Designing and Implementing Emergency Department Pain Management Curriculum: A Delphi Approach.

OBJECTIVES: Our primary objective was to use the Delphi method (DM) to choose learning objectives for an Internet-based pain management teaching module for emergency care providers. The DM is a structured communication technique that uses systematic, interactive data gathering to reach a consensus among a panel of experts. METHODS: We extracted preliminary educational objectives from nationwide pain fellowship training programs. After redundant objectives and those relating to procedures outside the scope of emergency medicine (EM) were removed, 23 preliminary objectives remained. We enlisted experts in EM, medical toxicology, anesthesia, pain, psychiatry, and medical education to evaluate the objectives in repeated rounds. Based on the time we had designated for teaching (3 hours) and our estimate of 15 to 20 minutes for each learning objective, we aimed for nine to 12 final learning objectives. The expert panel rated the 23 preliminary objectives with a 5-point Likert scale. Experts were blinded to each other's answers. When 80% of experts agreed with proposed objectives, objectives were considered "accepted" and retained. When 80% of experts disagreed with proposed objectives, the objectives were considered "rejected" and discarded. The remaining objectives were considered in subsequent rounds. In the first round, one objective was rejected and four were accepted. In the second round, four objectives were rejected and five were accepted. Having reached nine objectives the panel unanimously agreed that the nine objectives were sufficient to be used as a foundation for teaching modules. RESULTS: Using the DM, our expert panel identified nine educational objectives that were used as the foundation for an educational module. Of the nine objectives, three were categorized as "medical knowledge," two as "pharmacologic knowledge," two as "patient communication," and two as "systems-based practice." The learning objectives are as follows: recognize common barriers to treating pain; understand alternative interventional therapies used to treat different kinds of pain their implications, benefits, and risks; identify common component symptoms that may exacerbate chronic pain (i.e., depression, anxiety, delirium, cachexia, dyspnea); study the major drug groups used to treat different kinds of pain; recognize the risks of polypharmacy; set realistic expectations with patients early in their presentation to the emergency department (ED); educate patients as the risks of different classes of pain medications, including risk of addiction; understand the legal and regulatory issues that govern pain management in the ED; and understand in-hospital resources available for patient follow up and referral to pain clinics. CONCLUSIONS: We successfully used the DM to develop educational objectives for an e-learning module. Further work should evaluate educational outcomes of the teaching module.

Using the Electronic Medical Record to Reduce Unnecessary Ordering of Coagulation Studies for Patients with Chest Pain.

INTRODUCTION: Our goal was to reduce ordering of coagulation studies in the emergency department (ED) that have no added value for patients presenting with chest pain. We hypothesized this could be achieved via implementation of a stopgap measure in the electronic medical record (EMR). METHODS: We used a pre and post quasi-experimental study design to evaluate the impact of an EMR-based intervention on coagulation study ordering for patients with chest pain. A simple interactive prompt was incorporated into the EMR of our ED that required clinicians to indicate whether patients were on anticoagulation therapy prior to completion of orders for coagulation studies. Coagulation order frequency was measured via detailed review of randomly sampled encounters during two-month periods before and after intervention. We classified existing orders as clinically indicated or non-value added. Order frequencies were calculated as percentages, and we assessed differences between groups by chi-square analysis. RESULTS: Pre-intervention, 73.8% (76/103) of patients with chest pain had coagulation studies ordered, of which 67.1% (51/76) were non-value added. Post-intervention, 38.5% (40/104) of patients with chest pain had coagulation studies ordered, of which 60% (24/40) were non-value added. There was an absolute reduction of 35.3% (95% confidence interval [CI]: 22.7%, 48.0%) in the total ordering of coagulation studies and 26.4% (95% CI: 13.8%, 39.0%) in non-value added order placement. CONCLUSION: Simple EMR-based interactive prompts can serve as effective deterrents to indiscriminate ordering of diagnostic studies.

Case Series: Pneumorrhachis Secondary to Spontaneous Pneumomediastinum.

BACKGROUND: Pneumorrhachis (PR) describes the clinical finding of air within the spinal canal and rarely has been associated with spontaneous pneumomediastinum. There is little medical literature addressing the evaluation and management of these patients in the emergency department. CASE REPORT: We present a series of patients with PR secondary to a spontaneous pneumomediastinum and briefly review the available literature on the topic to discuss reasonable management strategies for patients presenting with this rare finding. In both cases, the patients had excellent outcomes with expectant management despite the worrisome finding of air in the spinal canal. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must be able to promptly recognize and appropriately assess even uncommon pathology. As with other rare conditions, there are no published guidelines for the ED management of PR, necessitating the use of case presentations to educate providers as to the complications and plan of care of this diagnosis.

A Review of the Toxicity of HIV Medications II: Interactions with Drugs and Complementary and Alternative Medicine Products.

For many patients today, HIV has become a chronic disease. For those patients who have access to and adhere to lifelong antiretroviral (ARV) therapy, the potential for drug-drug interactions has become a real and life-threatening concern. It is known that most ARV drug interactions occur through the cytochrome P450 (CYP) pathway. Medications for comorbid medical conditions, holistic supplements, and illicit drugs can be affected by CYP inhibitors and inducers and have the potential to cause harm and toxicity. Protease inhibitors (PIs) tend to inhibit CYP3A4, while most non-nucleoside reverse transcriptase inhibitors (NNRTIs) tend to induce the enzyme. As such, failure to adjust the dose of co-administered medications, such as statins and steroids, may lead to serious complications including rhabdomyolysis and hypercortisolism, respectively. Similarly, gastric acid blockers can decrease several ARV absorption, and warfarin doses may need to be adjusted to maintain therapeutic concentrations. Illicit drugs such as methylenedioxymethamphetamine (MDMA, "ecstasy") in combination with PIs lead to increased toxicity, while the concomitant administration of sedative drugs such as midazolam and alprazolam in patients taking PIs can result in prolonged sedation, delayed recovery, and increased length of stay. Even supplements like St. John's Wort can alter PI concentrations. In theory, any drug that is metabolized by CYP has potential for a pharmacokinetic drug-drug interaction with all PIs, cobicistat, and most NNRTIs. When adding a new medication to an ARV regimen, use of a drug-drug interaction software and/or consultation with a clinical pharmacist/pharmacologist or HIV specialist is recommended.

Calcium supplements controversy in osteoporosis: a physiological mechanism supporting cardiovascular adverse effects.

Recently, administration of calcium supplements for the prevention and treatment of osteoporosis has become a highly controversial issue. The findings of epidemiological studies are not necessarily supportive of the practice and are also open to different interpretations. In this article, we attempt to broaden the discussion and provide evidence that calcium supplementation may fail to compensate for renal calcium loss, and also that the resultant increased calcium load in the circulation could lead to extraskeletal deposition, including in the coronary arteries.

Ciclosporin use during pregnancy.

Ciclosporin (cyclosporine) is an immunosuppressive drug first approved for use in organ transplantation to prevent rejection. Ciclosporin is also known to be used for the treatment of psoriasis, rheumatoid arthritis, systemic lupus erythematosus and inflammatory bowel disease, among other indications. While it is recommended that all medications that are not absolutely necessary should be avoided during pregnancy, this may not be an option for many women whose quality of life is significantly impacted without treatment, or for those who must continue immunosuppressive therapy to avoid organ rejection. The purpose of this review is to provide a comprehensive report from the literature of ciclosporin exposure during pregnancy. PubMed, MEDLINE and the Cochrane Database of Systematic Reviews were searched for English-language articles published from 1970 to 2012 that included reports of pregnant women treated at any time during pregnancy with ciclosporin. On an initial search, it was evident that much of the available information is limited to pregnancy after transplant, which suggests that ciclosporin use during pregnancy appears to be associated with premature delivery and low birthweight infants. Comorbidities such as hypertension, pre-eclampsia and gestational diabetes mellitus are also reported at higher incidences than the general population. Medical literature concerning women with autoimmune disorders exposed to ciclosporin during pregnancy are currently limited to case reports and registry data, and, as such, it is difficult to determine if any risks associated with ciclosporin therapy during pregnancy are due to exposure to the drug alone or to pre-existing maternal comorbidities. The literature suggests that ciclosporin therapy during pregnancy should be carefully considered by the treating physician, but may be a safe alternative for patients with autoimmune disease refractory to conventional treatment. Continued monitoring of this patient population remains a key component to understanding the risk factors associated with ciclosporin exposure during pregnancy.

Soft tissue foreign body removal technique using portable ultrasonography.

Retained foreign objects account for as much as 2% of soft tissue injuries sustained in the wilderness. Subcutaneously embedded fragments are often missed during the initial medical evaluation and may result in morbidity secondary to delayed removal. Although the utility of ultrasonography in the emergency department for the detection of retained objects is established, the potential use of point-of-care ultrasound to aid with foreign body removal in the field has not been well described. We present 2 case reports that demonstrate the value of ultrasonography in detecting and successfully removing foreign bodies sustained in the wilderness, and outline a procedural technique that minimizes morbidity and uses equipment available in wilderness medical field kits. We propose that with the advent of portable and handheld ultrasound units, foreign body removal in the field has become feasible and may decrease the morbidity of soft tissue injuries, particularly in austere and wilderness environments with limited access to immediate medical care.

Loss of Rap1GAP in papillary thyroid cancer.

CONTEXT: Rap1 GTPase-activating protein (GAP) regulates the activity of Rap1, a putative oncogene. We previously reported Rap1GAP was highly expressed in normal human thyroid cells and decreased in five papillary thyroid carcinomas (PTCs). OBJECTIVES: To confirm the significance of these findings, we analyzed Rap1GAP expression in a larger set of benign tumors (adenomas and hyperplastic nodules) and PTCs. We determined whether the presence of the BRAF(V600E) mutation or allelic loss of Rap1GAP related to changes in Rap1GAP protein expression. To determine the consequences of Rap1GAP loss, we targeted Rap1GAP in culture using small interfering RNA. DESIGN, PATIENTS, AND METHODS: A highly specific Rap1GAP antibody was applied to sections of 55 human thyroid tissues. Genomic DNA was analyzed for the presence of the BRAF(V600E) mutation, and loss of Rap1GAP. Rap1GAP expression in rat thyroid cells was abolished using small interfering RNA. RESULTS: We observed that down-regulation of Rap1GAP in benign lesions and PTCs was common. Rap1GAP expression was more severely decreased in PTCs. Loss of Rap1GAP expression was observed in multiple histological variants of PTCs. Approximately 20% of PTCs and adenomas exhibited allelic loss of Rap1GAP. Loss of Rap1GAP was not associated with the presence of the BRAF(V600E) mutation. In vitro, loss of Rap1GAP was sufficient to increase Rap1 activity in thyroid cells. CONCLUSIONS: These data indicate that loss of Rap1GAP is a frequent event in PTC. The more frequent and greater down-regulation of Rap1GAP in PTCs compared with adenomas suggests a role for Rap1GAP depletion in the progression of human thyroid tumors, possibly through unrestrained Rap activity.