Effectiveness of an infection prevention strategy to limit exposure of high-risk patients to COVID-19 in a hospital-based subacute unit: a descriptive report.

The coronavirus (COVID-19) epidemic has put unprecedented stress on hospitals as well as skilled nursing facilities, where reside some of the most vulnerable individuals at high risk of mortality and complications of this infection. This report highlights the strategy and success of hospital infection prevention efforts to protect the residents of an in-hospital subacute unit with 24 at-risk patients with chronic pulmonary disease in northern California. Specific efforts are detailed, with results of surveillance testing reported, including both viral PCR and serological IgG assays. Implications for other long-term subacute care facilities are discussed, as well as advantages and specific challenges for 'distinct part' versus 'free-standing' subacute care units.

Acute Aortic Dissection With ST Segment Myocardial Infarction Following Masturbation.

BACKGROUND: Acute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection. CASE REPORT: A 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis.

Modafinil and zolpidem use by emergency medicine residents.

OBJECTIVES: The objective was to assess the prevalence and patterns of modafinil and zolpidem use among emergency medicine (EM) residents and describe side effects resulting from use. METHODS: A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national American Board of Emergency Medicine in-training examination. Data regarding frequency and timing of modafinil and zolpidem use were collected, as well as demographic information, reasons for use, side effects, and perceived dependence. RESULTS: A total of 133 of 134 residency programs distributed the surveys (99%). The response rate was 56% of the total number of EM residents who took the in-training examination (2,397/4,281). Past modafinil use was reported by 2.4% (57/2,372) of EM residents, with 66.7% (38/57) of those using modafinil having initiated their use during residency. Past zolpidem use was reported by 21.8% (516/2,367) of EM residents, with 15.3% (362/2,367) reporting use in the past year and 9.3% (221/2,367) in the past month. A total of 324 of 516 (62.8%) of zolpidem users initiated use during residency. Side effects were commonly reported by modafinil users (31.0%)-most frequent were palpitations, insomnia, agitation, and restlessness. Zolpidem users reported side effects (22.6%) including drowsiness, dizziness, headache, hallucinations, depression/mood lability, and amnesia. CONCLUSIONS: Zolpidem use is common among EM residents, with most users initiating use during residency. Modafinil use is relatively uncommon, although most residents using have also initiated use during residency. Side effects are commonly reported for both of these agents, and long-term safety remains unclear.

Substance use in emergency medicine training programs.

OBJECTIVES: To explore the prevalence of substance use among emergency medicine (EM) residents and compare to a prior study conducted in 1992. METHODS: A voluntary, anonymous survey was distributed in February 2006 to EM residents nationally in the context of the national in-service examination. Data regarding 13 substances, demographics, and perceptions of personal patterns of substance use were collected. RESULTS: A total of 133 of 134 residencies distributed the surveys (99%). The response rate was 56% of the total EM residents who took the in-service examination (2,397/4,281). The reported prevalence of most illicit drug use, including cocaine, heroin, amphetamines, and other opioids, among EM residents are low. Although residents reporting past marijuana use has declined (52.3% in 1992 to 45.0% in 2006; p < 0.001), past-year use (8.8%-11.8%; p < 0.001) and past-month use (2.5%-4.0%; p < 0.001) have increased. Alcohol use appears to be increasing, including an increase in reported daily drinkers from 3.3% to 4.9% (p < 0.001) and an increase in number of residents who indicate that their consumption of alcohol has increased during residency (from 4% to 12.6%; p < 0.001). CONCLUSIONS: Self-reported use of most street drugs remains uncommon among EM residents. Marijuana and alcohol use, however, do appear to be increasing. Educators should be aware of these trends, and this may allow them to target resources for impaired and at-risk residents.

Effects of ethanol on limited resuscitation in a model of traumatic brain injury and hemorrhagic shock.

OBJECT: Limited resuscitation following uncontrolled hemorrhagic shock (HS) has been associated with improved outcomes in various animal models, although it has not been previously studied in the setting of traumatic brain injury (TBI) and ethanol intoxication. The aim of the present study was to determine the effects of ethanol intoxication in a model of experimental TBI and HS treated with limited resuscitation. METHODS: After induction of anesthesia and the placement of instruments, swine were subjected to a fluid-percussion injury of 3 atm. Simultaneously, hemorrhage was induced from an arterial catheter via a computerized roller pump to a mean arterial blood pressure (MABP) of 50 mm Hg, at which time uncontrolled hemorrhage was induced by the creation of an aortic tear. When the MABP decreased to 30 mm Hg, limited resuscitation to a MABP of 60 mm Hg was begun. After 60 minutes, animals were aggressively resuscitated to baseline MABP levels. Two groups of animals were studied: those receiving tap water by gastrostomy tube and those receiving ethanol (4 g/kg) by gastrostomy tube. Animals were monitored for 180 minutes after TBI. Hemorrhage volumes were significantly greater in ethanol-infused animals (mean +/- standard deviation, 41 +/- 34 mm Hg) compared with tap water-infused animals (17 +/- 18 mm Hg; p = 0.048). Resuscitation requirements were significantly higher and metabolic parameters significantly worse in the ethanol group. Survival time was also significantly decreased in the animals infused with ethanol (81 +/- 60 minutes) compared with those infused with tap water (130 +/- 51 minutes; p = 0.035). CONCLUSIONS: Ethanol intoxication led to increased hemorrhage volume and worsened hemodynamic and metabolic profiles in this model of limited resuscitation after TBI and HS. Ethanol-exposed animals had increased resuscitation requirements and decreased survival times.

Effects of cocaine in an experimental model of traumatic brain injury.

BACKGROUND: Cocaine intoxication is found in a significant subset of emergency department (ED) patients presenting with traumatic brain injury (TBI). OBJECTIVES: To investigate the effects of acute cocaine intoxication on physiologic and metabolic parameters in a model of experimental TBI. METHODS: Under inhalational anesthesia, swine were instrumented and subjected to fluid percussion TBI of 3 atm. Two groups were studied: TBI and cocaine (n = 7) and TBI only (n = 7). Two sequential doses of cocaine hydrochloride were administered intravenously to the animals receiving cocaine: 4 mg/kg 10 minutes prior to injury and 2 mg/kg 1 minute prior to injury. Control animals received normal saline. Cardiorespiratory and cerebral physiologic data were monitored for 180 minutes following injury. Cerebral blood flow (CBF) was measured using dye-labeled microspheres. Serum cocaine levels were measured by gas chromatography/mass spectrometry. RESULTS: Mean (+/- SD) cocaine levels at the time of injury were 1,771 (+/- 403) ng/mL. All animals survived the 180-minute observation period. There was a trend toward higher intracranial pressure (ICP) in the control (15.4 +/- 8.2) vs. cocaine-treated (11.1 +/- 5.8) animals, although this did not reach statistical significance (p = 0.18). Cerebral venous lactate (CVL) levels also trended higher in the control (1.14 +/- 0.22) vs. cocaine-treated (0.91 +/- 0.19) groups (p = 0.06). Cerebral perfusion pressures (CPPs), however, did not differ between groups. The CBF values decreased significantly from baseline in both groups but were not different between groups. CONCLUSIONS: Cocaine-intoxicated animals subjected to TBI showed no significant difference in primary outcome measures of CPP or CBF, although a nonsignificant trend toward lower ICP was noted. Overall, acute cocaine intoxication did not adversely affect the physiologic parameters examined in this TBI model.

Lower gastrointestinal hemorrhage from an arterioenteric fistula in a pancreatorenal transplant patient.

We report a case of a severe lower gastrointestinal hemorrhage caused by arterioenteric fistula formation in a pancreas transplant patient. A rare but potentially deadly complication of pancreas transplant surgery, arterioenteric fistulas should be considered in every transplant patient presenting with voluminous gastrointestinal bleeding. If diagnosed promptly, angiographic and surgical intervention can prevent serious morbidity and mortality.