Search

BackgroundExtremity ischemia and necrosis after jellyfish envenomation can be mutilating and cause long-term functional deficits. The best way to manage these presentations is unknown. ObjectiveThe aim of this review was to establish an evidence-based consensus for the management of extremity ischemia after jellyfish envenomation. MethodsA systematic review of cases of extremity ischemia and necrosis after envenomation by marine cnidarians was performed to clarify what is and what is not known about management and outcomes, to draw conclusions about how best to manage these rare presentations, and to establish an evidence-based algorithm. ResultsThe ischemic sequelae of envenomation typically evolves over a few days. Close medical supervision is necessary to react promptly to the evolving clinical scenario. In the literature, 15 different pharmacologic classes have been used to manage these presentations. Only IV infusions of prostaglandin derivatives and intra-arterial thrombolytics have been found to improve the clinical picture and avoid the need for surgical fasciotomy and debridement in some cases. Anticoagulants, antiplatelet agents, steroids, antibiotics, and nitrates, which are among the most commonly prescribed pharmacologic agents, have not been observed to alter the clinical picture. ConclusionsSurgery for compartment syndrome and necrosis are common sequelae of extremity envenomation by marine cnidarians. Only prompt use of IV prostaglandins or intra-arterial thrombolytics can halt ischemic progression and avoid the need for surgery. An algorithm is proposed to guide management of these rare and mutilative presentations.

Objectives QTc interval is significant because prolongation may lead to ventricular dysrhythmia. Computerized electrocardiogram machines typically measure QT interval length and, using an algorithm assessment of multiple leads, calculate a QTc value. Manual measurement of the QT interval used to calculate the QTc value is more time-consuming but potentially more accurate. In this study, we compare the automated QTc calculation with the QTc value calculated using manual QT measurements. Methods We prospectively obtained 350 resting 12-lead electrocardiograms (ECGs) in children aged 2 to 14 years in an academic pediatric emergency department. Manual measurement of the QT interval was performed and the QTc was calculated using the 2 most commonly used correction methods, Bazzet and Fridericia formulas. The paired values were used to perform a Bland-Altman analysis and create a receiver operating characteristic curve. Results Bland-Altman analysis determined that QT-automated and QTc-Bazett had an average difference of 3.8 milliseconds, with a standard deviation of 86 milliseconds (95% confidence interval = -161 to 176). An automated QTc value of 455 milliseconds was sensitive to detect manual QTc values of greater than 480 milliseconds. Conclusions In children with resting ECGs, there is a poor agreement between the automated QTc produced by a computerized electrocardiogram and the QTc value obtained using manual QT measurement. Statistically and clinically relevant discrepancy between the automated QTc and QTc values calculated after manual QT measurement was present. Automated QTc values may be used as a screening tool to detect prolonged QTc, but for accurate determination of QTc, manual measurement is necessary.

Neck abscesses such as retropharyngeal, peritonsilar, and lateral pharyngeal are well described, typically cause a characteristic illness, and have a known epidemiology. We present a rare occurrence of case of confluent, mixed retropharyngeal, lateral pharyngeal, and peritonsilar abscess in a 9-month-old female infant. The symptoms at presentation were very mild and not expected in association with this extensive an abscess. The causative organism was methicillin-resistant Staphylococcus aureus.

While the incidence of syphilis has been persistently on the rise in the United States, hepatitis as a complication of early syphilis is relatively uncommon. We present a case of a 51-year-old homosexual, HIV-positive man who presented with acute cholestatic hepatitis with a predominantly elevated alkaline phosphatase. After laboratory studies and imaging were unrevealing, a liver biopsy was performed that showed expanded portal tracts with a predominantly lymphoplasmacytic infiltrate and prominent bile ductular proliferation with periductal neutrophils. Testing revealed a positive rapid plasma reagin, and a subsequent Warthin-Starry stain of the liver tissue demonstrated the presence of scattered spirochetes, confirmed as Treponema pallidum spirochetes on immunohistochemistry testing. These findings confirmed a diagnosis of syphilitic hepatitis. With therapy, symptoms and liver enzymes rapidly normalized. Given the persistent rise in syphilis incidence along with the morbidity and mortality associated with a missed diagnosis, keen suspicion, early identification, and treatment are crucial.

BACKGROUND AND OBJECTIVES: Hospital discharge requires multidisciplinary coordination. Insufficient coordination impacts patient flow, resource use, and postdischarge outcomes. Our objectives were to (1) implement a prospective, multidisciplinary discharge timing designation in the electronic health record (EHR) and (2) evaluate its association with discharge timing. METHODS: This quality-improvement study evaluated the implementation of confirmed discharge time (CDT), an EHR designation representing specific discharge timing developed jointly by a patient’s family and the health care team. CDT was intended to support task management and coordination of multidisciplinary discharge processes and could be entered and viewed by all team members. Four plan-do-study-act improvement phases were studied: (1) baseline, (2) provider education, (3) provider feedback, and (4) EHR modification. Statistical process control charts tracked CDT use and the proportion of discharges before noon. Length of stay was used as a balancing measure. RESULTS: During the study period from April 2013 through March 2017, 20 133 pediatric discharges occurred, with similar demographics observed throughout all phases. Mean CDT use increased from 0% to 62%, with special cause variations being detected after the provider education and EHR modification phases. Over the course of the study, the proportion of discharges before noon increased by 6.2 percentage points, from 19.9% to 26.1%, whereas length of stay decreased from 47 (interquartile range: 25–95) to 43 (interquartile range: 24–88) hours (both P CONCLUSIONS: The implementation of a prospective, multidisciplinary EHR discharge time designation was associated with more before-noon discharges. Next steps include replicating results in other settings and determining populations that are most responsive to discharge coordination efforts.

Background Urinary tract infections (UTI) are the most common type of infection in the United States. A Centers for Disease Control and Prevention report in March 2014 regarding antibiotic use in hospitals reported “UTI” treatment was avoidable at least 39% of the time. The accurate diagnosis and treatment of UTI plays an important role in cost-effective medical care and appropriate antimicrobial utilization. Objective We summarize the most common misperceptions of UTI that result in extraneous testing and excessive antimicrobial treatment. We present 10 myths associated with the diagnosis and treatment of UTI and succinctly review the literature pertaining to each myth. We explore the myths associated with pyuria, asymptomatic bacteriuria, candiduria, and the elderly and catheterized patients. We attempt to give guidance for clinicians facing these clinical scenarios. Discussion From our ambulatory, emergency department, and hospital experiences, patients often have urine cultures ordered without an appropriate indication, or receive unnecessary antibiotic therapy due to over-interpretation of the urinalysis. Conclusions Asymptomatic bacteriuria is common in all age groups and is frequently over-treated. A UTI diagnosis should be based on a combination of clinical symptoms with supportive laboratory information. This review will assist providers in navigating common pitfalls in the diagnosis of UTI.

Background The potential for ondansetron to cause QT prolongation and fatal dysrhythmia is well-reported, including a 2011 FDA report on the topic. Few clinical trials evaluating this phenomenon in the ED setting exist, and only one is pediatric. Objective We have sought to determine the effect of a standardized dose of intravenous ondansetron on the QTc duration of children under 14 years of age treated for gastroenteritis-associated vomiting in a pediatric ED. This study is modeled closely after an FDA “thorough QT study”. Methods EGCs were obtained before and 15, 30, 45, and 60 min after a 0.15 mg/kg IV dose of ondansetron given for gastroenteritis-associated vomiting. QT intervals were measured manually with digital calipers, and the QTc interval calculated both by Bazett's (QTcB) and Fridericia's (QTcF) correction. A paired t-test comparing QTc was conducted, and frequency of categorical outcomes of prolongation > 30 msec, > 60 msec, and absolute prolongation > 450 msec, > 480 msec, and > 500 msec were evaluated. Results In a 4-month period, 134 patients were included in the study, 46% were male. The average QTc prior to ondansetron administration was: QTcB 415 msec (95% CI 343–565) and QTcF 373 (95% CI 304–499). The mean difference in QTc after ondansetron was 0.4 msec for QTcB (95% CI − 35–45 msec) and 0.1 msec for QTcF (95% CI − 40–18 msec). Conclusion In these children, 0.15 mg/kg of intravenous ondansetron did not cause prolongation of QTcB or QTcF measured 15 min after administration, nor at later times.

Objectives Fever is among the most common reasons for emergency department (ED) visits by children. This study compares temporal artery thermometry to rectal thermometry in febrile children in an ED. Methods This was a retrospective evaluation of children younger than 36 months treated consecutively in an urban medical center. Patients underwent triage with temporal artery thermometry, and after transfer to the pediatric ED, they underwent rectal thermometry. Fever was defined as rectal temperature of 100.4 °F (38 °C) or greater, and 147 patients met this definition. Data extraction from electronic charts obtained paired temporal artery and rectal temperatures, and these were compared by Bland-Altman analysis. Temperature points of 100.4 °F (38 °C) and 102.2 °F (39 °C) were evaluated to compare temporal artery thermometry with rectal thermometry sensitivity and specificity. Results A statistically and clinically significant difference between temporal artery and rectal temperature was found. Temporal artery thermometry was 53% sensitive detecting rectal temperature 100.4 °F (38 °C) or greater, and 27% sensitive detecting rectal temperature of 102.2 °F (39 °C) or greater. Mean rectal temperature was 102.36 °F (39.09 °C) (95% confidence interval [CI], 102.14 °F-102.58 °F); mean temporal artery temperature was 100.36°F (37.98 °C) (95% CI, 100.08 °F-100.65 °F), and mean difference between the two was 1.99 °F (1.11 °C) (95% CI, 1.75 °F-2.23 °F). Conclusions Temporal artery thermometry is poorly sensitive detecting fever and does not accurately reflect rectal temperature. Temporal artery thermometry should not be used for clinical management of children younger than 36 months if detection of fever is of importance.

Background Cellulitis is commonly treated in the emergency department (ED). Patients who present with cellulitis incur significant health care costs and may be overtreated with antibiotics. The accurate diagnosis and treatment of cellulitis plays an important role in cost-effective, high-quality medical care, as well as appropriate antibiotic utilization. Objective We aim to describe common fallacies regarding cellulitis. We present 10 myths that result in misdiagnosis, overtreatment, or inappropriate empiric management of cellulitis. Clinical presentation, including swelling and redness, is explored in depth, along with incidence of community-acquired methicillin-resistance Staphylococcus aureus, management of tick bites, and effective antibiotic therapy for cellulitis. Discussion Patients are often treated for cellulitis unnecessarily or inappropriately. Awareness of these myths will help guide providers in clinical decision making in order to effectively tailor treatment for these infections. Conclusions Cellulitis is not as simple as it might seem, and is commonly misdiagnosed in the ED. Noninfectious causes of local symptoms, including lymphedema, venous stasis, and deep vein thrombosis need to be considered. Cellulitis should be treated with empiric antimicrobial therapy based on patient risk factors and regional susceptibility patterns. This review will assist providers in managing cellulitis and avoiding treatment errors that lead to high costs, unwanted side effects for patients, and overuse of antibiotics.

We describe a point-of-care ultrasonography to facilitate diagnosis of a femur fracture in a 13-year-old adolescent boy. Rapid detection of the fracture, which was not possible by physical examination alone, permitted immediate stabilization of the leg with traction, rapid communication with orthopedic surgeons, and facilitated analgesic therapy before transport and movement to obtain radiographs.

The following case report demonstrates the severe consequences of refractory convulsive status epilepticus from an unfamiliar imported toxin, tetramethylenedisulfotetramine (TETS), and the difficulties of identifying the offending agent.A previously healthy 15-month-old girl was found by her parents playing with a white rodenticide powder brought from China. Fifteen minutes later, the child developed generalized seizures and was brought to an Emergency Department (ED). Her initial fingerstick blood glucose was 108 mg/dL. In the ED, the child was intubated for status epilepticus. Despite aggressive therapy with lorazepam, phenobarbital, and pyridoxine, she had 4 h of intermittent generalized seizure activity. She was extubated on the third hospital day, but appeared to have absence seizures and cortical blindness. Continuous electroencephalogram monitoring, performed weeks later, revealed severe diffuse cerebral dysfunction with multiple epileptogenic foci. The child remains developmentally delayed and is on valproic acid therapy for seizure control. Translation of the Chinese package labeling did not clarify its contents. Tetramethylenedisulfotetramine was finally confirmed by gas chromatography-mass spectrometry (GC-MS) in this rodenticide product and then quantified against a TETS standard that was synthesized in our laboratory.Tetramethylenedisulfotetramine is grouped with other "cage convulsants," such as picrotoxin, since they have a similar intercalating cyclical molecular structure and cause seizures through non-competitive gamma-aminobutyric acid (GABA) antagonism. The oral lethal dose 50% (LD50) in humans is estimated to be as low as 100 microg/kg. Our patient has severe diffuse cerebral dysfunction likely secondary to prolonged seizure activity after exposure to TETS.

Background: Acute appendicitis can have various unusual presentations. Detection of this entity is often confounded by its presence in the company of symptoms consistent with distinctly different etiologies. Objectives: This article highlights an extremely rare presentation of appendicitis. Case Report: The case of a man presenting to an urban Emergency Department complaining of scrotal swelling and pain is discussed. On surgical exploration, the patient's symptomatology was diagnosed as acute appendicitis within an Amyand hernia. Conclusion: Appendicitis can sometimes be a challenging diagnosis. Thorough examination and maintenance of a wide differential diagnosis with common complaints can assist the emergency physician in reaching the correct diagnosis.

Hemolytic uremic syndrome (HUS) usually occurs after infection with Shiga toxin-producing bacteria. Thrombotic thrombocytopenic purpura, a disorder with similar clinical manifestations, is associated with deficient activity of a circulating metalloprotease that cleaves von Willebrand factor at the Tyr842-Met843 peptide bond in a shear stress-dependent manner. We analyzed von Willebrand factor-cleaving metalloprotease activity and the status of von Willebrand factor in 16 children who developed HUS after Escherichia coli O157:H7 infection and in 29 infected children who did not develop this complication. Von Willebrand factor-cleaving metalloprotease activity was normal in all subjects, but von Willebrand factor size was decreased in the plasma of each of 16 patients with HUS. The decrease in circulating von Willebrand factor size correlated with the severity of thrombocytopenia and was proportional to an increase in von Willebrand factor proteolytic fragments in plasma. Immunohistochemical studies of the kidneys in four additional patients who died of HUS demonstrated glomerular thrombi in three patients, and arterial and arteriolar thrombi in one patient. The glomerular thrombi contained fibrin but little or no von Willebrand factor. A decrease in large von Willebrand factor multimers, presumably caused by enhanced proteolysis from abnormal shear stress in the microcirculation, is common in HUS.

The majority of all patients with poison exposures in the United States are children. The evaluation and management of poisoned patients may be aided by the use of laboratory assays, ranging from basic assessments not uniquely indicated for the poisoned patient to highly sophisticated laboratory tests with very specific indications. Literature concerning poisoning in pregnant patients is evaluated and recommendations regarding the utility of pregnancy testing in poisoned females are discussed. Recent studies evaluating the use of toxicology testing in pediatrics have concluded that the use of comprehensive toxicology screening in pediatric patients is costly and does not affect the medical management of most poisoned patients. The utility of focused quantitative serum assays to determine serum levels of particular poisons is reviewed. Toxicology tests used for detection of drugs of abuse, with a particular focus on the capabilities and limitations of such tests, are discussed. The potential pitfalls that occur when toxicology tests are obtained indiscriminately, are misapplied, or are misunderstood are analyzed. Hair sampling as nonemergent toxicology testing for drugs of abuse is discussed.

Superior mesenteric artery (SMA) syndrome is a unique type of small bowel obstruction resulting from the compression of the duodenum by the SMA. This is a case of SMA syndrome in a cachectic 6-year-old boy with AIDS who presented after a 2.3-kg weight loss in the preceding month. Unfamiliarity with this condition coupled with its intermittent, nonspecific symptomatology probably results in underdiagnosis of SMA syndrome. The presentation, predisposing and associated factors, and methods of diagnosis and treatment of SMA syndrome are all discussed.

In an excellent investigation of endotracheal tube cuff pressure assessment, "Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Transport," Chapman et al measured endotracheal tube cuff pressure in patients who arrive at their emergency department after being intubated in the field. This, the first published American study of this type, presents clear and convincing evidence that patients who undergo endotracheal intubation before transport have endotracheal tube cuff pressures that exceed safe limits. Although a study of this type has not been conducted on patients who are endotracheally intubated by emergency medicine physicians within the confines of an emergency department, we pose the question to the academic and clinical emergency medicine community, "Should such a study be conducted?" Instead, should the evidence offered by Chapman et al, in addition to that of other publications, be enough to prompt emergency physicians to abandon the practice of endotracheal intubation without measurement and/or control of endotracheal tube cuff pressure? To adequately understand the complexity of such an apparently simple question, it is necessary to consider 2 concepts: equipoise and evidence. Our hope is that readers will acknowledge the study of Chapman et al as a strong piece of evidence indicating that patients who undergo endotracheal intubation without measurement of endotracheal tube cuff pressure very likely have a pressure that exceeds the safe range. We hope this study, in conjunction with the other available evidence, will prompt readers to adopt measurement of endotracheal tube cuff pressure as a routine.

MscL is a mechanosensitive channel in bacteria that responds directly to membrane tension by opening a large conductance pore. To determine functionally important residues within this molecule, we have randomly mutagenized mscL , expressed the genes in living bacteria, and screened for gain-of-function mutants with hampered growth. Expression of these genes caused leakage of cytoplasmic solutes on little or no hypo-osmotic stress. In excised patches, the mutant channels gated at membrane tensions that are less than that required for the gating of the wild-type MscL. Hence, the data suggest that the slowed or no-growth phenotype is caused by solute loss because of inappropriate gating of the channel. Most of the mutations mapped to the first transmembrane domain. When this domain is modeled as an α-helix, the most severe mutations are substitutions of smaller amino acids (three glycines and one valine) on one facet, suggesting an important role for this structure in MS channel gating.

The death of a child in the emergency department (ED) is one of the most challenging problems facing ED clinicians. This revised technical report and accompanying policy statement reaffirm principles of patient- and family-centered care. Recent literature is examined regarding family presence, termination of resuscitation, bereavement responsibilities of ED clinicians, support of child fatality review efforts, and other issues inherent in caring for the patient, family, and staff when a child dies in the ED. Appendices are provided that offer an approach to bereavement activities in the ED, carrying out forensic responsibilities while providing compassionate care, communicating the news of the death of a child in the acute setting, providing a closing ritual at the time of terminating resuscitation efforts, and managing the child with a terminal condition who presents near death in the ED.

In Bacillus subtilis, expression of the trp genes is negatively regulated by an RNA binding protein called TRAP (trp RNA-binding Attenuation Protein), which is activated to bind RNA by binding l-tryptophan. TRAP contains 11 identical subunits assembled in a symmetric ring. We have used alanine-scanning mutagenesis to analyze the functions of surface amino acid residues of TRAP. The in vivo regulatory activity of each mutant TRAP was analyzed in a B. subtilis reporter strain containing a trpE'-'lacZ fusion. Mutant TRAP proteins with defective in vivo regulatory activities were characterized in vitro by measuring their tryptophan binding and RNA binding activities. Most of the mutant proteins with altered tryptophan binding, either affinity or cooperativity, contained substituted residues located on two loops formed by residues 25 to 33 and residues 49 to 52, as well as on the beta-strand and beta-turn contiguous with these loops. Substitution of three residues (Lys37, Lys56 and Arg58) with alanine resulted in significant decreases in the RNA binding activity of TRAP without altering tryptophan binding. Structural analysis shows that these three residues are directly aligned on the outer edge of TRAP. Further mutagenic analysis of these three residues revealed that only lysine or arginine residues at positions 37 or 58 allow proper TRAP function, whereas at position 56, only lysine is functional. Residue Asn20 is the only other residue in TRAP that is located on the line formed by residues 37, 56 and 58, and virtually any amino acid residue is functional at position 20. We propose that RNA wraps around TRAP by interacting with residues Lys37, Lys56 and Arg58.

Background. In observance of the Sabbath and other religious holidays, many Orthodox Jews maintain a burning lamp that uses paraffin lamp oil as fuel. Unintentional pediatric exposure to paraffin lamp oil, a hydrocarbon, is typically by ingestion and carries a risk of aspiration with subsequent pneumonitis. This investigation was prompted by an apparent increase in paraffin lamp oil exposures during the Jewish Sabbath, from sunset Friday until sunset Saturday, noted by the staff of our regional poison control center.Objective. In this investigation, we retrospectively reviewed all exposures to paraffin lamp oil occurring in our large city in children Results. During these 25 months, 45 cases met inclusion criteria, and all were ingestions. Orthodox Jews accounted for 32 cases (71%), 4 cases (9%) occurred in children who were not Orthodox Jews, and demographic data were unavailable in 9 cases (20%). Twenty-four cases (53%) occurred within 10 hours before or during the Jewish Sabbath or Jewish religious holidays. The relative risk of Orthodox Jewish children to ingest paraffin lamp oil, calculated by using census data, is 374 times that of other children.Conclusions. Public health authorities and caregivers of Orthodox Jewish children should be cognizant of this phenomenon. Educational efforts directed toward both Orthodox Jews and the general public aimed at preventing paraffin lamp oil exposures are warranted.

Ferric chloride (FeCl3) is used to qualitatively test the urine of patients with presumed salicylate exposure. FeCl3 testing of an unidentified poison might provide evidence of salicylate exposure in situations where FeCl3 urine testing cannot be used. Such situations include the absence of a urine sample, immediately after ingestion before urine contains a detectable quantity of salicylate, or for patients chronically using salicylatesfor which FeCl3 testing is unhelpful. This study seeks to determine if FeCl3 can be used to identify salicylate-containing products.We assessed the reactivity of FeCl3 with commercially available salicylate-containing products. We applied 0.1 mL of 10% FeCl3 solution to each of 15 various salicylate-containing products including: regular and buffered acetylsalicylic acid, bismuth subsalicylate, methylsalicylate, physostigmine salicylate, salicylic acid, trolamine salicylate, and herbal tablets with salicin-containing white willow bark (Salix sp.). These products tested were: regular and enteric-coatedpills (n = 4), powder (n = 1), topical creams (n = 5), topical liquids (n = 4), and intravenous solution (n = 1). FeCl3 was applied to crushed tablets and added directly to liquids and creams. Fifteen salicylate-free controls including liquids, pills, and creams similar in appearance to experimental samples were also tested. Three blinded physiciansfamiliar with FeCl3 testing independently observed the addition of FeCl3 to each sample and rated a positive or negative result.All salicylate-containing products were interpreted to be clearly FeCl3 positive and all control samples were interpreted to be clearly FeCl3 negative.Salicylate-containing products may be identified using FeCl33. When using FeCl3

Toxin-related seizures are secondary to an imbalance in the brain's equilibrium of excitation-inhibition. This delicate balance is maintained via excitatory neurotransmis- sion (eg, glutamate or the N-methyl-D-aspartate (NMDA) receptor) and inhibitory neurotransmission (eg, gaminobutyric acid (GABA) or the GABA receptor complex). Balance is also dependent on normal ion flux and homeostasis of biogenic amines and acetylcholine. Perturbation of this equilibrium can be the result of the presence of a toxin or the abrupt removal of one (withdrawal). This article reviews the epidemi- ology, pathophysiology, toxicology, clinical features, and management of toxin- related seizures. Particular emphasis is placed on contrasting the management of toxin-related seizures with seizures of other etiologies, because clinicians are likely to have greater experience, knowledge, and comfort dealing with the latter. Despite the differences, the basic management principles for any seizure are the same: rapidly stabilize the patient and provide supportive care; expediently terminate seizure activity; diagnose the cause of the seizure; and abate associated morbidity and mortality.

Staphylococcal enterotoxin B (SEB) is a CDC category B bioterror agent that may cause significant morbidity. We assessed the in vitro binding of SEB by activated charcoal (AC).Aqueous solutions of SEB at three concentrations (0.4, 2 and 10 mcg/mL) were combined in volume rations of 3:1, 6:1, and 12:1 with AC at three concentrations (62.5, 125, and 250 mg/mL) or left untreated as control samples. Subsequently, each sample was tested with a qualitative SEB immunoassay to detect the presence of SEB at concentrations of12.5 ng/mL.SEB was detectable in each untreated control solution. SEB was undetectable in the 2 mcg/mL and 0.4 mcg/mL solutions after treatment with AC in all quantities. SEB was detected in the 10 mcg/mL solution after combination with all three concentrations of AC. The difference in assay results between charcoal treated and untreated pairs was statistically significant.At ratios of 3:1 and above, SEB was adsorbed by AC when combined in the manner described in concentrations of 2 mcg/mL and 0.4 mg/mL. In a quantity of 10 mcg/mL complete charcoal binding of SEB did not occur with any ratio of AC used. These results support a role for AC in treating patients exposed to SEB or purifying liquids or gases containing SEB.

Objective Tracheal necrosis, stenosis, and rupture may result from overinflated endotracheal tube cuffs (ETTcs). We sought to determine the ability of faculty emergency medicine (EM) physicians to safely inflate ETTc as well as to estimate pressure of previously inflated ETTc. Methods Using a previously tested tracheal simulation model, we assessed EM physician inflation of ETTc pilot balloons. Participants also palpated the pilot balloon of 9 ETTc inflated to pressures ranging from extremely low to extremely high in a random order and reported their estimate of pressure. Results We sampled 41 faculty EM physicians from 5 EM residency programs. Using palpation, participants were only 22% sensitive detecting overinflated ETTc. The average ETTc pressure produced by inflation was more than 93 cm H 2 O (normal, 15-25 cm H 2 O). Conclusions Participants were unable to inflate ETTc to safe pressures or estimate pressure of ETTc by palpation. Clinicians should consider using devices to facilitate safe inflation and accurate measurement of ETTc pressure.

Background Although chemiluminescent plastic rods, commonly called "glow sticks" or "light sticks," are typically considered to be minimally toxic or nontoxic, published data about exposure to these products are scarce. Objectives To test our hypothesis that exposure to chemiluminescent products is unlikely to result in significant morbidity or mortality and to describe factors associated with exposure by reviewing reports to our urban poison control center of human exposure to chemiluminescent products. Methods Pediatric and young adult exposure to chemiluminescent products reported between January 1, 2000, and April 1, 2001, to our poison control center were evaluated with regard to demographic group, type of product involved, circumstances of exposure, symptoms, and management. Results Reported routes of exposure (n = 118) included ingestion (n = 108), ocular (n = 9), and dermal exposure (n = 1). Only patients exposed to chemiluminescent fluid from a leaking container reported symptoms (n = 27). Symptoms were limited to transient irritation of the exposure site, and no systemic toxicity occurred. All adults (n = 4) inadvertently ruptured or swallowed intact light sticks while at a dance club or dance party. Most exposure and all adult exposure occurred on holidays or weekends. Conclusions Most incidences of exposure to chemiluminescent products involve asymptomatic ingestion of fluid that leaks from glow sticks or ingestion of an intact glow stick. Symptoms occur after exposure to chemiluminescent fluid and consist of transient irritation at the site of exposure. The clustering of reported exposure on weekends and in dance clubs and parties coupled with a lack of occupational or workplace exposure suggest that recreational use is a major contributory factor. Exposure to chemiluminescent products infrequently resulted in symptoms and the symptoms reported were minor. Exposure to chemiluminescent products as described is unlikely to cause significant morbidity or mortality.

Clenbuterol is a long acting beta2-adrenergic agonist used in the treatment of pulmonary disorders. Acute clenbuterol toxicity resembles that of other beta2-adrenergic agonists. Most previously reported cases of clenbuterol toxicity describe patients who ate livestock illicitly treated with clenbuterol.We report a case of human clenbuterol toxicity confirmed and correlated with qualitative and quantitative serum clenbuterol assays. This poisoned patient, a 28-year-old woman, developed sustained sinus tachycardia at 140/min, hypokalemia (2.4 mEq/L, 2.4 mmol/L), hypophosphatemia (0.9 mg/dL, 0.29 mmol/L), and hypomagnesemia (1.52 mg/dL, 0.76 mmol/L) after ingesting a reportedly small quantity of clenbuterol. The patient received repeated doses of metoprolol to treat her cardiovascular stimulation and potassium chloride to treat her hypokalemia. She remained symptomatic for more than 20 hours after the ingestion. Analysis by enzyme-linked immunosorbent assay and liquid chromatography/mass spectrometry revealed a serum clenbuterol concentration of 2.93 mcg/L 3 hours after the ingestion and an undetectable serum concentration 20 hours after ingestion. It is noteworthy that at a serum concentration below the limit of detection by liquid chromatography/mass spectrometry, the patient remained symptomatic. Acute clenbuterol toxicity is rarely reported following illicit use in humans, and this is the first such case to provide confirmatory toxicological analysis.

Vaginal laceration resulting from coitus is not uncommon and is well described. Perforation of the vagina during coitus is a very rare occurrence, and there is scant literature reporting it. This is a case of a 14-year-old female who suffered both laceration and perforation of the vagina as a result of her first coitus, which was consensual. The characteristics of vaginal laceration and perforation, presentation, treatment, complications, as well as predisposing factors, are discussed.

Importance The Centers for Medicare & Medicaid Services (CMS) defines observation status for hospitalized patients as a “well-defined set of specific, clinically appropriate services,” usually lasting less than 24 hours, and that in “only rare and exceptional cases” should last more than 48 hours. Although an increasing proportion of observation care occurs on hospital wards, studies of patients with observation status have focused on the efficiency of dedicated units. Objective To describe inpatient and observation care. Design and Setting Descriptive study of all inpatient and observation stays between July 1, 2010, and December 31, 2011, at the University of Wisconsin Hospital and Clinics, a 566-bed tertiary academic medical center. Participants All patients with observation or inpatient stays during the study period. Main Outcomes and Measures Patient demographics, length of stay, difference between cost and reimbursement per stay, and percentage of patients discharged to skilled nursing facilities. Results Of 43 853 stays, 4578 (10.4%) were for observation, with 1141 distinct diagnosis codes. Mean observation length of stay was 33.3 hours, with 44.4% of stay durations less than 24 hours and 16.5% more than 48 hours. Observation care had a negative margin per stay (−$331); the inpatient margin per stay was positive (+$2163). Adult general medicine patients accounted for 2404 (52.5%) of all observation stays; 25.4% of the 9453 adult general medicine stays were for observation. The mean length of stay for general medicine observation patients was 41.1 hours, with 32.6% of stay durations less than 24 hours and 26.4% more than 48 hours. Compared with observation patients on other clinical services, adult general medicine had the highest percentage of patients older than 65 years (40.9%), highest percentage female patients (57.9%), highest percentage of patients discharged to skilled nursing facilities (11.6%), and the most negative margin per stay (−$1378). Conclusions and Relevance In an academic medical center, observation status for hospitalized patients differed markedly from the CMS definition. Patients had a wide variety of diagnoses; lengths of stay were typically more than 24 hours and often more than 48 hours. The hospital lost money, primarily because reimbursement for general medicine patients was inadequate to cover the costs. It is uncertain what role, if any, observation status for hospitalized patients should have in the era of health care reform.

The mtrB gene from Bacillus pumilus encodes a 76-amino-acid polypeptide with 77% identity to the trp RNA-binding attenuation protein (TRAP) from Bacillus subtilis. B. pumilus TRAP binds trp leader RNA from either B. subtilis or B. pumilus in a tryptophan-dependent manner. Altering threonine 52 to alanine eliminated RNA-binding activity of B. pumilus TRAP.