCAMPs chest pain guideline. Findings were analyzed for diagnostic elements, patterns of care, and compliance with the guideline. Results from the NECCA practices were compared with those of Boston Children’s Hospital, a regional core academic center.RESULTS:Two patients had chest pain due to a cardiac etiology, 1 with pericarditis and 1 with an anomalous coronary artery origin. Testing performed outside of guideline recommendations demonstrated only incidental findings. Patients returning for persistent symptoms did not have cardiac disease. The pattern of care for the NECCA practices and BCH differed minimally.CONCLUSIONS:By using SCAMPs methodology, we have demonstrated that chest pain in children is rarely caused by heart disease and can be evaluated in the ambulatory setting efficiently and effectively using minimal resources. The methodology can be implemented regionally across a wide range of clinical practice settings and its approach can overcome a number of barriers that often limit clinical practice guideline implementation.

Concepts: Medicine, Atherosclerosis, Coronary artery disease, Hospital, Cardiology, Heart, Artery, Boston