Sustained intracranial hypertension and acute brain herniation are “brain codes,” signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this emergency neurological life support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.

Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this Emergency Neurological Life Support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.

Objective Missed diagnoses of acute ischemic stroke (AIS) in the ED may result in lost opportunities to treat AIS. Our objectives were to describe the rate and clinical characteristics of missed AIS in the ED, to determine clinical predictors of missed AIS, and to report tissue plasminogen (tPA) eligibility among those with missed strokes. Methods Among a population of 1.3 million in a five-county region of southwest Ohio and northern Kentucky, cases of AIS that presented to 16 EDs during 2010 were identified using ICD-9 codes followed by physician verification of cases. Missed ED diagnoses were physician-verified strokes that did not receive a diagnosis indicative of stroke in the ED. Bivariate analyses were used to compare clinical characteristics between patients with and without an ED diagnosis of AIS. Logistic regression was used to evaluate predictors of missed AIS diagnoses. Alternative diagnoses given to those with missed AIS were codified. Eligibility for tPA was reported between those with and without a missed stroke diagnosis. Results Of 2,027 AIS cases, 14.0% (n = 283) were missed in the ED. Race, sex, and stroke subtypes were similar between those with missed AIS diagnoses and those identified in the ED. Hospital length of stay was longer in those with a missed diagnosis (5 days vs. 3 days, p < 0.0001). Younger age (adjusted odds ratio [aOR] = 0.94, 95% confidence interval [CI] = 0.89 to 0.98) and decreased level of consciousness (LOC) (aOR = 3.58, 95% CI = 2.63 to 4.87) were associated with higher odds of missed AIS. Altered mental status was the most common diagnosis among those with missed AIS. Only 1.1% of those with a missed stroke diagnosis were eligible for tPA. Conclusion In a large population-based sample of AIS cases, one in seven cases were not diagnosed as AIS in the ED, but the impact on acute treatment rates is likely small. Missed diagnosis was more common among those with decreased LOC, suggesting the need for improved diagnostic approaches in these patients.

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Three classes of hydroxy-tethered platinum(II) complexes have been synthesized from K(2)PtCl(4) and appropriate amino alcohols. A sequence of selective oxidation and hydrolysis has been developed to prepare hydroxy-tethered platinum(IV) complexes. A novel procedure for the synthesis of amminetrichloroplatinate(II) anion has been generated and used to synthesize a number of monohydroxy-tethered nonchelating platinum complexes. These tethered platinum complexes, including hydroxy-tethered, phosphoramidite-tethered, and monodeoxyribonucleotide-tethered platinum(II) and -(IV) complexes, have been examined in vitro for antitumor activity in both leukemia and ovarian cancer cell lines. Activity of some of these complexes was similar to cis-platin, and most of them showed much better potency than carboplatin. We observed an interesting structure-activity correlation for platinum(II) complexes for both PA-1 and SK-OV-3 ovarian cancer cell lines. However, platinum(IV) complexes showed much more diversified response among cancer cell lines studied. We observed enhanced selectivity among different cancer cell lines for some agents. The most promising is the monodeoxyribonucleotide-tethered platinum(IV) complex, which is the first analogue of the conjugates between a platinum fragment and monodeoxyribonucleotides, showing antitumor activity and selectivity among the cell lines. Finally, the p53 status of the cells appears to contribute to the effectiveness of these agents in that cells harboring wild-type p53 appear to be more sensitive to these agents.