Recommended Musculoskeletal and Sports Medicine Model Curriculum for Emergency Medicine Residency Training.

ABSTRACT: Musculoskeletal and sports medicine conditions are common in the emergency department (ED). Emergency physicians may not be receiving adequate education to achieve clinical competency in musculoskeletal medicine during residency training. This article aims to provide a standardized musculoskeletal and sports medicine curriculum for emergency medicine training. Broad curriculum goals include proficiency in evaluating and managing patients presenting to the ED with acute and chronic musculoskeletal complaints and other medical conditions related to or affected by physical exertion, sports participation, or environmental exposure. Specific objectives focus on knowledge of these disorders, physical examination skills, procedural skills including musculoskeletal ultrasound, appropriate consultation and referral, and patient education for these conditions. Educational methods will consist of didactics; online self-directed learning modules; simulation; and supervised clinical experiences in the ED, primary care sports medicine clinics, and orthopedic clinics if available. Curriculum implementation is expected to vary across programs due to differences in residency program structure and resources.

Analysis of Central and Peripheral Vision Reaction Times in Patients With Postconcussion Visual Dysfunction.

OBJECTIVE: To determine whether central and peripheral vision reaction times (PVRTs) are prolonged in patients with visual dysfunction after sustaining a concussion. DESIGN: Comparison of Dynavision D2 central and PVRTs in patients with postconcussion visual dysfunction were compared with control data from a normative patient database. Concussion patients without visual dysfunction were not included in this study. SETTING: National Collegiate Athletic Association Division 1 college training room and university based, academic health center. PARTICIPANTS: Patients were selected for inclusion based on diagnosis of new visual dysfunction as indicated either by physical examination of the team physician or by patient self-report of symptoms. Patients included college athletes, college students, and concussion patient's presenting to a university based, academic health center. INTERVENTION: Measurement of central and PVRTs using a Dynavision D2 reaction time program were used as the dependent variables. Evaluations were conducted from 3 days to 11 months postconcussion, depending on the temporal development of visual symptoms after the concussion. No intervention was used. MAIN OUTCOME MEASURES: Average central and PVRTs for patients with postconcussion visual symptoms were compared with an asymptomatic control group with no history of concussion. RESULTS: Both central and PVRTs were significantly prolonged in patients with postconcussion visual symptoms compared with patients with no history of concussion. CONCLUSIONS: Central and PVRTs are both prolonged in patients with postconcussion visual dysfunction with PVRT being disproportionately prolonged. The percent change from central to PVRT was also increased in patients with postconcussion visual dysfunction.

Consideration for Hemiballismus in the Differential Diagnosis: A Rare Case of Hyperosmolar Hyperglycemic State.

We present a case of a 58-year-old male with a past medical history of hypertension and diabetes mellitus presenting to the emergency department with a complaint of abnormal and uncontrollable right arm jerking motions occurring since the afternoon on the day prior to presentation. Arm movements such as these may be consistent with either focal seizures or hemiballismus, a movement disorder classified as a choreiform subtype consisting of involuntary violent movements of an extremity with wide amplitudes. Although oftentimes focal seizures and hemiballismus are associated with neurologic etiologies such as strokes, the second most common cause of hemiballismus appears to be non-ketotic hyperosmolar hyperglycemia. While symptomatic treatment in managing focal seizures and hemiballismus may consist of benzodiazepines and dopamine receptor antagonists, respectively, it is important to treat the underlying cause, which in this case was the non-ketotic hyperosmolar hyperglycemic state associated with this patient's long-standing history of poorly controlled diabetes mellitus.

Acute Calcific Tendonitis of the Longus Colli: An Uncommon Cause of Neck Pain in the Emergency Department.

The longus colli muscle has three major parts that originate and insert in the upper cervical and thoracic spine. It is a weak flexor of the neck, and when contracted also serves to rotate the neck to the ipsilateral side. It is innervated by the anterior rami of the C2-C6 spinal nerves and receives its blood supply from the anterior cervical and inferior thyroid arteries. In a post motor vehicle collision (MVC) patients presenting weeks later, the physician has to ensure there is no subacute fracture. Clinically, these patients present with severe anterior neck pain that will often be described as a deep pain. A 43-year-old female with a past medical history of diabetes and prior surgical history of a tonsillectomy and uvulectomy presented with sudden onset of sore throat that woke her up from sleep at 3:00 am. Associated with the sore throat, she had hoarseness of her voice, difficulty breathing and felt that her throat was closing. She forced herself to vomit and then felt better. She denied any fevers or chills. Later, the patient mentioned that she had chronic neck pain from a prior accident and had been told that she has C5-C6 stenosis. About a week prior, she had been involved in another MVC and had some neck pain after that. Significantly, she was also on lisinopril for her hypertension (HTN). She was tolerating secretions, protecting her airway and no gross inflammation was noted on physical exam. On labs, there was no leukocytosis noted. Soft tissue neck X-ray showed reversal of the cervical lordosis, degenerative and erosive changes at C4-C5 and C5-C6, and thickening of the prevertebral soft tissues. She obtained a CT of the neck and cervical spine that showed osteophyte complexes at C4-C5 and C5-C6, as well as calcific tendonitis of the longus colli with a moderate amount of prevertebral free fluid. Neurosurgery was consulted from the ED who recommended getting an MRI of the neck, and consulting ENT as well. ENT happened to be in the ED and performed a bedside laryngoscopy that showed edema of the left arytenoid with full functionality of the vocal cords, and no signs of airway compromise. The patient was started on steroids, antibiotics, H2 blockers, and the ACE-inhibitor was discontinued due to suspected angioedema per ENT. She was also admitted to the ICU for airway monitoring. The MRI of the neck again showed calcific tendonitis of the longus colli with moderate prevertebral fluid. Meanwhile, the patient had complete resolution of her symptoms in 24 hours and she was cleared from both neurosurgery and ENT to be discharged. Acute calcific tendonitis is due to the deposition of calcium hydroxyapatite, which can cause significant pain and edema. In terms of calcific tendonitis of the longus colli muscle, this condition is frequently misdiagnosed and continues to be a challenge, especially in the emergency department. The differential diagnosis is diverse in etiology and severity, ranging from meningitis and retropharyngeal abscess to vertebral fracture and muscle strain.

A virtual screen for diverse ligands: discovery of selective G protein-coupled receptor antagonists.

Virtual screening has become a major focus of bioactive small molecule lead identification, and reports of agonists and antagonists discovered via virtual methods are becoming more frequent. G protein-coupled receptors (GPCRs) are the one class of protein targets for which success with this approach has been limited. This is likely due to the paucity of detailed experimental information describing GPCR structure and the intrinsic function-associated structural flexibility of GPCRs which present major challenges in the application of receptor-based virtual screening. Here we describe an in silico methodology that diminishes the effects of structural uncertainty, allowing for more inclusive representation of a potential docking interaction with exogenous ligands. Using this approach, we screened one million compounds from a virtual database, and a diverse subgroup of 100 compounds was selected, leading to experimental identification of five structurally diverse antagonists of the thyrotropin-releasing hormone receptors (TRH-R1 and TRH-R2). The chirality of the most potent chemotype was demonstrated to be important in its binding affinity to TRH receptors; the most potent stereoisomer was noted to have a 13-fold selectivity for TRH-R1 over TRH-R2. A comprehensive mutational analysis of key amino acid residues that form the putative binding pocket of TRH receptors further verified the binding modality of these small molecule antagonists. The described virtual screening approach may prove applicable in the search for novel small molecule agonists and antagonists of other GPCRs.

Bacterial Contamination of CT Equipment: Use of ATP Detection and Culture Results to Target Quality Improvement.

RATIONALE AND OBJECTIVE: This study aimed to evaluate the use of an adenosine triphosphate (ATP) monitoring system to minimize surface contamination on inpatient computed tomography (CT) scanners. METHODS: The bore, table, and wrap of two quaternary care inpatient CT scanners (load/scanner: ~ 30-40 CT examinations/day) were assayed with bacterial cultures and an ATP detection system during six prospective iterative plan-do-check-act improvement cycles from January 6, 2016 to October 12, 2016. Per-cycle sampling was for eight consecutive weekdays. ATP detection was expressed as relative light units (RLUs) through a luciferase reaction, with >350 RLU considered contaminated per manufacturer recommendations. Culture swabs were placed into 6.5% NaCl broth, a Staphylococcus enrichment broth, and incubated aerobically at 37°C for 48 hours. Positive broths were plated to chromogenic Staphylococcus media. Culture rates (Fisher exact test) and RLU values (Mann-Whitney U test) were compared. RESULTS: In Cycle 1, both culture results and median RLU values indicated the wrap was the most contaminated item (positive culture rate: 63% [10/16], median RLU interquartile range: 173 [IQR: 56-640]); however, RLU values were not predictive of per-sample culture results (P = .36). Following iterative improvements, RLU values at Cycle 6 were significantly lower than at peak (P = .02-.04) and within manufacturer's recommendations: all samples: 45 (IQR: 16-87), bore: 26 (IQR: 0-51), table: 68 (IQR: 21-89), wrap: 47 (IQR: 38-121). CONCLUSION: The Velcro wrap is the most contaminated item on a CT scanner, and special processes may be needed to ensure adequate cleansing. ATP detection is a crude surrogate for bacterial culture results but benefits from speed, reduced cost, and greater statistical power.

Evaluation of small-molecule modulators of the luteinizing hormone/choriogonadotropin and thyroid stimulating hormone receptors: structure-activity relationships and selective binding patterns.

The substituted thieno[2,3-d]pyrimidine 3 (Org 41841), a partial agonist for the luteinizing hormone/choriogonadotropin receptor (LHCGR) and the closely related thyroid-stimulating hormone receptor (TSHR), was fundamentally altered, and the resulting analogues were analyzed for their potencies, efficacies, and specificities at LHCGR and TSHR. Chemical modification of the parent compound combined with prior mutagenesis of TSHR provided compelling experimental evidence in support of computational models of 3 binding to TSHR and LHCGR within their transmembrane cores. Biochemical analysis of a specific modification to the chemical structure of 3 provides additional evidence of a H-bond between the ligand and a glutamate residue in transmembrane helix 3, which is conserved in both receptors. Several key interactions were surveyed to determine their respective biochemical roles in terms of both van der Waals dimensions and hydrogen bond capacity and the respective relationship to biological activity.