The Relationship between the Subjective Visual Horizontal and Ocular Vestibular Evoked Myogenic Potentials in Acute Vestibular Neuritis.

OBJECT: Vestibular evoked myogenic potentials (VEMPs) and the subjective visual horizontal (SVH) (or vertical [SVV]) have both been considered tests of otolith function: ocular-VEMPs (oVEMPs) utricular function, cervical VEMPs (cVEMPs) saccular function. Some studies have reported association between decreased oVEMPs and SVH, whereas others have not. DESIGN: A retrospective study of test results. SETTING: A tertiary, neuro-otology clinic, Royal Prince Alfred Hospital, Sydney, Australia. METHOD: We analyzed results in 130 patients with acute vestibular neuritis tested within 5 days of onset. We sought correlations between the SVH, oVEMPs, and cVEMPs to air-conducted (AC) and bone-conducted (BC) stimulation. RESULTS: The SVH deviated to the side of lesion, in 123 of the 130 AVN patients, by 2.5 to 26.7 degrees. Ninety of the AVN patients (70%) had abnormal oVEMPs to AC, BC or both stimuli, on the AVN side (mean asymmetry ratio ± SD [SE]): (64 ± 45.0% [3.9]). Forty-three of the patients (35%) had impaired cVEMPs to AC, BC or both stimuli, on the AVN side, [22 ± 41.6% (4.1)]. The 90 patients with abnormal oVEMP values also had abnormal SVH. Correlations revealed a significant relationship between SVH offset and oVEMP asymmetry (r = 0.80, p < 0.001) and a weaker relationship between SVH offset and cVEMP asymmetry (r = 0.56, p < 0.001). CONCLUSIONS: These results indicate that after an acute unilateral vestibular lesion, before there has been a chance for vestibular compensation to occur, there is a significant correlation between the SVH, and oVEMP results. The relationship between SVH offset and oVEMP amplitude suggests that both tests measure utricular function.

Subjective visual horizontal correlates better with ocular than with cervical vestibular evoked myogenic potentials.

OBJECTIVE: To examine the relationship between widely used otolith function tests: the Subjective Visual Horizontal (SVH) and Vestibular Evoked Myogenic Potentials (VEMP). METHODS: A retrospective analysis was performed on 301 patients who underwent SVH, ocular and cervical VEMP (oVEMP and cVEMP) tests on the same day. Correlations between the mean SVH tilt and amplitude asymmetry ratios for bone-conducted (BC) oVEMP and air-conducted (AC) cVEMP were examined. Diagnoses included vestibular neuritis, stroke, vestibular migraine, Meniere's disease, sudden sensorineural hearing loss (SSNHL) and vestibular schwannoma. RESULTS: SVH results were concordant with the oVEMP in 64% of cases and the cVEMP in 51%. Across all patients, SVH demonstrated a significant moderate correlation with BC oVEMP amplitude asymmetry ratios (r = 0.55, p < 0.001) and a weak correlation with AC cVEMP amplitude asymmetry ratios (r = 0.35, p < 0.001). A stronger correlation between SVH and oVEMPs was observed in patients with vestibular neuritis (r = 0.67, p < 0.001) and SSNHL (r = 0.76, p = 0.001). CONCLUSIONS: SVH correlates better with oVEMP than cVEMP symmetry. SIGNIFICANCE: This finding reinforces the hypothesis of a common utricular origin for both SVH and oVEMPs which is distinct from the saccular origin of cVEMPs.

Modern vestibular tests can accurately separate stroke and vestibular neuritis.

OBJECTIVES: To separate posterior-circulation stroke (PCS) and vestibular-neuritis (VN) using quantitative vestibular tests. METHODS: Patients were prospectively recruited from the emergency room within 72 h of presentation. Video-nystagmography (VNG), three-dimensional video head-impulse testing (vHIT), vestibular-evoked myogenic potentials (VEMPs), and subjective visual-horizontal (SVH) were performed. RESULTS: There were 128 PCS and 134 VN patients. Common stroke-territories were: posterior-inferior cerebellar artery, basilar-perforators, multi-territory and anterior-inferior cerebellar artery (41.4%, 21.1%, 14.1%, 7.8%). VN included superior, inferior and pan-neuritis (53.3%, 4.2%, and 41.5%). Most VN and stroke patients presented with acute vestibular syndrome (96.6%, 61.7%). In VN, we recorded horizontal (98.5%) or vertical/torsional spontaneous nystagmus (1.5%) and in PCS, absent-nystagmus (53.9%), horizontal (32%) or vertical/torsional (14.1%) nystagmus. The mean slow-phase velocity of horizontal nystagmus was faster in VN than PCS (11.8 ± 7.2 and 5.2 ± 3.0°/s, p < 0.01). Ipsilesional horizontal-canal (HC) vHIT-gain was lower in VN than in stroke (0.47 ± 0.24, 0.92 ± 0.20, p < 0.001). Ipsilesional catch-up saccades occurred earlier, and their amplitude, prevalence, and velocity were greater in VN than PCS (p < 0.01). Ipsilesional SVH deviation > 2.5° occurred more often in VN than in stroke (97.6% and 24.3%, p < 0.01). Abnormal bone-conducted ocular-VEMP asymmetry ratio was more common in VN than PCS (50% and 14.4%, p < 0.01). Using the ten best discriminators (VNG, vHIT, SVH, and oVEMP metrics), VN was separated from PCS with a sensitivity of 92.9% and specificity of 89.8%. Adding VNG and vHIT to the bedside head-impulse-nystagmus-and-test-of-skew (HINTS) test enhanced sensitivity and specificity from 95.3% and 63.4% to 96.5% and 80.6%. CONCLUSION: Quantitative vestibular testing helps separate stroke from vestibular neuritis and, when used, could improve diagnostic accuracy in the emergency room.

The long-term outcomes of patients with negative prolonged ambulatory electroencephalography tests: A cross-sectional follow-up study.

Background: Ambulatory electroencephalography (AEEG) recording is an essential aid for detecting interictal discharges and providing a clinical diagnosis. This study aimed to describe long-term outcomes among a cohort of patients who yielded negative results on AEEG at the time of assessment and identify factors associated with contemporary quality of life (QOL) and ultimate epilepsy diagnosis. Methods: This cross-sectional telephone follow-up study was conducted in June-November 2021 at the Neurology Department in a metropolitan hospital in Sydney, Australia. Results: In total, 47 of 105 eligible (45%) participants were enrolled. Overall, 21 (45%) participants had been diagnosed with epilepsy at a 12-year follow-up. Taking anti-seizure medication, having experienced a seizure event, and having marriage and education-related characteristics were associated with an epilepsy diagnosis. QOL was found to be associated with age, employment status and history of experience of a seizure event. QOL and an epilepsy diagnosis were not shown to be statistically related. Conclusions: Nearly half of the participants had received an epilepsy diagnosis at long-term follow-up, despite having tested negative on AEEG at the time of assessment. Prolonged AEEG testing is an important tool to aid the diagnostic process. However, clinical examination, including accurate history taking, is vital in establishing an epilepsy diagnosis.

Ambulatory electroencephalography (AEEG) recording is an essential aid for detecting interictal discharges and providing a clinical diagnosis. This study aimed to describe long-term outcomes among a cohort of patients who yielded negative results on AEEG at the time of assessment and identify factors associated with contemporary quality of life (QOL) and ultimate epilepsy diagnosis. This cross-sectional telephone follow-up study was conducted in June-November 2021 at the Neurology Department in a metropolitan hospital in Sydney, Australia. In total, 47 of 105 eligible (45%) participants were enrolled. Overall, 21 (45%) participants had been diagnosed with epilepsy at a 12-year follow-up. Taking anti-seizure medication, having experienced a seizure event, and having marriage and education-related characteristics were associated with an epilepsy diagnosis. QOL was found to be associated with age, employment status and history of experience of a seizure event. QOL and an epilepsy diagnosis were not shown to be statistically related. Nearly half of the participants had received an epilepsy diagnosis at long-term follow-up, despite having tested negative on AEEG at the time of assessment. Prolonged AEEG testing is an important tool to aid the diagnostic process. However, clinical examination, including accurate history taking, is vital in establishing an epilepsy diagnosis.

Radial Hemostasis Is Facilitated With a Potassium Ferrate Hemostatic Patch: The STAT2 Trial.

OBJECTIVES: The aim of this trial was to test whether the potassium ferrate hemostatic patch (PFHP) as an adjunct to the TR Band (TRB) facilitated an early deflation protocol. BACKGROUND: Shorter TRB compression times may reduce the rate of radial artery occlusion (RAO) and reduce observation time after transradial access. METHODS: A total of 443 patients were randomized to the TRB or PFHP + TRB, with complete TRB deflation attempted 60 minutes postprocedure. The primary outcome was the time to successful full deflation of the TRB without bleeding, with secondary outcomes of time to discharge and complications including hematoma, RAO, or bleeding requiring intervention beyond TRB reinflation. RESULTS: Time to complete TRB deflation was 66 ± 14 minutes with the PFHP vs 113 ± 56 minutes for the TRB alone (P < 0.001). Minor rebleeding requiring TRB reinflation was much more frequent without the PFHP (0% vs 67.7%; P < 0.001) with 2.3 ± 1.3 additional reinflation and deflation attempts needed for hemostasis. Hematomas developed in 4.0% of the PFHP group and 6.8% of the TRB group (P = 0.20). RAO was rare (<1%), although 41% of patients received <5,000 U heparin. Among percutaneous coronary intervention patients, time to TRB deflation (68 ± 15 minutes vs 138 ± 62 minutes; P < 0.001) and composite complications (10.0% vs 24.2%; P = 0.04) were reduced with the PFHP. CONCLUSIONS: Compared with the TRB alone, the PFHP facilitated early 60-minute TRB deflation following transradial catheterization, with a numeric reduction in vascular complications. RAO occurs rarely with early deflation regardless of heparin dose. (Comparing TR Band to StatSeal in Conjunction With TR Band II [StatSeal II]; NCT04046952).

2020 webPOISONCONTROL data summary.

INTRODUCTION: Increasing use of the internet for health information has decreased utilization of traditional telephone-based poison centers in the United States. webPOISONCONTROL®, a browser-based tool and app was launched to meet the growing demand for online, personalized recommendations for human poison exposures. This study was conducted to characterize webPOISONCONTROL cases and highlight its potential for real-time monitoring of poisoning. METHODS: Case data for all completed, nonduplicated public cases entered in 2020 were analyzed using a custom Qlik Sense dashboard. RESULTS: Of the 156,202 cases, 52.9% occurred in children younger than 4 years. Most cases (109,057, 69.8%) were initially triaged to home, 28.4% were advised to call Poison Control, and 1.7% were referred to the ED. Follow-up was available for 33.3% of home-triaged cases; 1.7% of those had a change in triage recommendation. Pharmaceuticals were implicated in 41.5% of cases (nonpharmaceuticals in 58.5%). Ingestion was the most common route (88.4%, 138,012). One-time double dose therapeutic error cases were implicated in 17,901 cases (27.6% of pharmaceutical cases). Cosmetics (13.9%) and cleaning substances (12.9%) were the most frequent substance categories. Melatonin was the most frequently implicated generic substance (4.5% of cases). Most (72.0%) cases had no effect (21.4%), a minor effect (3.9%) or were minimally toxic with unknown outcome (46.7%). There were no deaths, 17 major outcomes (0.01%), and 26.7% of cases had potentially toxic exposures with no outcome determination. In 2020, webPOISONCONTROL handled 7.3% as many human poison exposure cases as were reported to U.S. phone-based poison centers. Online cases are skewed towards younger ages (53% in children younger than 4 years vs 37% of phone-based cases) and towards nonpharmaceuticals (58.5% vs 43.5%). Near real-time data visualizations enabled detection of COVID-19-related increases in exposures to hand sanitizers and cleaners, illustrating the public health surveillance and hazard detection capabilities of webPOISONCONTROL. CONCLUSION: The webPOISONCONTROL tool provides a safe, quick and fully-automated alternative to those who are unable or unwilling to use the telephone to call a traditional poison center.

Capturing vertigo in the emergency room: three tools to double the rate of diagnosis.

OBJECTIVE: Many patients attending the emergency room (ER) with vertigo, leave without a diagnosis. We assessed whether the three tools could improve ER diagnosis of vertigo. METHODS: A prospective observational study was undertaken on 539 patients presenting to ER with vertigo. We used three tools: a structured-history and examination, nystagmus video-oculography (VOG) in all patients, additional video head-impulse testing (vHIT) for acute-vestibular-syndrome (AVS). RESULTS: In the intervention-group (n = 424), case-history classified AVS in 34.9%, episodic spontaneous-vertigo (ESV 32.1%), and episodic positional-vertigo (EPV 22.6%). In AVS, we employed "Quantitative-HINTS plus" (Head-Impulse, Nystagmus and Test-of-Skew quantified by vHIT and VOG, audiometry) to identify vestibular-neuritis (VN) and stroke (41.2 and 31.1%). vHIT gain ≤ 0.72, catch-up saccade amplitude > 1.4○, saccade-frequency > 154%, and unidirectional horizontal-nystagmus, separated stroke from VN with 93.1% sensitivity and 88.5% specificity. In ESV, 66.2 and 14% were diagnosed with vestibular migraine and Meniere's Disease by using history and audiometry. Horizontal-nystagmus velocity was lower in migraine 0.4 ± 1.6○/s than Meniere's 5.7 ± 5.5○/s (p < 0.01). In EPV, benign positional vertigo (BPV) was identified in 82.3% using VOG. Paroxysmal positional-nystagmus lasting < 60 s separated BPV from non-BPV with 90% sensitivity and 100% specificity. In the control group of ER patients undergoing management-as-usual (n = 115), diagnoses included BPV (38.3%) and non-specific vertigo (41.7%). Unblinded assessors reached a final diagnosis in 90.6 and 30.4% of the intervention and control groups. Blinded assessors provided with the data gathered from each group reached a diagnosis in 86.3 and 41.1%. CONCLUSION: Three tools: a structured-assessment, vHIT and VOG doubled the rate of diagnosis in the ER.

Supersized alcopop related calls in the National Poison Data System, 2010-2019.

BACKGROUND: Supersized alcopops are single-serving high-alcohol-content beverages frequently consumed by underage drinkers. However, little data exist regarding the public health burden of supersized alcopops during the last decade. The current study examined the characteristics of calls to U.S. poison control centers involving supersized alcopops. This study also compared the proportion of calls for underage consumers between calls involving consumption of supersized alcopops and calls involving other types of alcohol (e.g., liquor, beer, wine). METHODS: Data from the National Poison Data System (NPDS) repository of calls to U.S. poison control centers were analyzed. RESULTS: Between 2010 and 2019, poison control centers received 1719 calls for exposures to supersized alcopops. Nearly one-half of calls involving supersized alcopop consumption (46.3 %) were made for consumers who were below the legal drinking age. In all years, the proportion of calls for supersized alcopops that were for underage exposures greatly exceeded the proportion of calls that were for underage exposures for other types of alcohol. For those 0-11 years of age, 91 % of supersized alcopop exposures were unintentional; however, for each other age group, at least 84 % of exposures were intentional. Supersized alcopop exposures involved a co-ingested product in more than 80 % of cases among patients of legal drinking age and less than 50 % of cases among patient under legal drinking age. CONCLUSIONS: Compared to other alcohol products, calls to U.S poison control centers for supersized alcopops disproportionately involved underage drinkers. To protect youth, improved regulation of supersized alcopop products is urgently needed.

Bone-Conducted oVEMP Latency Delays Assist in the Differential Diagnosis of Large Air-Conducted oVEMP Amplitudes.

Background: A sensitive test for Superior Semicircular Canal Dehiscence (SCD) is the air-conducted, ocular vestibular evoked myogenic potential (AC oVEMP). However, not all patients with large AC oVEMPs have SCD. This retrospective study sought to identify alternate diagnoses also producing enlarged AC oVEMPs and investigated bone-conducted (BC) oVEMP outcome measures that would help differentiate between these, and cases of SCD. Methods: We reviewed the clinical records and BC oVEMP results of 65 patients (86 ears) presenting with dizziness or balance problems who underwent CT imaging to investigate enlarged 105 dB nHL click AC oVEMP amplitudes. All patients were tested with BC oVEMPs using two different stimuli (1 ms square-wave pulse and 8 ms 125 Hz sine wave). Logistic regression and odds ratios were used to determine the efficacy of BC oVEMP amplitudes and latencies in differentiating between enlarged AC oVEMP amplitudes due to dehiscence from those with an alternate diagnosis. Results: Fifty-three ears (61.6%) with enlarged AC oVEMP amplitudes were identified as having frank dehiscence on imaging; 33 (38.4%) had alternate diagnoses that included thinning of the bone covering (near dehiscence, n = 13), vestibular migraine (n = 12 ears of 10 patients), enlarged vestibular aqueduct syndrome (n = 2) and other causes of recurrent episodic vertigo (n = 6). BC oVEMP amplitudes of dehiscent and non-dehiscent ears were not significantly different (p > 0.05); distributions of both groups overlapped with the range of healthy controls. There were significant differences in BC oVEMP latencies between dehiscent and non-dehiscent ears for both stimuli (p < 0.001). A prolonged n1 125 Hz latency (>11.5 ms) was the best predictor of dehiscence (odd ratio = 27.8; 95% CI:7.0-111.4); abnormal n1 latencies were identified in 79.2% of ears with dehiscence compared with 9.1% of ears without dehiscence. Conclusions: A two-step protocol of click AC oVEMP amplitudes and 125 Hz BC oVEMP latency measures optimizes the specificity of VEMP testing in SCD.

Randomized Trial of Radial Hemostasis Using Focused vs Balloon Compression Devices.

BACKGROUND: Radial artery hemostasis devices differ in compression mechanisms, which may influence time to hemostasis and hand perfusion. METHODS: Subjects (n = 52) undergoing transradial diagnostic coronary catheterization or percutaneous coronary intervention (PCI) were randomized 1:1 to either focused compression (VasoStat; Forge Medical) or balloon compression device (TR Band; Terumo Medical) for radial artery hemostasis. Time to complete hemostasis enabling device removal was measured in each subject. Hand perfusion was quantitated using the perfusion index (PI) with oximetry (1) before; (2) during device use; (3) during device use with ulnar artery compression; and (4) following device removal. RESULTS: Focused compression resulted in a significantly shorter time to complete hemostasis vs balloon compression (208 min [IQR, 115-320 min] vs 242 min [IQR, 120-439 min], respectively; P=.04). This difference was greatest among the subset undergoing PCI, where the VasoStat resulted in a 43-minute reduction until complete hemostasis (P=.04). Baseline PI was similar between the focused and balloon compression groups (4.9 vs 3.9, respectively; P=.09). Focused compression resulted in a similar reduction in median PI from baseline to during device use compared with balloon compression (-27% vs -18%, respectively; P=.26). Both devices decreased PI over 50% from baseline during simultaneous ulnar artery compression (P<.01), and increased PI over 50% from baseline following device removal (P=.02). No radial artery occlusion occurred, and rates of device manipulation and access-site bleeds were low in both groups. CONCLUSION: Complete hemostasis was achieved earlier with the VasoStat focused compression device compared with the TR Band balloon compression device. Both devices transiently reduced hand perfusion, particularly during ulnar compression, which increased from baseline following device removal. Larger trials comparing these radial hemostasis devices and outcomes are warranted.

Time to perforation for button batteries lodged in the esophagus.

INTRODUCTION: New strategies recently proposed to mitigate injury caused by lithium coin cell batteries lodged in the esophagus include prehospital administration of honey to coat the battery and prevent local hydroxide generation and in-hospital administration of sucralfate suspension (or honey). This study was undertaken to define the safe interval for administering coating agents by identifying the timing of onset of esophageal perforations. METHODS: A retrospective study of 290 fatal or severe battery ingestions with esophageal lodgment was undertaken to identify cases with esophageal perforations. RESULTS: Esophageal perforations were identified in 189 cases (53 fatal, 136 severe; 95.2% in children ≤4 years). Implicated batteries were predominantly lithium (91.0%) and 92.0% were ≥20 mm diameter. Only 2% of perforations occurred in <24 h following ingestion, including 3 severe cases with perforations evident at 11-17 h, 12 h, and 18 h. Another 7.4% of perforations (11 cases) became evident 24 to 47 h post ingestion and 10.1% of perforations (15 cases) became evident 48 to 71 h post ingestion. By 3 days post ingestion, 26.8% of perforations were evident, 36.9% by 4 days, 46.3% by 5 days, and 66.4% by 9 days. CONCLUSION: Esophageal perforation is unlikely in the 12 h after battery ingestion, therefore the administration of honey or sucralfate carries a low risk of extravasation from the esophagus. This first 12 h includes the period of peak electrolysis activity and battery damage, thus the risk of honey or sucralfate is low while the benefit is likely high.

Vestibular neuritis affects both superior and inferior vestibular nerves.

OBJECTIVE: To characterize the profiles of afferent dysfunction in a cross section of patients with acute vestibular neuritis using tests of otolith and semicircular canal function sensitive to each of the 5 vestibular end organs. METHODS: Forty-three patients fulfilling clinical criteria for acute vestibular neuritis were recruited between 2010 and 2016 and studied within 10 days of symptom onset. Otolith function was evaluated with air-conducted cervical and bone-conducted ocular/vestibular evoked myogenic potentials and the subjective visual horizontal test. Canal-plane video head impulse tests (vHITs) assessed the function of each semicircular canal. Patterns of recovery were investigated in 16 patients retested after a 6- to 12-month follow-up period. RESULTS: Rates of horizontal canal (97.7%), anterior canal (90.7%), and utricular (72.1%) dysfunction were significantly higher than rates of posterior canal (39.5%) and saccular (39.0%) dysfunction (p < 0.008). Twenty-four patients (55.8%) had abnormalities localizing to both vestibular nerve divisions; 18 patients (41.9%) had superior neuritis; and 1 patient (2.3%) had inferior neuritis. A test battery that included horizontal and posterior canal vHIT and the cervical/vestibular evoked myogenic potentials identified superior or inferior neuritis in all patients tested acutely. Eight of 16 patients who were retested at follow-up had recovered a normal vestibular evoked myogenic potential and vHIT profile. CONCLUSIONS: Acute vestibular neuritis most often affects both vestibular nerve divisions. The horizontal vHIT alone identifies superior nerve dysfunction in all patients with vestibular neuritis tested acutely, whereas both cervical/vestibular evoked myogenic potentials and posterior vHIT are necessary for diagnosing inferior vestibular nerve involvement.

Elevated acetaminophen concentration measured after nasal insufflation of Percocet®.

BACKGROUND: Prescription opioid products are often formulated with acetaminophen, but the pharmacokinetics of nasally administered acetaminophen are poorly characterized. We report a case of a potentially toxic acetaminophen concentration after nasal insufflation of oxycodone/acetaminophen tablets. CASE REPORT: A 38-year-old female presented to the emergency department after 2 days of nasally insufflating a total of 50 oxycodone/acetaminophen 5/325 mg tablets. On day 3, she was evaluated for nausea and pharyngitis. She denied oral ingestion of the drug. The initial acetaminophen concentration was 14 µg/mL, although the patient had not insufflated any medication in approximately 24 h. Initial AST and ALT were normal. The patient was treated with a 21-h course of intravenous N-acetylcysteine. On hospital day 2, the measured acetaminophen concentration was < 10 µg/mL and the patient's liver enzymes remained within normal limits. CONCLUSIONS: The pharmacokinetics of nasally administered acetaminophen have not been well studied, yet there is potential for significant exposure with prescription opioid abuse. Clinicians should be vigilant in evaluating patients for toxicity due to adjunct medications formulated in narcotic pain preparations used by routes other than ingestion.

Effect of cough and cold medication restriction and label changes on pediatric ingestions reported to United States poison centers.

OBJECTIVE: To determine the impact of industry and Food and Drug Administration initiatives implemented to limit the use of over-the-counter (OTC) cough and cold medications in children younger than 6 years of age. STUDY DESIGN: This is a retrospective database study of OTC cough and cold medication ingestions reported to US poison centers between 2000 and 2010. Data analyzed from the National Poison Data System included the month and year of ingestion, reason for ingestion, health care utilization, and medical outcome. Ingestion frequencies were stratified by age and reason. Data were divided into pre- and postintervention periods for comparative analysis. RESULTS: Unintentional ingestions of OTC cough and cold medications decreased 33.4% and therapeutic errors by 46.0%. Health care facility referral declined for unintentional ingestions (28.9% <2 years of age, 19.9% 2-5 years of age, P < .0001) and therapeutic errors in children younger than 2 years of age (59.2%, P < .0001). Moderate and severe adverse outcomes decreased for unintentional ingestions in children younger than 2 years of age by 32.4% and by 21.3% in 2- to 5-year olds, P < .0001. CONCLUSIONS: The restriction of OTC cough and cold medications has led to a decline in unintentional ingestions, therapeutic errors, health care facility referral, and serious medical outcomes in children younger than 2 years of age. There has also been a decline in ingestions in 2- to 5-year-old children.

Use of ultrasound to facilitate accurate femoral nerve block in the emergency department.

OBJECTIVE: To compare the accuracy of ultrasound (US)-assisted femoral nerve blocks (FNB) with the fascial pop (FP) technique, examining the rates of success and complications. METHODS: This is a prospective unblinded pseudo-randomized controlled trial of US-assisted versus FP FNB techniques. The primary outcome measure was nerve block stratified to level of blockade (intact, partial or complete) with FNB assessed by skin sensation. Participants were assessed at 15 and 60 min post nerve block. RESULTS: Sixty-seven patients were enrolled. Thirty-four (50.7% [95% CI 44.7-56.8]) underwent the US-assisted technique whereas thirty-three (49.2% [95% CI 43.4-55.2]) underwent the FP technique. At 15 min, FNB using US was intact, partial or complete for 9 (26.5% [95% CI 22.5-30.4]), 15 (44.1% [95% CI 36.8-51.5]) and 10 (29.4% [95% CI 24.9-33.9]) patients, respectively, compared with 14 (42.4% [95% CI 35.3-49.6]), 17 (51.5% [95% CI 42.7-60.3]) and 2 (6.1% [95% CI 5.6-6.6]) patients, respectively (P = 0.038). There was no difference at 60 min. Complete block at 15 min was achieved in 10/34 patients (29% [95% CI 14.1-44.7]) in the US group and 2/33 patients (6% [95% CI -2.1-14.2]) in the FP group (P = 0.029); no difference was seen at 60 min. No complications were recorded in either group. CONCLUSIONS: A more complete blockade is achieved earlier using the US-assisted technique. The US-assisted technique will become the technique of choice for FNB in this department.

The Toxic Exposure Surveillance System (TESS): risk assessment and real-time toxicovigilance across United States poison centers.

The Toxic Exposure Surveillance System (TESS) is a uniform data set of US poison centers cases. Categories of information include the patient, the caller, the exposure, the substance(s), clinical toxicity, treatment, and medical outcome. The TESS database was initiated in 1985, and provides a baseline of more than 36.2 million cases through 2003. The database has been utilized for a number of safety evaluations. Consideration of the strengths and limitations of TESS data must be incorporated into data interpretation. Real-time toxicovigilance was initiated in 2003 with continuous uploading of new cases from all poison centers to a central database. Real-time toxicovigilance utilizing general and specific approaches is systematically run against TESS, further increasing the potential utility of poison center experiences as a means of early identification of potential public health threats.