From intern to "accepted": A guide to preparing for fellowship in emergency medicine.

Introduction: The number of fellowship options for emergency medicine (EM) physicians continues to expand. While guides exist to help residents explore individual fellowship pathways, we aimed to create a comprehensive guide for all residents considering fellowship. Methods: At the direction of the Society for Academic Emergency Medicine (SAEM) Board, 9 members of the Fellowship Guide Workgroup, including members of the Fellowship Approval Committee, and 2 members of SAEM Residents and Medical Students (RAMS) group collaboratively developed the guide using available evidence and expert opinion when high-quality evidence was unavailable. The guide was reviewed and approved by all members. Results: The guide offers advice to EM residents on how to conceptualize key aspects of their training with respect to preparation for fellowship, including scholarship, teaching, leadership, and electives. Additionally, it offers perspective on selecting a fellowship that matches the resident's interests and goals and successfully applying. Conclusion: This fellowship guide for EM residents considering fellowship summarizes the best currently available advice for residents considering fellowship training after residency.

Persistent Bradycardia with the Long-term Use of Phenytoin and Oxycodone: First Case Report.

Phenytoin is a medication that is used primarily in the treatment of epilepsy as well as generalized tonic-clonic seizures and status epilepticus. Phenytoin is also considered a class IB antiarrhythmic medication by shortening the duration of the action potential and increasing myocardial conduction. The neurologic adverse effects of phenytoin are well-documented and include altered mental status, ataxia, and nystagmus. Some adverse cardiac manifestations have also been reported, including arrhythmias, hypotension, and respiratory arrest. Oxycodone is an opioid that exerts its effects by binding to Mu opioid receptors located in the central nervous system. This selective binding results in the opening of potassium (k+) channels and the closing of calcium channels, decreasing synaptic transmission. Oxycodone, unlike phenytoin, has not been observed to elicit cardiotoxicity independent of other medications. However, in combination with other medications, bradycardia and hypotension have been observed. We report the case of a 62-year-old male who developed persistent bradycardia following treatment with phenytoin and oxycodone for seizure disorder and pain, respectively. To our knowledge, this is the first case report where bradycardia was induced by a combination of these medications.

Celiac Disease and Concomitant Conditions: A Case-based Review.

Celiac disease is a chronic autoimmune disease with genetic predisposition, triggered by the ingestion of gluten. It has a wide range of clinical manifestations ranging from asymptomatic forms to classic presentation of malabsorption with diarrhea and abdominal cramps. Celiac disease can also present with several other concomitant disorders (at the time of diagnosis or during the course of celiac disease) such as: type 1 diabetes, inflammatory bowel disease, rheumatoid arthritis, thyroid disorders, nutritional deficiencies, and gram-negative sepsis. We present a 57-year-old female with past medical history of rheumatoid arthritis, who presented to the emergency department with a complaint of chronic diarrhea, complicated by gram-negative sepsis. The family history of the patient was significant for celiac disease, type 1 diabetes, and rheumatoid arthritis. The patient was closely monitored and treated appropriately. In this case-based review, we explore different associated conditions of celiac disease in the literature, as well as the patient's risk of developing malignancy.

Management of Persistent Hyponatremia Induced by Long-acting Injectable Risperidone Therapy.

We present the case of a 55-year-old Caucasian male with a history of schizophrenia presenting with severe hyponatremia attributed to long-acting injectable risperidone treatment. Antipsychotic-induced hyponatremia is an uncommon but serious side effect that should be considered when assessing individuals on chronic psychiatric regimens. In this report, we will discuss our treatment plan for the patient when water deprivation and hypertonic saline failed to correct his serum sodium levels. The goal of this case report is to raise awareness of severe hyponatremia as a side effect of long-acting risperidone, and to encourage further studies to create guidelines for its management when current protocols fail to correct sodium levels.

Fibrillary Glomerulonephritis in a Patient with Sjogren's Syndrome.

Fibrillary glomerulonephritis (FGN) is an uncommon cause of primary glomerular disease. FGN is usually idiopathic; however, it has been associated with underlying malignancy or autoimmune diseases in some patients as well. The most commonly found autoimmune diseases in FGN patients include Graves' disease, systemic lupus nephritis, Chron's disease, and idiopathic thrombocytopenia purpura. FGN in a patient with underlying asymptomatic Sjogren's syndrome is very rare in the literature, with only two previously reported cases of this association. We present the case of a 75-year-old female with a past medical history of asymptomatic primary Sjogren's syndrome and fibromyalgia, who presented to emergency department with a new episode of hypertension. The electron microscopy (EM) showed randomly arranged nonamyloid fibrillar deposits in the mesangium and glomerular capillary walls, confirming FGN. In this case-based review, we describe in detail the diagnostic work-up, clinical course, and complications in management. We also discuss some of the other nonamyloid fibrillary glomerular diseases.

Cutaneous, Intranasal Blastomycosis Infection in Two Patients from Southern West Virginia: Diagnostic Dilemma.

Blastomycosis is a dimorphic fungus caused by the species of Blastomyces dermatitidisand Blastomyces gilchristii, which are endemic to the Ohio River and Mississippi River Valleys. It is commonly found in soil or decomposing wood. It is capable of infecting both immunocompromised and immunocompetent patients via the respiratory tract by inhaling conidia, where it may remain asymptomatic for a prolonged period of time. Extrapulmonary complications can occur in disseminated disease due to haematogenous spread from the lungs to other organ systems. Haematogenous dissemination from the lungs occurs most commonly to the skin. Although rare, primary cutaneous blastomycosis can also occur with direct inoculation through the trauma of the skin. Patients presenting with cutaneous blastomycosis are often misdiagnosed with malignant neoplasms and may not be appropriately managed until further testing and tissue biopsy. Currently, there are only four previous case reports of blastomycosis presenting in the intranasal region. We report two cases of cutaneous blastomycosis of the nasal passages and upper lip with pulmonary manifestations in Southern West Virginia. These patients first presented with cutaneous symptoms, which were originally treated for melanoma and squamous cell carcinoma and were later diagnosed with systemic blastomycosis.

Pancreatic Divisum: An Unusual Cause of Chronic Pancreatitis in a Young Patient.

Pancreatic divisum is a condition that occurs in 4-14% of the population. Pancreatic divisum occurs in development when the ventral bud and dorsal bud of the pancreas fail to fuse. Patients with this condition are usually asymptomatic, however, 25-38% of these patients experience recurrent pancreatitis that may further progress to chronic pancreatitis. This case is of a 20-year-old female presenting with abdominal pain in the left and right upper quadrants of the abdomen with a significant history of recurrent pancreatitis since the age of seven. The patient was examined with computed tomography (CT), which identified pancreatitis. Further magnetic resonance cholangiopancreatography (MRCP) assisted in the diagnosis of a type III pancreatic divisum, given the remnant of short communication between the dorsal and ventral duct.

Classic and Non-Classic Features in Pseudohypoparathyroidism: Case Study and Brief Literature Review.

Pseudohypoparathyroidism is a rare condition that is due to a defect in the stimulatory G-protein coupled receptor, resulting in end-organ resistance to parathyroid hormone. Hereditary forms of pseudohypoparathyroidism present with certain classic features such as obesity, short stature, brachydactyly, and intellectual disability. Constellation of these physical features is known as Albright's hereditary osteodystrophy. In this case, 41-year-old male presented with the classic features of pseudohypoparathyroidism and with 59 lbs weight gain over six months. It was determined that the cause of the patient's weight gain was due to concomitant hypothyroidism, which is a common association. There are several non-classic features and associated pathologies associated with pseudohypoparathyroidism. These conditions should be regularly screened for and assessed when a patient presents with pseudohypoparathyroidism.

Atypical Initial Presentation of Painful Muscle Cramps in a Patient with Amyotrophic Lateral Sclerosis: A Case Report and Brief Review of the Literature.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder characterized clinically by progressive muscle weakness that can occur proximally or distally in either the upper or lower extremities. It includes both upper motor neuron signs (spasticity, hyperreflexia, clonus, and Babinski sign) and lower motor neuron signs (atrophy, weakness, and muscle fasciculation). Initial presentation of progressively painful muscle cramps should lead the physician to screen for other signs of amyotrophic lateral sclerosis. We report the case of a 51-year-old male, who presented with dull muscle cramps in the right upper shoulder and arm. After a careful history and physical exam, it was found that patient had both upper and lower motor neuron signs; therefore, a diagnosis of amyotrophic lateral sclerosis was made. Amyotrophic lateral sclerosis should strongly be considered in the differential diagnosis of patients presenting with an atypical initial presentation of progressively painful muscle cramps.

An Atypical Clinical Presentation of Post-traumatic Syringomyelia: A Case Report and Brief Review of the Literature.

Syringomyelia classically presents as a bilateral sensory loss of the dissociated type which includes the loss of pain and temperature with the preservation of fine touch, vibratory sensation, and proprioception in the shoulder, arm, and hand. Eventually, weakness of the legs, muscle wasting, and ataxia can also be seen due to the involvement of the corticospinal tracts and the posterior columns of the spinal cord. We present the case of a 64-year-old patient with an atypical presentation of post-traumatic syringomyelia. This atypical presentation included a unilateral sensory loss of fine touch, pain, and temperature in the shoulder, arm, and hand which was of the non-dissociated type with no weakness, muscular atrophy, loss of vibratory sensation, or proprioception.

"Beer Potomania" - A Syndrome of Severe Hyponatremia with Unique Pathophysiology: Case Studies and Literature Review.

Beer potomania, a unique syndrome of hyponatremia, was first reported in 1972. It is described as the excessive intake of alcohol, particularly beer, together with poor dietary solute intake that leads to fatigue, dizziness, and muscular weakness. The low solute content of beer, and suppressive effect of alcohol on proteolysis result in reduced solute delivery to the kidney. The presence of inadequate solute in the kidney eventually causes dilutional hyponatremia secondary to reduced clearance of excess fluid from the body. Early detection of hyponatremia due to beer potomania in the hospital is necessary to carefully manage the patient in order to avoid neurological consequences as this syndrome has unique pathophysiology. We are reporting two cases, presenting to the emergency department with severe hyponatremia. After a detailed initial evaluation of the patients and labs for hyponatremia, a diagnosis of beer potomania was established in both cases. Considering the unique pathophysiology of beer potomania syndrome, the patients were closely monitored and treated appropriately to prevent any neurological sequelae.

Calcium and Phosphorus Detection Using Benchtop Versus Handheld X-ray Fluorescence Spectrometers.

Elemental analysis of calcium (Ca) and phosphorus (P) has been shown to be useful in differentiating skeletal and nonskeletal material. X-ray fluorescence spectrometry (XRF) is an attractive, nondestructive technique for forensic anthropologists, and the development of portable XRF instrumentation is promising for field applications. This study examines the performance of handheld XRF instrumentation operated in air compared to a traditional benchtop XRF device that has the ability to control the analysis atmosphere. Both instruments can be used to effectively distinguish skeletal from nonskeletal remains. However, as the measurement atmosphere affects detection levels for calcium and phosphorus, Ca/P ratios obtained from the instruments and analysis conditions were found to differ significantly, with analyses conducted in air showing significantly lower phosphorus detection. Consequently, comparison of Ca/P ratios to conclude skeletal versus nonskeletal origin must be based on data collected under similar analysis conditions.