Profound Weakness and Blurry Vision in a Pandemic: A Case Report.

INTRODUCTION: Neuro-Behçet's disease (NBD) is a manifestation of Behçet's disease, a relapsing inflammatory multisystem disease. Data on patients with autoimmune disease in the setting of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is limited. CASE REPORT: We discuss the case of a 22-year-old male with SARS-CoV-2 who presented to the emergency department with weakness and vision changes. Brain imaging showed enhancing lesions. History revealed possible autoimmune disease. A diagnosis of NBD exacerbated by SARS-CoV-2 was made. CONCLUSION: Patients with SARS-CoV-2 are presenting with exacerbations of systemic illnesses. Although NBD is uncommon, medical professionals need to consider this in the differential of central nervous system disorders, as it is a potentially treatable condition.

Anchoring on COVID-19: A Case Report of Human Granulocytic Anaplasmosis Masquerading as COVID-19.

INTRODUCTION: Human granulocytic anaplasmosis (HGA) is caused by Anaplasma phagocytophilum and transmitted through the deer tick. Most cases are mild and can be managed as an outpatient, but rare cases can produce severe symptoms. CASE REPORT: A 43-year-old male presented with severe respiratory distress mimicking coronavirus disease 2019 (COVID-19). Labs and imaging were consistent with COVID-19; however, polymerase chain reaction was negative twice. Peripheral smear revealed inclusion bodies consistent with HGA. CONCLUSION: Human granulocytic anaplasmosis is an uncommon diagnosis and rarely causes severe disease. Recognition of unique presentations can aid in quicker diagnosis, especially when mimicking presentations frequently seen during the COVID-19 pandemic.

Labels improve emergency medicine physician comfort and ability to use a slit lamp.

Slit-lamp (SL) biomicroscopy is an important skill for emergency medicine (EM) clinicians. However, residents and faculty have varying levels of comfort and skill with this procedure. While some of the discomfort may be from a knowledge gap, we hypothesized that at least some difficulty came from infrequent use and forgetting which of the many knobs, levers, buttons, and switches of the SL create the desired effects. We strategically labeled a SL and tested the impact of this on the ability of 39 EM faculty and residents to identify a target on a maladjusted SL. Time to target identification was significantly lower with the labeled SL compared to the unlabeled SL, with median (IQR) time decreasing from 93 (31.5-154.5) seconds to 47 (0-141) seconds (p < 0.0001). Comfort level, as measured by a written survey and a graphic rating scale, also increased significantly with the labeled SL compared to the unlabeled SL.

Impact and feasibility of an emergency department-based ventilator-associated pneumonia bundle for patients intubated in an academic emergency department.

BACKGROUND: Ventilator-associated pneumonia (VAP) has been linked to emergency department (ED) intubation and length of stay (LOS). We assessed VAP prevalence in ED intubated patients, feasibility of ED VAP prevention, and effect on VAP rates. METHODS: This was a quality improvement initiative using a pre/post design. Phase 1 (PRE1) comprised patients before intensive care unit (ICU) bundle deployment. Phase 2 (PRE2) occurred after ICU but before ED deployment. Phase 3 (POST) included patients received VAP prevention starting at ED intubation. Log-rank test for equality and Cox regression using a Breslow method for ties were performed. Bundle compliance was reported as percentages. Number needed to treat (NNT) was calculated by ventilator day. RESULTS: PRE1, PRE2, and POST groups were composed of 195, 192, and 153 patients, respectively, with VAP rates of 22 (11.3%), 11 (5.7%), and 6 (3.9%). Log-rank test showed significant reduction in VAP (χ2 = 9.16, P = .0103). The Cox regression hazard ratio was 1.38 for the Clinical Pulmonary Infection Score (P = .001), and the hazard ratio was 0.26 for the VAP bundle (P = .005). Bundle compliance >50% for head-of-bed elevation, oral care, subglottic suctioning, and titrated sedation improved significantly with introduction of a registered nurse champion. NNT varied from 7 to 11. CONCLUSIONS: VAP was common for ED intubated patients. ED-based VAP prevention is feasible. We demonstrate significant reduction in VAP rates, which should be replicated in a multicenter study.

Spontaneous Compartment Syndrome of the Thigh in the Absence of Trauma.

BACKGROUND: Compartment syndrome occurs when an increase in pressure results in vascular and functional impairment of the underlying nerve and muscles. Thigh compartment syndrome (TCS) is uncommon, but clinical suspicion warrants emergent surgical consultation and fasciotomy. CASE REPORT: We present a 42-year-old man evaluated for right lateral thigh pain, without a history of trauma, deep venous thrombosis (DVT), previous surgery, or intravenous drug use. He was febrile, tachycardic, with a mild leukocytosis, an elevated C-reactive protein level, and an elevated creatinine kinase level. Radiographs showed no abnormality and right lower extremity duplex ultrasound showed no DVT. A computed tomography scan of the right lower extremity was concerning for compartment syndrome. Surgical consultation was obtained, and the patient was taken to the operating room for fasciotomy. He was diagnosed with compartment syndrome intraoperatively. The patient was discharged on hospital day 10. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: TCS is exceedingly rare, especially in the absence of underlying traumatic and nontraumatic etiologies. The diagnosis is challenging because more elastic fascia with larger space in the thigh allows for accommodation of acute increases in pressure. Consequently, there may not be the expected acute rise in compartment pressures; increased compartment pressure may only be a late sign, when underlying neurovascular damage has already occurred. TCS is complicated by high morbidity and mortality. Emergent surgical consultation should be obtained when there is a high clinical suspicion for TCS, and limb-saving fasciotomy should not be delayed. This case shows the importance of a high level of suspicion for TCS in patients with no identifiable etiology and no historical risk factors for development of compartment syndrome, because TCS may not present with classic symptoms.

Does the experience of the writer affect the evaluative components on the standardized letter of recommendation in emergency medicine?

BACKGROUND: The Standardized Letter of Recommendation (SLOR) was developed in an attempt to standardize the evaluation of applicants to an emergency medicine (EM) residency. OBJECTIVE: Our aim was to determine whether the Global Assessment Score (GAS) and Likelihood of Matching Assessment (LOMA) of the SLOR for applicants applying to an EM residency are affected by the experience of the letter writer. We describe the distribution of GAS and LOMA grades and compare the GAS and LOMA scores to length of time an applicant knew the letter writer and number of EM rotations. METHODS: We conducted a retrospective review of all SLORs written for all applicants applying to three EM residency programs for the 2012 match. Median number of letters written the previous year were compared across the four GAS and LOMA scores using an equality of medians test and test for trend to see if higher scores on the GAS and LOMA were associated with less experienced letter writers. Distributions of the scores were determined and length of time a letter writer knew an applicant and number of EM rotations were compared with GAS and LOMA scores. RESULTS: There were 917 applicants representing 27.6% of the total applicant pool for the 2012 United States EM residency match and 1253 SLORs for GAS and 1246 for LOMA were analyzed. The highest scores on the GAS and LOMA were associated with the lowest median number of letters written the previous year (equality of medians test across groups, p < 0.001; test for trend, p < 0.001). Less than 3% received the lowest score for GAS and LOMA. Among letter writers that knew an applicant for more than 1 year, 45.3% gave a GAS score of "Outstanding" and 53.4% gave a LOMA of "Very Competitive" compared with 31.7% and 39.6%, respectively, if the letter writer knew them 1 year or less (p = 0.002; p = 0.005). Number of EM rotations was not associated with GAS and LOMA scores. CONCLUSIONS: SLORs written by less experienced letter writers were more likely to have a GAS of "Outstanding" (p < 0.001) and a LOMA of "Very Competitive" (p < 0.001) than more experienced letter writers. The overall distribution of GAS and LOMA was heavily weighted to the highest scores. The length of time a letter writer knew an applicant was significantly associated with GAS and LOMA scores.

A review of cost-effectiveness, cost-containment and economics curricula in graduate medical education.

OBJECTIVE: Numerous studies performed over the last 30 years suggest that doctors have poor knowledge of the costs of medical care. In most graduate medical education programmes, trainees do not receive formal training in cost-effective medical practice. METHODS: Comprehensive literature search of electronic bibliographic databases for articles that describe health economics, cost-containment and cost-effectiveness curricula in graduate medical education. Critical appraisal of the literature and qualitative description is presented. Heterogeneity of curricula precluded quantitative summary of data. RESULTS: We identified 40 articles that met the inclusion criteria for this review. Internal medicine residents were the targeted learners in 27 studies (68%); Family Medicine and Surgery residents were each targeted in five studies (13%); Rehabilitation, Paediatrics and Emergency Medicine residents were each targeted in one study. In general, the methodological quality of the included studies was poor to moderate and mostly targeted knowledge of health economics or cost-containment as opposed to targeting cost-effectiveness. In terms of describing the standard curricular components, studies sufficiently described the different educational strategies (e.g. didactics, interactive, experiential, self-directed) and the component of learner assessment, but lacked the description of other elements such as needs assessment and curriculum evaluation. CONCLUSION: Cost-effectiveness curricula in graduate medical education are lacking and clearly needed.