Guided, motor, and mental imagery adjuncts to teaching central venous access.

Background: Mental, motor, and guided imagery techniques are commonly used in sports psychology, but less often in medical education. Utilization of imagery-based techniques (IBTs) in combination with traditional teaching methods may provide a low-cost, innovative approach to improving outcomes in graduate medical education. Objective: The objective was to assess whether medical students demonstrate greater proficiency in the ability to obtain central venous access in simulation trainers following exposure to guided, mental, and motor imagery teaching methods in comparison to traditional methods. Methods: Volunteer fourth-year medical students during their emergency medicine rotation were randomly assigned to two groups, traditional plus imagery teaching or traditional teaching alone. The control group watched a video tutorial on central line placement methods. The study group watched the same video with the addition of imagery components. Participants filled out survey questions before and after the video and again after line placement. Proctors blinded to student group assignments then observed student placement of an internal jugular triple-lumen catheter on a simulation trainer and completed a standardized performance rubric. Results: Sixty medical students participated. Two were excluded for having performed five or more lines either clinically or in a previous simulation. There was no difference in self-perceived competence in line placement prior to watching the video or in the number of lines previously performed between groups. The imagery group (n = 25) averaged 1.3 errors/need for intervention compared to 2.2 errors/need for intervention in the control group (n = 33; p = 0.045, 95% confidence interval [CI] 0.02 to 1.61). Time to place the line was similar-8.9 min for the control group versus 8.6 min for the imagery group (p = 0.74, 95% CI -1.39 to 1.95). Conclusions: The use of IBTs may be a promising adjunct to traditional medical teaching of procedures in emergency medicine.

Safety and Efficacy of External Nasal Dilator Strips with N95 Respirator Masks by Emergency Department Personnel.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has prompted increased use of personal protective equipment (PPE) to maintain the health and safety of caregivers. This study was conducted in 2020 to evaluate the safety and efficacy of external nasal dilator strips (ENDS) coupled with N95 respirators in a sample of community hospital emergency department personnel. METHODS: After obtaining written consent, the authors tested participants' response to exercise (i.e., walking up 10 flights of stairs) while wearing an N95 respirator, both with and without an ENDS. The authors measured participants' heart rate and respiratory effort responses over four minutes following their exercise trial. A convenience sample of these personnel also repeated their respirator fit testing while wearing an ENDS with the N95 style they had previously been fitted for. RESULTS: A total of N = 50 participants were enrolled. Peak heart rate while wearing an ENDS was 125 beats per minute (BPM) with the ENDS versus 130 BPM without (p = 0.21). The Borg Exertion Score while wearing an ENDS peaked at 13 with the ENDS versus 14 without (p = 0.08). However, when subjects were surveyed before and after the trial upon whether they would consider using an ENDS beneath their N95 using a scale of 1-5, their interest in this significantly increased (p = 0.004). Four of the 13 (31%) participants who completed repeated fit testing while wearing the ENDS beneath their N95 respirator failed the repeat testing. CONCLUSIONS: These results first suggest that a sizable proportion of ED personnel may fail N95 fit testing while wearing an ENDS beneath the N95 mask for which they had been previously fitted. Although providers' subjective interest in use of ENDS increased, these results also demonstrate that use of an ENDS beneath an N95 respirator may not significantly increase exercise tolerance.

Legionella Pneumonia on Point-of-care Ultrasound in the Emergency Department: A Case Report.

INTRODUCTION: Legionella is an uncommon, atypical organism that can cause community-acquired pneumonia. Commonly associated with high fevers, gastrointestinal symptoms, and hyponatremia, it can be easily overlooked, especially during the coronavirus disease of 2019 (COVID-19) pandemic. Legionella has specific antibiotic treatment that will improve outcome; thus, its recognition is important. CASE REPORT: We present a case of Legionella pneumonia in a man presenting with shortness of breath and fever. The patient's initial chest radiography was negative. With the use of point-of-care ultrasound (POCUS) the changes of atypical pneumonia could be seen. Ultimately Legionella was confirmed with urine antigen testing, and appropriate antibiotic treatment was started. DISCUSSION: Given the increased awareness of COVID-19 it is important to consider a broad differential with respiratory illness. Legionella pneumonia on POCUS is consistent with atypical pneumonia descriptions on ultrasound. Point-of-care ultrasound can be used to diagnose atypical pneumonia, specifically caused by Legionella in our case. CONCLUSION: Legionella is evident on POCUS but is difficult to distinguish from other infections with POCUS alone. One should consider Legionella if POCUS is positive for signs of atypical infection.

A randomized cohort study of the efficacy of PO magnesium in the treatment of acute concussions in adolescents.

INTRODUCTION/STUDY OBJECTIVE: Concussions are becoming a growing concern in society today with one out of every five adolescents being affected. This accounts for 1.6 to 3.8 million emergency department visits annually. The current standard of care involves an initial period of mental rest with symptomatic care and symptom-based return to daily activities/sports. High dose IV magnesium has been proven to be neuroprotective in severe TBI. We hypothesized that oral magnesium replacement following a concussion will decrease the overall symptomatic period allowing a quicker return to functional baseline. METHODS: We used a randomized cohort study involving patients aged 12-18 who presented within 48 h after a concussion. Our study design had a treatment arm including acetaminophen, ondansetron, and magnesium PO and a placebo arm of acetaminophen and ondansetron. We then utilized the Post- Concussion Severity Score (PCSS) to evaluate the extent of the patient's symptoms. This score was collected immediately prior to obtaining medications, 1 h, 48 h, and 120 h after starting the study. The study relied on outpatient follow up through phone conversations, and a Sports Medicine clinic locally. RESULTS: Our data shows that there was a statistically significant decrease in the PCSS at 48 h (p = 0.016) in the magnesium group relative to the placebo treatment arm. This study does imply that magnesium supplementation has potential benefit in treatment of concussions acutely. CONCLUSION: Oral magnesium replacement decreases symptoms acutely following a concussion and should be provided with symptomatic management following a concussion in the emergency setting.

The Prisoner Who Cried Wolf, and Then Swallowed a Sprinkler Head.

CASE PRESENTATION: A 37-year-old man presented from jail reporting foreign body ingestion of a sprinkler head. While initial radiography did not reveal the foreign body, subsequent imaging with computed tomography demonstrated the sprinkler head. When confronted with this discrepancy the patient admitted to having the sprinkler head in his possession and choosing to swallow it after his initial radiography. DISCUSSION: This case demonstrates the importance of maintaining a high threshold for real illness in situations where there is suspected malingering, a situation not infrequently encountered in the emergency department.

Teenage Curiosity: Magnetic Attraction Gone Wrong.

A 13-year-old male presented with suprapubic pain, hesitancy, and dysuria beginning seven hours prior to arrival. After initial evasiveness, the patient admitted to inserting small, magnetic ball bearings into his penis. Vital signs and physical exam were unremarkable aside from mild suprapubic tenderness to palpation. Pelvic radiograph demonstrated about 45 radiopaque beads within the urethra and bladder. While urethral foreign body (FB) is an uncommon diagnosis, it is essential to identify quickly as lifelong complications can arise. Magnetic FBs are particularly concerning due to possible ischemia from compression injury and difficulty of removal. Safety concerns led to temporary market removal of neodymium magnetic toys, but sales resumed in 2016.

Fatal Influenza B Myocarditis in a 34-Year-Old Female.

A 34-year-old female reported to the emergency department with a chief complaint of epigastric pain. Initial rapid screening was negative for both influenza A and B. The patient eventually developed myocarditis that led to pulseless ventricular tachycardia and death within 24 hours of admission. Viral smear was positive for influenza B postmortem despite the initial negative rapid screen. This case demonstrates the need for a new diagnostic criteria and treatment strategy for viral myocarditis due to influenza while concisely illustrating how the disease can progress in adults despite commonly presenting as a disease in adolescents.

Probable Locally Acquired Babesia divergens-Like Infection in Woman, Michigan, USA.

We report an asplenic patient who was infected with Babesia divergens-like/MO-1. The clinical course was complicated by multiorgan failure that required intubation and dialysis. The patient recovered after an exchange transfusion and antimicrobial drug therapy. Physicians should be alert for additional cases, particularly in asplenic persons.

Randomized Trial of Adding Parenteral Acetaminophen to Prochlorperazine and Diphenhydramine to Treat Headache in the Emergency Department.

INTRODUCTION: Headaches represent over three million emergency department (ED) visits per year, comprising 2.4% of all ED visits. There are many proposed methods and clinical guidelines of treating acute headache presentations. However, data on intravenous acetaminophen usage in these settings are lacking. In this study, we sought to determine the efficacy of intravenous (IV) acetaminophen as an adjunct to a standard therapy for the treatment of patients who present to the ED with a chief complaint of "headache." METHODS: We conducted a single site, randomized, double-blind, placebo-controlled trial investigating the clinical efficacy of IV acetaminophen as an adjunct to a standard therapy with prochlorperazine and diphenhydramine for the treatment of patients who present to the ED with a chief complaint of "headache" or variants thereof. (See below for variants). The primary outcome measure of the efficacy of parenteral acetaminophen as an adjunct treatment for headache in addition to a standard therapy was a threshold two-point reduction in visual analog scale (VAS) pain scores on a 1-10 level at 90 minutes. Secondary outcomes measures included assessment of decreased requirement of "rescue" pain medicines, defined as any analgesic medications outside of diphenhydramine, prochlorperazine and acetaminophen, with particular interest to potential opioid-sparing effects with parenteral acetaminophen. Additional secondary outcome measure included time to disposition from arrival in the ED. RESULTS: For the acetaminophen group the initial mean pain score was 8.67, for the placebo group 8.61. At 90 minutes pain score was 2.23 for the acetaminophen group and 3.99 for placebo (p<0.01, 95% confidence interval (CI) [0.8%-16%]. Of 45 patients in each group, we observed at least a threshold two-point decrease in pain score 36/45 (80%) with acetaminophen vs. 25/45 (55%) with placebo (p <0.01) 95% CI [5%-41%], number needed to treat (NNT) = 4). Secondary outcome measure did not demonstrate a difference in length of stay (161 minutes for acetaminophen arm and 159 minutes for placebo). However, 17/45 (38%) of patients who received IV acetaminophen required rescue analgesia, opposed to 24/45 (53%) of patients in the placebo group (p=0.13) 95% CI [-5%-34%]. CONCLUSION: IV acetaminophen when used with prochlorperazine and diphenhydramine to treat acute headaches in the ED resulted in statistically significant pain reduction compared with prochlorperazine and diphenhydramine alone as measured by both threshold of lowering VAS pain score by at least two points (NNT = 4) and overall decline in VAS pain score. Further study is required to validate these results.

Organic chemicals in sewage sludges.

Sewage sludges are residues resulting from the treatment of wastewater released from various sources including homes, industries, medical facilities, street runoff and businesses. Sewage sludges contain nutrients and organic matter that can provide soil benefits and are widely used as soil amendments. They also, however, contain contaminants including metals, pathogens, and organic pollutants. Although current regulations require pathogen reduction and periodic monitoring for some metals prior to land application, there is no requirement to test sewage sludges for the presence of organic chemicals in the U. S. To help fill the gaps in knowledge regarding the presence and concentration of organic chemicals in sewage sludges, the peer-reviewed literature and official governmental reports were examined. Data were found for 516 organic compounds which were grouped into 15 classes. Concentrations were compared to EPA risk-based soil screening limits (SSLs) where available. For 6 of the 15 classes of chemicals identified, there were no SSLs. For the 79 reported chemicals which had SSLs, the maximum reported concentration of 86% exceeded at least one SSL. Eighty-three percent of the 516 chemicals were not on the EPA established list of priority pollutants and 80% were not on the EPA's list of target compounds. Thus analyses targeting these lists will detect only a small fraction of the organic chemicals in sludges. Analysis of the reported data shows that more data has been collected for certain chemical classes such as pesticides, PAHs and PCBs than for others that may pose greater risk such as nitrosamines. The concentration in soil resulting from land application of sludge will be a function of initial concentration in the sludge and soil, the rate of application, management practices and losses. Even for chemicals that degrade readily, if present in high concentrations and applied repeatedly, the soil concentrations may be significantly elevated. The results of this work reinforce the need for a survey of organic chemical contaminants in sewage sludges and for further assessment of the risks they pose.