The diagnosis and management of acute cholecystitis (AC) continues to evolve. Among the most common surgically treated conditions in the USA, appropriate diagnosis and management of AC require astute clinical judgment and operative skill. Useful diagnostic and grading systems have been developed, most notably the Tokyo guidelines, but some recent clinical validation studies have questioned their generalizability to the US population. The timing of surgical intervention is another area that requires further investigation. US surgeons traditionally pursue laparoscopic cholecystectomy (LC) for AC patients with symptoms onset <72 hours, but for patients with symptoms over 72 hours, surgeons often elect to treat the patients with antibiotics and delay LC for 4‐6 weeks to permit the inflammation to subside. This practice has recently been called into question, as there are data suggesting that LC even for AC patients with over 72 hours of symptoms confers decreased morbidity, shorter length of stay, and reduced overall healthcare costs. Finally, the role of percutaneous cholecystostomy (PC) needs to be better defined. Traditional role of PC is a temporizing measure for patients who are poor surgical candidates. However, there are data suggesting that in AC patients with organ failure, PC patients suffered higher mortality and readmission rates when compared with a propensity‐matched LC cohort. Beyond diagnosis, the surgical management of AC can be remarkably challenging. All surgeons need to be familiar with best‐practice surgical techniques, adjunct intra‐operative imaging, and bail‐out options when performing LC.

Background: Rapid administration of intravenous alteplase (IV tPA) leads to better outcomes, but language barriers have the potential to introduce delays and to hinder effective communication with patients and collateral historians during the acute evaluation. Hypothesis: Acute ischemic stroke patients with a non-English primary language will have significantly longer door-to-needle times for IV tPA. Methods: We abstracted information on primary language for all adults that received IV tPA for acute ischemic stroke in the emergency department of an academic referral center in San Francisco, CA, from February 2008 to May 2015. Approximately 38% of San Francisco residents speak a language other than English at home. Primary language was determined from the electronic medical record and was confirmed by reviewing specific documentation in subsequent speech therapy evaluations and admission notes. Age, sex, race, presenting NIHSS, aphasia as a presenting symptom, whether the patient was accompanied to the emergency department by a family member or caregiver, discharge disposition, and door-to-needle (DTN) administration time for IV tPA were abstracted from clinical records and quality improvement registries. Results: A total of 237 patients received IV tPA for acute ischemic stroke in the emergency department during the study period. Median age was 76 years (IQR 64-86), 53% were female, and median DTN time was 62 minutes (IQR 48-86). A total of 34% of patients had a primary language other than English (20% Cantonese, 6% Russian, 3% Spanish). These patients were more likely to be older (median age 80 vs. 73 years, p = 0.001), to be accompanied by a family member or caregiver (80% vs. 59%, p = 0.003), and to have a higher NIHSS (median 9 vs. 11, p = 0.03), but DTN times were similar among English and non-English primary language speakers (median 62 vs. 62, p=0.88) and short-term outcomes were not significantly different (in-hospital mortality 9% English primary language vs 14% non-English primary language, p=0.27; discharge to home 43% vs 32%, p=0.16) . Conclusions: At a center serving a multiethnic population, a patient’s primary language did not appear to predict DTN times for acute ischemic stroke.

Introduction: The incidence of sentinel headache (SH) in the days or weeks prior to a aneurysmal subarachnoid hemorrhage (SAH) has been reported to be as high as 10-43% and SH has been linked with early re-bleeding risk. Hypothesis: We evaluated whether ED visits for headache were more common in the month preceding a hospitalization for SAH and if this was associated with increased mortality after SAH. Methods: We identified all hospital discharges for SAH at all licensed nonfederal hospitals in California from 2008 -11 using comprehensive data from the Office of Statewide Healthcare Planning and Development. Encounters with invalid or missing record linkage numbers (based on social security number) or for non-California residents, and those with concurrent trauma diagnoses or external injury codes were excluded. We identified the first hospitalization for SAH during the study period for each distinct patient. We then identified any ED encounters for headache without SAH during the month prior to the admission for SAH and during a one-month period exactly one year prior to the index admission for SAH. Results: A total of 7,723 patients that were hospitalized for non-traumatic SAH during the study period met study eligibility criteria (mean age 59 years [SD 16], 62% female). A majority were white (62%) and non-Hispanic (73%), and 14% were Asian/Pacific Islander and 9% were black. Just 33 (0.4%) SAH patients had had an ED visit for headache in the preceding month compared to 2 ED visits (0.03%) for headache during a month-long period one-year prior to the hospitalization for SAH (RR 16.5, 95% CI 4.0-68, p<0.0001). SAH patients with a recent ED visit for headache had a similar length of hospital stay (10 vs 9.1 days, p=0.27), but were younger (59 vs 49 years, p=0.0002) had lower 30-day mortality (3.0% vs. 22%, p= 0.005), and were more likely to be discharged directly home (81% vs. 44%, p<0.001). Conclusion: We identified very few ED visits for headache in the month prior to a hospitalization for aneurysmal SAH, and SAH patients who had visited the ED for headache had lower mortality and better outcomes, though SAH patients with sentinel headache who did not visit the ED were not captured in our analysis.

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