UMEM Educational Pearls

Background

• Stroke is common in the first few weeks after a transient ischemic attack (TIA) or minor ischemic stroke.
• Aspirin reduces the risk of recurrent stroke by 12% or so.
• Thus far there is a trend toward no benefit from dual anti-platelet treatment.

Trial

• Randomized, double blind, placebo-controlled trial conducted in China.
• 5170 patients were randomized to either combination therapy with clopidogrel and aspirin (clopidogrel at an initial dose of 300 mg, followed by 75mg per day for 90 days, plus aspirin 75 mg per day for 21 days) or to placebo plus aspirin.
• Primary outcome was stroke during 90 days of follow-up using intention to treat analysis

Results

• Stroke occurred in 8.2% of patients in the aspirin-clopidogrel group as compared with 11.7% in the aspirin group (Hazard ratio 0.68; 95% confidence interval, 0.57-0.81; p<0.001). Rates of hemorrhage were similar in both groups (0.3%).
• Relative risk reduction of stroke at 90 days by 32%.

Conclusions

• Patients with acute TIA or minor stroke may benefit from combination therapy with no increased risk of hemorrhage

Bottom Line:

• 41,561 patients were screened in order to find 5170 appropriate patients! 
• Patients with major stroke, who are risk for hemorrhage, and have isolated sensory TIAs, were excluded.
• The trial was conducted in China, so the results may not apply in other countries (A similar trial, the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) study is being done in North America).
• Decision to treat should be made with neurology assistance.  

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Question

23 year-old patient presents with a rash on his palms and soles. He also states that he had a something strange on his genitals several weeks before. What's the diagnosis and what’s the treatment (including dosing) for this disease?

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• 1^st generation drug-eluting stents (DES) have been shown to reduce restenosis and target vessel revascularizations (TVR) compared with bare-metal stents (BMS) in patients with STEMI
• 1^st generation DES have also been associated with increased rates of very late stent thrombosis (ST), raising concerns over the safety of these devices in patients with STEMI, who compared to patients with stable coronary artery disease, have greater rates of ST due to heightened platelet activation and the presence of thrombus
• The most important finding in this study is the significantly reduced risk of 1-year cardiac death, MI, and ST with CoCr-EES (cobalt-chromium everolimus eluting stent) compared to BMS
• The observed reduction in MI, ST, and composite cardiac death rates with CoCr-EES compared to BMS is consistent with experimental data suggesting that stents covered by fluorinated polymers are less thrombogenic than even BMS

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We will all see a patient that comes into the Emergency Department stating they have ingested some wild or self-picked mushrooms. Usually they will be actively vomiting and there will be no mushroom to identify. If there is, identification may still be difficult. There are no other clinical relevant symptoms that you can see until its too late. Amanita species is lethal and may require liver transplant. The most important question you can ask after trying to identify the mushroom is:

When did you eat the mushroom and how long after did the vomiting start?

As a general rule (with some exceptions), Amanita species cause vomiting and diarrhea in a delayed fashion 5-6 hours after ingestion. The other non hepatotoxic species usually cause vomiting within 1-3 hours.

Immediate vomiting <6 hrs from time of ingestion is good (usually).

General Information:

    ·You must know the diagnosis to deliver effective and high quality care to patients; likewise for health systems to be effective, it is necessary to understand what the global burden of disease is.

    ·In 1991, the World Bank and World Health Organization launched the Global Burden of Disease Study which as of 2010 evaluates 291 disease and injuries as well as 1160 sequelae of these causes.

    ·In order to compare the burden of one disease with that of another, you must consider death and life expectancy of persons affected by the disease as well as disability imposed by the condition.

    ·The combined composite summary metric is termed disability adjusted life years (DALYs).

    ·There have been three major worldwide studies to date (1990, 2005, 2010) attempting to quantify the burden of disease yet no study to date has ever attempted to quantify the burden of disease requiring emergent intervention.

Bottom Line:

DALYs are a useful tool for quantifying the burden of disease and provides essential input into health policy dialogues to identifies conditions and risk factors that may be relatively neglected and others for which progress is not what was expected. To date, there has been no rigorous scientific effort to quantify the burden of disease worldwide that requires emergent intervention to avoid death and disability.

University of Maryland Section of Global Emergency Health

Author: Emilie J. B. Calvello, MD, MPH

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Question

Which echocardiographic view of the heart is this and can you name all 6 segments of the left ventricle? (Hint: A = Anteroseptal wall)

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Charcot Joint - Neuropathic arthropathy

A Charcot Joint is a progressive degeneration of a weight bearing joint that is normally seen in patients that have decreased peripheral sensation and proprioception.

Conditions associated with Charcot Joints are:
    •    Alcohol neuropathy
    •    Cerebral palsy
    •    Diabetes mellitus
    •    Spinal Cord Injury
    •    Strokes
    •    Syphilis (tabes dorsalis)

The foot is most commonly affected and radiographs can also show bony destruction, bone resorption, and gross deformity. The onset of pain and deformity is typically insidious.  Charcot joints are often associated with ulcerations, secondary osteomyelitis, and can lead to amputations.

It is important to recognize the presence of a Charcot Joint so that the patient can be referred to Orthopaedics and treated (often with cast immobilization) to prevent further destruction of the joint.
 

A facial laceration on a child can present a unique challenge which is not limited to the initial visit.  The traditional teaching has been to use nonabsorbable sutures and have the patient return in 5 days for removal.  A recent study compared the cosmetic outcome of linear facial lacerations 1 to 5 cm that were closed with either Ethicon fast absorbing surgical gut or monocryl nonabsorbable sutures.  Patients were randomized and returned to the ED in 4-7 days and 3-4 months. Scars were assessed by caregivers and blinded physicians.  Results showed that caregivers preferred absorbable sutures.  Visual analog scores as given by caregivers were not statistically different between the 2 groups at the 3 month mark.  The blinded physicians did give better cosmetic outcome scores to the absorbable suture group which differs from previous studies that had shown equivocal results.  Of note, all absorbable sutures were no longer visible after 14 days.

Bottom line:  Try absorbable sutures the next time you are suturing a child and the parents may be happier and you will not have to try and take out your sutures from a squirming, screaming child.

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There is minimal evidence of cross-reactivity between sulfonamide antibiotics and non-antibiotics [1-4]. Despite this, the U.S. FDA-approved product information for many non-antibiotic sulfonamide drugs contains warnings concerning possible cross-reactions.

Key Findings from a New Review Article [5]:

• An estimated 3-6% of the general population is allergic to sulfonamides.
• Structurally, none of the non-antibiotic sulfonamides exhibit both of the features shown to be responsible for sulfonamide reactions (i.e., an N-containing ring attached to the N1 nitrogen of the sulfonamide group and an arylamine group at the N4 position).
• A comprehensive literature search (1966-December 2011) identified only 9 case reports indicating possible cross-reactivity to sulfonamide medications; however, in most cases, adequate patient testing was not conducted to firmly establish either sulfa allergy or sulfonamide cross-sensitivity.

Bottom line: You can feel safe prescribing furosemide, glyburide, and hydrochlorothiazide to your patient with an allergy to sulfamethoxazole/trimethoprim.

Other blog reference on this topic: http://lifeinthefastlane.com/2011/04/sulfa-drug-discombobulation/

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General Information:

XDR TB is “extensively drug resistant tuberculosis”—resistant to isoniazid, rifampin, any fluoroquinolone, and at least one of the 3 injectable 2^nd line drugs

Clinical Presentation:

- Identical to regular TB (weight loss, fevers, night sweats, cough, hemoptysis)

- Suspect in patients who are failing usual treatment

-Exposure in Eastern Europe or Russia (highest prevalence, although 84 countries have had documented XDR, including the US.)

Diagnosis:

- Plating on agar or liquid media for drug susceptibility testing

Treatment:

- Should be guided by susceptibility testing

- Isolate the patient!

Bottom Line:

XDR TB is increasing in prevalence, have a high index of suspicion in patients with persistent symptoms who are receiving treatment and isolate if any concerns.

University of Maryland Section of Global Emergency Health

Author: Andi Tenner, MD, MPH

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Clostridium Difficile Associated Diarrhea and The Elderly Patient

• Infectious diseases remain the leading cause of mortality in the elderly.
• An infection that is increasing in prevlance among elderly patients is Clostridium difficile-associated diarrhea (CDAD).
• Mortality rates are up to 3.5 times higher in elderly patients with CDAD compared to younger patients.
• Antimicrobial therapy within the previous 6 weeks is the strongest risk factor for CDAD.
• Though any antibiotic may cause CDAD, clindamycin, fluoroquinolones, and cephalosporins have the highest risk.
• Importantly, the diarrhea may not always bloody.
• Metronidazole remains the treatment of choice for uncomplicated infections.

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Question

Patient with liver disease presents with dyspnea, fever, and the following ultrasound? What's the diagnosis? (Hint: there are two)?

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The flexor tendons of the finger may become thickened and narrowed from chronic inflammation and irritation.

 - Causes limitation in range of motion and snapping or locking during flexion

 - Can involve any digit but usually the ring and the long finger

CC: pain, "catching" May awake to finger being "locked" with spontaneous resolution during the day

Stenosis occurs at the MCP level

PE: Distal flexor crease tender to palpation and may have a painful nodule 

Full finger flexion is sometimes not possible

Tx: NSAIDs and steroid injection in tendon sheath. If this fails - surgical release.

Clinically important traumatic brain injuries are rare in children.  The PECARN study provides decision rules for when to avoid unnecessarily obtaining a CT for children who have suffered head trauma.

For children < 2 years old: <0.02% risk of clinically important TBI

• Normal mental status
• No scalp hematoma, except frontal
• Loss of consciousness < 5 seconds
• No palpalble skull fracture
• Normal behavior
• Nonsevere mechanism (fall < 3ft, pedestrian struck, rollover MVC)

For children > 2 years old: <0.05% risk of clinically important TBI

• Normal mental status
• No signs of basilar skull fracture
• No loss of consciousness
• No vomiting
• No severe headache
• Nonsever mechanism (fall < 5ft, pedestrian struck, rollover MVC)

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Naloxone can be administered via pretty much any route. One that has gained popularity in the past several years is nebulized naloxone. Although anecdotal reports tout the benefits of nebulized naloxone, what does the literature say?

• Case report of 46 y/o f with initial oxygen saturation of 61%. Naloxone was administered by nebulizer and within 5 min oxygen saturation was 100% and mental status was normal. [1]
• Retrospective analysis of prehospital adminstration in 105 patients. 22% had "complete response" and 59% had "partial response." Problem is the initial respiratory rate was 14 bpm with GCS of 12. [2]
• Prospective analysis of 26 patients in an inner-city, academic ED. Pre-naloxone respiratory rate was 13 with GCS of 11. Post-naloxone respiratory rate was 16 with GCS of 13. Three patients (12%) experienced moderate-to-severe agitation and 2 (8%) were diaphoretic. [3]

Bottom Line: Many of the studied patients may not have needed naloxone in the first place (initial respiratory rate 13-14), with a few developing withdrawal symptoms. Nebulized naloxone may have a role in the not-too-sick opioid overdose in whom you want to prove your diagnosis and wake the patient up enough to obtain a history. It is not a therapy for the apneic opioid overdose.

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General Information:

    ·You must know the diagnosis to deliver effective and high quality care to patients; likewise for health systems to be effective, it is necessary to understand what the global burden of disease is.

    ·In 1991, the World Bank and World Health Organization launched the Global Burden of Disease Study which as of 2010 evaluates 291 disease and injuries as well as 1160 sequelae of these causes.

    ·In order to compare the burden of one disease with that of another, you must consider death and life expectancy of persons affected by the disease as well as disability imposed by the condition.

    ·The combined composite summary metric is termed disability adjusted life years (DALYs).

    ·There have been three major worldwide studies to date (1990, 2005, 2010) attempting to quantify the burden of disease yet no study to date has ever attempted to quantify the burden of disease requiring emergent intervention.

Bottom Line:

DALYs are a useful tool for quantifying the burden of disease and provides essential input into health policy dialogues to identifies conditions and risk factors that may be relatively neglected and others for which progress is not what was expected. To date, there has been no rigorous scientific effort to quantify the burden of disease worldwide that requires emergent intervention to avoid death and disability.

University of Maryland Section of Global Emergency Health

Author: Emilie J. B. Calvello, MD, MPH

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Bad brain, good lungs.... Right?

A recent retrospective study reviewed the incidence of acute respiratory distress syndrome (ARDS) in patients presenting with spontaneous intracerebral hemorrhage over a 10-year period.  After reviewing 1,665 patients, the authors found that:

• The development of ARDS occurred in approximately 27% of patients with spontaneous ICH (similiar to previous literature).
• The incidence ARDS after spontaneous ICH was similiar to other "high-risk" conditions such as sepsis, trauma, & aspiration.
• Modifiable risk factors include: high tidal volume ventilation, higher total fluid balance, & transfusion of PRBCs/FFP.
   

It's of particular importance to note that high tidal volume ventilation (>8cc/kg) was the single greatest modifiable factor for the development of ARDS.

Bottom line:  Try and use lung-protective ventilation strategies (6-8cc/kg ideal body weight) and avoid excessive volume resuscitation in your critically-ill patients whenever possible.  Even in cases of isolated intracerebral hemorrhage - where the patient's lungs may appear to be completely normal - traditional tidal volume settings may be harmful.

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Question

45 year-old man presents after he cannot close his left eye. In the photo below, he is trying to simultaneously raise his forehead and smile. Of note, he was also started on doxycycline recently for Lyme disease. What two medications should he receive?

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• Classically MVP is considered a benign diagnosis associated w/palpitations, atypical chest pain, dyspnea, and carries a low risk of complications 
• A recent study investigated MVP and its association w/ventricular arrhythmias in a cohort of unexplained out-of-hospital cardiac arrest (OHCA)
• A small subset of patients w/MVP experienced life threatening arrhythmias coined "malignant" MVP
• Malignant MVP was most often associated w/female sex, bileaflet valve, and frequent complex ventricular ectopic activity

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A recent review identified 5 key points to consider when prescribing fluids.

1. Fluids should be prescribed as drugs, recognizing that any fluid can be harmful if dosed incorrectly.
2. The differences in efficacy between administering a 'crystalloid versus colloid' are modest; however, the cumulative differences in safety appear more significant.
3. The qualitative toxicity associated with hydroxyethyl starch (HES) and isotonic saline remains a concern.
4. The differences in chloride load and strong ion difference between cystalloid solutions, such as isotonic saline compared with physiologically more balanced solutions, appear to have clinical relevance.
5. The 'default' resuscitation fluid for acutely ill patients should likely be physiologically balanced crystalloid solutions (eg, PlasmaLyte or Ringer's lactate ).

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