Excited Delirium Syndrome (ExDS): defining based on a review of the literature.

BACKGROUND: Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, "superhuman" strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as "Excited Delirium" deaths. OBJECTIVES: This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations. DISCUSSION: Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both. CONCLUSIONS: Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.

NOD protein expression and function in first trimester trophoblast cells.

PROBLEM: Through the expression of pattern recognition receptors, the trophoblast can recognize and respond to infectious microorganisms and, therefore, participate in the control of pathogens that may compromise fetal well-being. We hypothesize that the trophoblast has the ability to sense invasive intracellular bacteria through the cytoplasmic-based nucleotide-binding oligomerization domain (NOD) proteins. The aim of this study was to characterize the expression and function of NOD proteins in first trimester trophoblast cells. METHOD OF STUDY: NOD1 and NOD2 expressions by first trimester trophoblast cells were evaluated by immunohistochemistry, Western blot analysis and reverse transcription-polymerase chain reaction. The effect of NOD2 activation on trophoblast cells was determined by analyzing the cytokine response following treatment with muramyl dipeptide (MDP). RESULTS: Both NOD1 and NOD2 were expressed by first trimester placental villi and localized to trophoblast cells. Moreover, NOD1, NOD2 and the signaling effector protein, RIP-like interacting CLARP kinase (RICK), were all expressed by isolated trophoblast cells. Following exposure to the NOD2 ligand, MDP, trophoblast cells generated a pro-inflammatory cytokine response. This response was confirmed to be specific, as an NOD2-deficient trophoblast cell line failed to respond to MDP unless transfected with NOD2. CONCLUSION: These findings suggest that, through the expression and function of NOD proteins, first trimester trophoblast cells are able to recognize and respond to invasive intracellular pathogens that may have evaded other forms of pattern recognition.

Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department.

INTRODUCTION: Healthy People 2010 seeks to eliminate racial and ethnic disparities in health care; however, disparities due to age and race have been described in emergency department pain treatment. Although pain is a common patient complaint in emergency departments, many people receive no analgesia. This study examined the influence of patient and provider characteristics on ED and discharge analgesia and opioid prescribing practices. METHODS: This descriptive study used chart review of selected variables from ED patients 18 years and older who presented with musculoskeletal pain and were treated by core ED faculty. Logistic regression analyses were performed to determine whether analgesia- and opioid-prescribing disparities existed and were influenced by patient and provider characteristics. RESULTS: A total of 868 patient records were examined. Physician characteristics and wide variation in practice were the only sources of disparities in the prescription of analgesics in the emergency department, but patient characteristics including race, age, chronic pain, and trauma influenced prescription of ED opioids and discharge analgesics. No gender or financial status disparities were found. Fewer opioids and discharge analgesics were prescribed for black patients than for white patients. Younger patients, those with trauma, and those with chronic pain received more opioids and discharge analgesics compared with older patients and those without trauma or chronic pain. Providers who completed emergency medicine residencies and had fewer than 3 years' experience prescribed more analgesics in the emergency department. DISCUSSION: Pain management in our emergency department is widely variable, with some disparities based on patient and physician characteristics. Multicenter prospective studies are needed to validate these findings and examine knowledge and attitude development about pain and its management. Protocols for nurse-initiated analgesia may help improve and standardize ED pain care.

Determinants of variation in analgesic and opioid prescribing practice in an emergency department.

OBJECTIVE: Adequate treatment of patients' pain is a top priority for the World Health Organization (WHO), American Medical Association (AMA), and American College of Emergency Physicians (ACEP), but "adequate" is not clearly defined. Most previous studies of emergency department (ED) pain treatments have centered on musculoskeletal pain in terms of rates of analgesia and disparities in treatment based on race and age. This study will examine complaints of pain other than musculoskeletal and will focus on treatment disparities that may result from differences inpatient and physician characteristics. METHODS: This retrospective study is of ED patients 18 years and older with nonmusculoskeletal pain who were seen by ED faculty over a period of eight weeks. Logistic regression and CHI2 tests were performed to quantify effects of doctor, patient, and clinical characteristics on rates of ED analgesia, ED opioids, and analgesic prescriptions at discharge. RESULTS: A total of 1360 patients were included. There was wide variation in the type and frequency of ED analgesia depending on the attending doctor. For example, patients seen by one specific ED doctor were less than half as likely to receive any analgesia and seven times less likely to receive an opioid than those seen by another doctor. Age, race, doctor's training and experience, and whether the patient had chronic pain were important predictors of ED analgesia. There were similar findings for ED opioids and discharge analgesics. CONCLUSION: Pain practices in EDs are highly variable and seem inadequate when measured against the goals of WHO, AMA, and ACEP. Patient age, race, and type of pain and the physician's identity, training, and experience all contribute to practice variation. Further research is needed to identify the causes of these variations, and there is a need to develop interventions to standardize and improve pain assessment and treatment.