Emergency Medicine Procedures: A Review of Approved Instructional Resources from the World of Free Open Access Medical Education.

The Academic Life in Emergency Medicine (ALiEM) Approved Instructional Resources (AIR) Series was created in 2014 to address the Free Open Access Medical Education (FOAM) movement's decentralized nature and lack of inherent peer review. The AIR series provides a topic-based, curated list of online educational content vetted by academic emergency medicine (EM) faculty that meets individualized interactive instruction criteria for EM trainees. Relevant FOAM resources were identified from the top 50 FOAM websites using the Social Media Index and then scored by EM faculty using a validated instrument to identify the highest quality posts related to a topic. This article reviews FOAM resources pertaining to EM procedures that were labeled as an "Approved Instructional Resource" or "Honorable Mention" using the AIR series methodology.

Spinosad at 0.9% in the treatment of scabies: Efficacy results from 2 multicenter, randomized, double-blind, vehicle-controlled studies.

BACKGROUND: Scabies is a contagious skin disease resulting from Sarcoptes scabiei infestation. There are no approved over-the-counter treatments, and approved prescription products have disadvantages, including potential resistance. Spinosad, an insecticide derived from fermentation of a soil actinobacterium, shows promise as a potential treatment agent. OBJECTIVE: Combined results from 2 controlled clinical studies were used to evaluate the efficacy of 0.9% spinosad topical suspension in the eradication of scabies. METHODS: Each study included index subjects (the youngest household members with active scabies) and up to 5 other members in each household. Subjects applied 0.9% spinosad or vehicle once. Primary efficacy was the percentage of index subjects with complete cure on day 28. Additional efficacy included clinical cure, microscopic cure, and lesion counts. RESULTS: Spinosad at 0.9% is not equivalent to vehicle in the percentage of index subjects achieving complete cure on day 28 (78.1% vs 39.6%, respectively; P < .0001; n = 206). Additional efficacy analyses confirmed the consistent treatment effect of 0.9% spinosad. No safety signals were observed. LIMITATIONS: The studies used small sample sizes to assess equivalency. CONCLUSIONS: Spinosad at 0.9% performed better than vehicle in the treatment of scabies in these studies of subjects of 4 years of age or older following 1 application of study drug.

Pediatric volvulus induced thyroid storm.

Thyroid storm is an unusually rare but life-threatening pediatric occurrence, carrying significant mortality. Skewed towards the adolescent population, thyroid decompensation occurs due to inciting factors ranging from infection, trauma, surgery, burns, medications, direct thyroid trauma, and rarely volvulus. Emergent care focuses on both reversing the inciting event as well as quelling the metabolic hyperactivity associated with thyroid storm. In review of the available literature, this case is the first to date of thyroid storm secondary to malrotation with midgut volvulus in a previously euthyroid adolescent patient.

Pancreaticopleural fistula, a rare mediastinal emergency.

A pancreaticopleural fistula (PPF) is a rare condition that causes thoracic symptoms such as dyspnea and chest pain secondary to exudative pleural effusions. While PPF is a very rare complication with only 52 cases reported between 1960 and 2007, they typically occur in patients who are male, middle aged, and have a history of chronic alcohol use and chronic pancreatitis (Aswani and Hira, 2015; Francisco et al., n.d.; Valeshabad et al., 2018; Ali et al., 2009). The fistula between the pancreas and pleural cavity causes large, rapidly accumulating, and recurrent pleural effusions which cause symptoms that can be difficult to differentiate from other acute thoracic pathologies (Francisco et al., n.d.). As a result, it is essential that providers have a high index of suspicion for PPF in these appropriate populations. We present a case study to review the typical presentation, pathophysiology, and current approach to treatment of PPF. This case is unique as the patient had no known risk factors. Due to limited data on this topic, there are no evidence-based guidelines on this topic, leaving a variety of case reports to inform clinical management in the emergency department.

Cardiomegaly Masquerading as a Pediatric Thymoma: A Case Report.

Thymoma is a very rare pediatric tumor, accounting for less than 1% of all childhood mediastinal tumors with scant literature, and only 23 pediatric cases were identified by a pediatric tumor surveillance registry between 1973 and 2008. In contrast to adult thymomas, pediatric thymomas have an aggressive tendency, though the majority is discovered as incidental findings. Patient presentations to the emergency department (ED) are often subtle and non-specific such as dyspnea, cough, and chest pain, requiring a broad differential on the part of the emergency clinician. Because of this presentation, diagnosis often occurs later in the disease process when compared with adults. Chest radiograph may demonstrate an enlarged thymic shadow or cardiomegaly, necessitating further cardiac workup, commonly routed through cardiology. Computed tomography and biopsy are required for definitive diagnosis, requiring a multidisciplinary approach to management. We present a case of a 16-year-old female complaining of progressive dyspnea and chest pain over the course of one to two months with radiographic cardiomegaly. She was found to have a Masaoka stage III World Health Organization (WHO) type B3 thymic endothelial neoplasm and underwent surgical resection.

Man with Penile Pain.

CASE PRESENTATION: We describe a case of spontaneous partial segmental thrombosis of the corpus cavernosum (PSTCC). DISCUSSION: PSTCC is a rare condition in which thrombus formation occurs in the corpus cavernosum. This condition is managed in conjunction with a urologist, and management typically includes anticoagulation and pain control.

Academic Life in Emergency Medicine (ALiEM) Blog and Podcast Watch: Infectious Diseases.

The Academic Life in Emergency Medicine (ALiEM) Approved Instructional Resources (AIR) Series and Approved Instructional Resources - Professional (AIR-Pro) Series were created in 2014 and 2015, respectively, in response to the growing need to curate online educational content as well as create a nationally available curriculum that meets individualized interactive instruction criteria for emergency medicine (EM) trainees. These two online series identify high-quality educational blog and podcast content using an expert-based approach. The AIR series is a continuously building curriculum originally based on the Council of Emergency Medicine Directors (CORD) testing schedule. In September 2019, 61 blog posts and podcasts published within the previous 12 months and relevant to infectious diseases were evaluated by eight attending physicians using the ALiEM AIR scoring instrument. In this review, we summarize the accredited posts on infectious diseases meeting our a priori quality criteria per evaluation by the reviewers.

Pancreaticopleural fistula, a rare mediastinal emergency: A case report.

A pancreaticopleural fistula (PPF) is a rare condition that causes thoracic symptoms such as dyspnea and chest pain secondary to exudative pleural effusions. While PPF is a very rare complication with only 52 cases reported between 1960 and 2007, they typically occur in patients who are male, middle aged, and have a history of chronic alcohol use and chronic pancreatitis (Aswani and Hira, 2015; Francisco et al., n.d.; Valeshabad et al., 2018; Ali et al., 2009). The fistula between the pancreas and pleural cavity causes large, rapidly accumulating, and recurrent pleural effusions which cause symptoms that can be difficult to differentiate from other acute thoracic pathologies (Francisco et al., n.d.). As a result, it is essential that providers have a high index of suspicion for PPF in these appropriate populations. We present a case study to review the typical presentation, pathophysiology, and current approach to treatment of PPF. This case is unique as the patient had no known risk factors. Due to limited data on this topic, there are no evidence-based guidelines on this topic, leaving a variety of case reports to inform clinical management in the emergency department.

Interpreting troponin in renal disease: A narrative review for emergency clinicians.

INTRODUCTION: Patients with chronic kidney disease (CKD)/end stage renal disease (ESRD) can experience several severe complications, including acute coronary syndrome (ACS). While troponin is the biomarker of choice for evaluation of ACS, interpretation of troponin in CKD/ESRD can be challenging. OBJECTIVE: This narrative review evaluates troponin elevation in patients with CKD/ESRD, pitfalls in the evaluation with troponin, and an approach to using troponin in these high-risk patients. DISCUSSION: Patients with CKD/ESRD are at greater risk for ACS and possess higher levels of circulating troponin. Relatedly, these patients often present atypically for ACS. Several pitfalls must be considered in the use of troponin when evaluating for ACS. While troponin elevation in patients with CKD/ESRD is often considered to be due to underlying renal disease, this elevation has several etiologies including uremic skeletal myopathy, microinfarctions, left ventricular hypertrophy (LVH), decreased clearance, and unrecognized congestive heart failure (CHF). Utilizing troponin assays in this patient population requires a nuanced approach, as the sensitivity and specificity for troponin testing in CKD varies. Concern for ACS with elevated troponin warrants treatment for ACS until proven otherwise, with consideration of atypical presentations along with other causes for patient symptoms that may result in troponin elevation. CONCLUSIONS: Patients with CKD/ESRD presenting with symptoms concerning for ACS are challenging. The utilization of troponin assays is important in this population given their high risk of ACS but requires an educated and nuanced approach.

Pediatric cefepime neurotoxicity.

Cefepime toxicity is characterized by altered mental status, confusion, and decreased responsiveness. We describe a 14-year-old girl who developed acute encephalopathy associated with supratherapeutic cefepime concentrations in the setting of acute renal failure. The authors were unable to identify any previous reports of this occurrence in a child.

Development of PEGylated PLGA nanoparticle for controlled and sustained drug delivery in cystic fibrosis.

BACKGROUND: The mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene results in CF. The most common mutation, ΔF508-CFTR, is a temperature-sensitive, trafficking mutant with reduced chloride transport and exaggerated immune response. The ΔF508-CFTR is misfolded, ubiquitinated, and prematurely degraded by proteasome mediated- degradation. We recently demonstrated that selective inhibition of proteasomal pathway by the FDA approved drug PS-341 (pyrazylcarbonyl-Phe-Leuboronate, a.k.a. Velcade or bortezomib) ameliorates the inflammatory pathophysiology of CF cells. This proteasomal drug is an extremely potent, stable, reversible and selective inhibitor of chymotryptic threonine protease-activity. The apprehension in considering the proteasome as a therapeutic target is that proteasome inhibitors may affect proteostasis and consecutive processes. The affect on multiple processes can be mitigated by nanoparticle mediated PS-341 lung-delivery resulting in favorable outcome observed in this study. RESULTS: To overcome this challenge, we developed a nano-based approach that uses drug loaded biodegradable nanoparticle (PLGA-PEGPS-341) to provide controlled and sustained drug delivery. The in vitro release kinetics of drug from nanoparticle was quantified by proteasomal activity assay from days 1-7 that showed slow drug release from day 2-7 with maximum inhibition at day 7. For in vivo release kinetics and biodistribution, these drug-loaded nanoparticles were fluorescently labeled, and administered to C57BL6 mice by intranasal route. Whole-body optical imaging of the treated live animals demonstrates efficient delivery of particles to murine lungs, 24 hrs post treatment, followed by biodegradation and release over time, day 1-11. The efficacy of drug release in CF mice (Cftr-/-) lungs was determined by quantifying the changes in proteasomal activity (~2 fold decrease) and ability to rescue the Pseudomonas aeruginosa LPS (Pa-LPS) induced inflammation, which demonstrates the rescue of CF lung disease in murine model. CONCLUSION: We have developed a novel drug delivery system to provide sustained delivery of CF "correctors" and "anti-inflammatories" to the lungs. Moreover, we demonstrate here the therapeutic efficacy of nano-based proteostasis-modulator to rescue Pa-LPS induced CF lung disease.

Characterization of the spv locus in Salmonella enterica serovar Arizona.

Salmonella enterica serovar Arizona (S. enterica subspecies IIIa) is a common Salmonella isolate from reptiles and can cause serious systemic disease in humans. The spv virulence locus, found on large plasmids in Salmonella subspecies I serovars associated with severe infections, was confirmed to be located on the chromosome of serovar Arizona. Sequence analysis revealed that the serovar Arizona spv locus contains homologues of spvRABC but lacks the spvD gene and contains a frameshift in spvA, resulting in a different C terminus. The SpvR protein functions as a transcriptional activator for the spvA promoter, and SpvB and SpvC are highly conserved. The analysis supports the proposal that the chromosomal spv sequence more closely corresponds to the ancestral locus acquired during evolution of S. enterica, with plasmid acquisition of spv genes in the subspecies I strains involving addition of spvD and polymorphisms in spvA.

Stereotyped and specific gene expression programs in human innate immune responses to bacteria.

The innate immune response is crucial for defense against microbial pathogens. To investigate the molecular choreography of this response, we carried out a systematic examination of the gene expression program in human peripheral blood mononuclear cells responding to bacteria and bacterial products. We found a remarkably stereotyped program of gene expression induced by bacterial lipopolysaccharide and diverse killed bacteria. An intricately choreographed expression program devoted to communication between cells was a prominent feature of the response. Other features suggested a molecular program for commitment of antigen-presenting cells to antigens captured in the context of bacterial infection. Despite the striking similarities, there were qualitative and quantitative differences in the responses to different bacteria. Modulation of this host-response program by bacterial virulence mechanisms was an important source of variation in the response to different bacteria.