• Significant intracranial hemorrhage occurs in 20% to 50% of patients with metastatic brain tumors.• Therapeutic anticoagulation in patients with brain metastasis did not increase the risk for intracranial hemorrhage.Venous thromboembolism occurs frequently in patients with cancer who have brain metastases, but there is limited evidence supporting the safety of therapeutic anticoagulation. To assess the risk for intracranial hemorrhage associated with the administration of therapeutic doses of low-molecular-weight heparin, we performed a matched, retrospective cohort study of 293 patients with cancer with brain metastases (104 with therapeutic enoxaparin and 189 controls). A blinded review of radiographic imaging was performed, and intracranial hemorrhages were categorized as trace, measurable, and significant. There were no differences observed in the cumulative incidence of intracranial hemorrhage at 1 year in the enoxaparin and control cohorts for measurable (19% vs 21%; Gray test, P 5 .97; hazard ratio, 1.02; 90% confidence interval [CI], 0.66-1.59), significant (21% vs 22%; P 5 .87), and total (44% vs 37%; P 5 .13) intracranial hemorrhages. The risk for intracranial hemorrhage was fourfold higher (adjusted hazard ratio, 3.98; 90% CI, 2.41-6.57; P < .001) in patients with melanoma or renal cell carcinoma (N 5 60) than lung cancer (N 5 153), but the risk was not influenced by the administration of enoxaparin. Overall survival was similar for the enoxaparin and control cohorts (8.4 vs 9.7 months; Log-rank, P 5 .65). We conclude that intracranial hemorrhage is frequently observed in patients with brain metastases, but that therapeutic anticoagulation does not increase the risk for intracranial hemorrhage. (Blood. 2015;126(4):494-499)

Children with chronic conditions may be at risk of increased disruptions in health care following natural disasters such as Hurricane Katrina. The objective of this cross-sectional study was to evaluate differences between children and adolescents with and without chronic conditions immediately following Katrina. Of 531 participants, there were 79.8% younger than 13 years old, 50.5% male, 42.8% African American. Participants with pre-existing conditions (39.4% of the total sample) were more likely than those without to be at the clinic for a non-chronic health condition rather than another problem (43.5 vs. 16.2%), to take asthma medication (37.4 vs. 3.9%), to have asthma worsen (16.3 vs. 1.9%), to miss a visit (49.2 vs. 39.8%), to run out of medications (33.9 vs. 7.9%), to live with flood damage (19.7 vs. 11.3%) or mold (23.6 vs. 15.8%), and to experience disruption in care (58.4 vs. 38.3%) or negative psychological consequences (ranging from 2.5% to 12.9%). While the medical differences are unsurprising, given the groups being compared, the other differences between the groups merit attention from policymakers and health care providers. Children and adolescents with chronic conditions are at increased risk of adverse outcomes following a natural disaster. Providers may be able to reduce negative effects on this population by developing condition-specific preparedness care mechanisms.

Objectives: The most effective technique for ultrasound-guided peripheral intravenous access (USGPI-VA) is unknown. In the traditional short-axis technique (locate, align, puncture [LAP]), the target vessel is aligned in short axis with the center of the transducer. The needle is then directed toward the target under real-time ultrasound (US) guidance. Locate, align, mark, puncture (LAMP) requires the extra step of marking the skin at two points over the path of the vein and proceeding with direct visualization as in LAP. The difference in success between these two techniques was compared among variably experienced emergency physician and emergency nurse operators.Methods: Subjects in an urban academic emergency department (ED) were randomized to obtain intravenous (IV) access using either LAP or LAMP after two failed blind attempts. Primary outcomes were success of the procedure and time to complete the procedure in variably experienced operators.Results: A total of 101 patients were enrolled. There was no difference in success between LAP and LAMP, even among the least experienced operators. Of successful attempts, LAMP took longer than LAP (median 4 minutes, interquartile range [IQR] 4-10.5 vs. median 2.9 minutes, IQR 1.6-7; p = 0.004). Only the most experienced operators were associated with higher levels of success (first attempt odds ratio [OR] 6.64; 95% confidence interval [CI] = 2 to 22). Overall success with up to two attempts was 73%. Complications included a 2.8% arterial puncture rate and 12% infiltration rate.Conclusions: LAMP did not improve success of USGPIVA in variably experienced operators. Experience was associated with higher rates of success for USGPIVA.ACADEMIC EMERGENCY MEDICINE 2008; 15:723-730 ª

The high psychological burden of a benign breast biopsy among older women significantly diminishes with time but does not completely resolve. To reduce this burden, older women need more information about undergoing a breast biopsy.