Correction: Correction to 'Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department' [Annals of Emergency Medicine 68 (2016) 354-370.e29].

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused.

Blueprint for the development of resuscitation and emergency critical care fellowships.

The volume of critically ill patients presenting to the emergency department (ED) is increasing rapidly. Continued growth will likely further stress an already strained U.S. health care system. Numerous studies have demonstrated an association with worsened outcomes for critically ill patients boarding in the ED. To address the increasing volume and complexity of critically ill patients presenting to EDs nationwide, resuscitation and emergency critical care (RECC) fellowships were developed. RECC programs teach a general approach to the management of the undifferentiated critically ill patient, advanced management of critically ill patients by disease presentation, and ongoing supportive care of the critically ill patient boarding in the ED. The result is critical care training beyond that of a typical emergency medicine (EM) residency with a focus on the unique features and challenges of caring for critically ill patients in the ED not normally found in critical care fellowships. Graduates from RECC fellowships are well suited to practicing in any ED practice model and may be especially well prepared for EDs that distinguish acuity between zones (e.g., resuscitative care units, ED-based intensive care units). In addition to further developing clinical acumen, RECC fellowships provide graduates with a niche in EM education, research, and administration. In this article, we describe the philosophical principles and practical components necessary for the creation of future RECC fellowships.

Rare but Foreseeable: Rapidly Expanding Retropharyngeal Hematoma After Fall from Height.

CASE PRESENTATION: An elderly man presented to the emergency department after a fall from a 15-foot height. Initial examination revealed signs of head and neck trauma without airway compromise. Computed tomography imaging identified cervical fractures at the first and second level with a retropharyngeal hematoma. In discussion with the trauma service, the patient was admitted to the hospital for airway monitoring. After 10 hours he clinically deteriorated, resulting in acute respiratory failure, and ultimately required intubation. The patient was intubated with a hyperangulated video laryngoscopy, and a surgical set-up was also prepared. The intubation was uncomplicated and resulted in clinical improvement. The patient was extubated after three days without difficulty and was ultimately discharged following an uncomplicated hospital course. DISCUSSION: Retropharyngeal hematoma is a rare but significant clinical condition. Rapid decline and airway compromise have been described. Patients often require intubation and mechanical ventilation to avoid airway obstruction and respiratory failure. Coagulopathies should be reversed, if present. Prompt recognition and treatment of this condition is crucial to successful management.

Increasing ventilator surge capacity in disasters: ventilation of four adult-human-sized sheep on a single ventilator with a modified circuit.

OBJECTIVE: Recent manmade and natural disasters have focused attention on the need to provide care to large groups of patients. Clinicians, ethicists, and public health officials have been particularly concerned about mechanical ventilator surge capacity and have suggested stock-piling ventilators, rationing, and providing manual ventilation. These possible solutions are complex and variously limited by legal, monetary, physical, and human capital restraints. We conducted a study to determine if a single mechanical ventilator can adequately ventilate four adult-human-sized sheep for 12h. METHODS: We utilized a four-limbed ventilator circuit connected in parallel. Four 70-kg sheep were intubated, sedated, administered neuromuscular blockade and placed on a single ventilator for 12h. The initial ventilator settings were: synchronized intermittent mandatory ventilation with 100% oxygen at 16 breaths/min and tidal volume of 6 ml/kg combined sheep weight. Arterial blood gas, heart rate, and mean arterial pressure measurements were obtained from all four sheep at time zero and at pre-determined times over the course of 12h. RESULTS: The ventilator and modified circuit successfully oxygenated and ventilated the four sheep for 12h. All sheep remained hemodynamically stable. CONCLUSION: It is possible to ventilate four adult-human-sized sheep on a single ventilator for at least 12h. This technique has the potential to improve disaster preparedness by expanding local ventilator surge capacity until emergency supplies can be delivered from central stockpiles. Further research should be conducted on ventilating individuals with different lung compliances and on potential microbial cross-contamination.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Lung-protective ventilation strategies and adjunctive treatments for the emergency medicine patient with acute respiratory failure.

Respiratory failure is a frequent disease process encountered in the emergency department. There is significant need for improvement in the care of patients on mechanical ventilation. If not contraindicated, lung-protective ventilation strategies should be used. It is important to consider pathophysiology (shunting, dead space ventilation, and low venous admixture) when formulating treatment strategies in patients who are difficult to oxygenate or ventilate or when Pao2, Paco2, and pH can only be maintained at unsafe ventilator settings.

Quantitative analysis of 3alpha,6alpha,24-trihydroxy-24,24-di(trifluoromethyl)-5beta-cholane, a potent synthetic steroidal liver X receptor agonist in plasma using liquid chromatography-tandem mass spectrometry.

The steroidal liver X receptor agonist, 3alpha,6alpha,24-trihydroxy-24,24-di(trifluoromethyl)-5beta-cholane (ATI-829) is a potential therapeutic agent for the treatment of atherosclerosis. A sensitive and selective liquid chromatography-tandem mass spectrometry (LC-MS-MS) method for the quantification of ATI-829 in mouse plasma was developed and validated. Proteins in a 25 microL aliquot of mouse plasma were precipitated, and ATI-829 was extracted from the precipitate by the addition of 125 microL methanol. The overall extraction efficiency was greater than 99%. LC-MS-MS with negative ion electrospray and selected reaction monitoring was used for the quantitative analysis of ATI-829. The lower limit of quantitation of ATI-829 corresponded to 5.0 ng/mL (9.7 nM) plasma. Interference from matrix was negligible. The calibration curve was linear over the range 5-2000 ng/mL. The intra-day precision and inter-day precision of the analyses were <4.5% and <6%, respectively, and the accuracy ranged from 92% to 103%. ATI-829 in plasma was stable for at least 6 h at room temperature, 1 week at 4 degrees C, and 3 weeks at -20 degrees C. The validated method was then utilized for pharmacokinetic studies of ATI-829 administered to mice.

Screening antioxidants using LC-MS: case study with cocoa.

Oxidative stress enhances pathological processes contributing to cancer, cardiovascular disease, and neurodegenerative diseases, and dietary antioxidants may counteract these deleterious processes. Because rapid methods to evaluate and compare food products for antioxidant benefits are needed, a new assay based on liquid chromatography-mass spectrometry (LC-MS) was developed for the identification and quantitative analysis of antioxidants in complex natural product samples such as food extracts. This assay is based on the comparison of electrospray LC-MS profiles of sample extracts before and after treatment with reactive oxygen species such as hydrogen peroxide or 2,2-diphenyl-1-picrylhydrazyl radical (DPPH). Using this assay, methanolic extracts of cocoa powder were analyzed, and procyanidins were found to be the most potent antioxidant species. These species were identified using LC-MS, LC-MS/MS, accurate mass measurement, and comparison with reference standards. Furthermore, LC-MS was used to determine the levels of these species in cocoa samples. Catechin and epicatechin were the most abundant antioxidants followed by their dimers and trimers. The most potent antioxidants in cocoa were trimers and dimers of catechin and epicatechin, such as procyanidin B2, followed by catechin and epicatechin. This new LC-MS assay facilitates the rapid identification and then the determination of the relative antioxidant activities of individual antioxidant species in complex natural product samples and food products such as cocoa.