Pediatric Takotsubo cardiomyopathy resulting from clonidine overdose.

Takotsubo cardiomyopathy is a syndrome characterized by localized apical dysfunction of the left ventricle. It is rarely seen in pediatric patients, but can carry significant morbidity and mortality. While most commonly associated with psychosocial stressors or physical exertion, a growing number of cases are being attributed to medications. We describe a case of a six-month-old male diagnosed with Takotsubo cardiomyopathy in the setting of an accidental clonidine overdose. The patient presented with altered mental status and hypertension. In the course of his broad workup, cardiac dysfunction was indicated by bedside ultrasound in the Emergency Department. The classic apical dyskinesis was seen on a follow-up, cardiology-based echocardiogram. The patient responded to high-dose naloxone and only briefly required an epinephrine infusion. His symptoms resolved in a few days and serial echocardiograms showed a return to normal LV function. Rates of pediatric clonidine overdoses are increasing in the setting of changing prescribing practices. Our case illustrates some key features of the clinical presentation, as well as demonstrates a rare sequelae to this common toxic exposure. To our knowledge, this is the first reported pediatric case of Takotsubo cardiomyopathy secondary to a clonidine overdose.

Parental Perspectives on Life-Altering News in Emergency Settings: A Qualitative Evaluation.

INTRODUCTION: Delivering life-altering news is a difficult task that is frequently the responsibility of emergency physicians. However, the existing frameworks for guiding such interactions fail to address the physician-parent-patient dynamic of pediatric emergency encounters. To date, no study has investigated the parental perspective, limiting the ability to provide evidence-based recommendations. This study describes how parents experience receiving life-altering news about their child in emergency settings. METHODS: This qualitative study used virtual asynchronous focus groups. Through purposeful sampling of virtual support and advocacy groups, we recruited parents of children diagnosed with either malignancy or type 1 diabetes in an emergency department. Participants were then assigned to private Facebook groups established solely for this study. Questions were posted to these groups over the course of 5 days. At their convenience, participants could post responses, replies, or new questions. Three members of the research team performed thematic analysis and used team consensus to ensure validity. RESULTS: Four focus groups were conducted with a total of 28 participants. Parents described their experiences receiving life-altering news as a process with 4 primary emergent themes: lens through which they view the experience, the ED encounter, the immediate response, and the long-term impact. Each parent entered into the ED encounter with a unique collection of personal experiences, circumstances, and knowledge. These factors shaped the lens through which they perceived the events of the ED encounter. Ultimately, this determined participants' response to the life-altering news, leading to many long-term impacts on the various dynamics within each parent's life. CONCLUSIONS: The words used to disclose life-altering news are only a small piece of the experience for parents. Personal lenses changed how encounters were perceived, resulting in variable and long-lasting implications. We recommend the following framework for providers: understand the lens, control encounters, manage responses, and respect long-term impacts.

Primaquine overdose in a toddler.

Antimalarial medications carry a risk of rare, but serious side effects. Primaquine in particular is known to cause methemoglobinemia and hemolytic anemia. In patients with underlying glucose-6-phosphate dehydrogenase (G6PD) deficiency, these side effects become amplified and can be life-threatening. This can complicate treatment plans as the recommended first-line management of severe methemoglobinemia, methylene blue, may cause or worsen hemolytic anemia in G6PD deficient patients. We present a case of a toddler with an accidental primaquine overdose who had undiagnosed G6PD deficiency. Over the 2 days following his ingestion he developed severe methemoglobinemia and hemolytic anemia toxicity. He was initially treated with a dose of methylene blue prior to learning of his G6PD deficiency. He was subsequently given additional doses of ascorbic acid and a blood transfusion. His condition gradually improved and he was ultimately discharged in good condition. To our knowledge, this case represents a unique presentation of mixed methemoglobinemia and hemolytic toxicity due to an accidental primaquine overdose in a G6PD deficient pediatric patient. Though cases remain relatively rare, pediatric patients represent the vast majority of known primaquine overdoses. Their diagnosis and treatment require maintaining a high index of suspicion and a good working knowledge of antimalarial toxicities and management options.

Myocarditis Following mRNA COVID-19 Vaccine.

ABSTRACT: A growing number of adolescents are being diagnosed with acute myocarditis following mRNA COVID-19 vaccinations. This case describes an adolescent who presented to the emergency department with chest pain and tachycardia following the Pfizer-BioNTech COVID-19 vaccination. Point-of-care ultrasound was performed prior to the return of laboratory studies and revealed depressed left ventricular systolic function. Point-of-care ultrasound may be a tool used to rapidly diagnose or risk stratify patients with potential post-COVID-19 vaccine myocarditis.

The importance of developing global emergency medicine research network.

Despite the fact that emergency care can impact health of populations, the global epidemiology of emergencies in children and adults is unknown and substantial variation exists in emergency infrastructure among different nations, especially among the low and middle income countries. Various research networks which are etiology specific or subspecialty specific, including emergency care based networks have positively impacted the health of populations. However, emergency departments (ED) in low and middle income counties are underrepresented in most international networks. Creation of a global ED based research network will help generate generalizable evidence that can then be translated into locally relevant evidence-based guidelines, nurture future researchers in emergency medicine, standardize training/education and improve patient outcomes by reducing variation in clinical care.

Global Perspectives on Innovations in Emergency Care during the COVID-19 Pandemic: A Mixed Methods Study.

Introduction: In mid-2020, the Emergency Medicine Education and Research by Global Experts (EMERGE) network surveyed the emergency response to the COVID-19 pandemic. We demonstrated that innovative measures were being generated at unprecedented rates. Our aim was to build on these findings to develop the first theoretical model with utility in assessing and developing emergency innovations. Methods: Phase 1 of a two-phase, explanatory sequential mixed methods study was a secondary analysis of the original EMERGE survey. Phase 2 involved follow-up interviews of a purposeful sample of 15 of the original survey respondents, representing 12 countries and all 6 World Health Organization regions. Thematic analysis was performed by three members of the research team. Results: Innovation is a nonlinear process in which ideas are developed, implemented, refined, and spread. Ideas grew from departmental needs or the spread of successful innovations from other sites. Development was highly localized, influenced by institutional and regional factors. Obtaining buy-in from relevant stakeholders and addressing various barriers were essential to implementation. The majority of innovations then underwent a process of evolution before some were spread to other institutions through a largely unidirectional flow of information. Conclusions: This study proposes the first model for emergency innovation processes and highlights multiple areas for improvement. Understanding how to prioritize departmental needs and the barriers may streamline development and implementation. Furthermore, the apparent unidirectional flow of information demonstrated by our participants suggests both an opportunity and a need for improved information systems. We present a framework for further research and an outline for innovation management.

Discovery of a Hidden Schistosomiasis Endemic in the Salamat Region of Chad, Africa.

There is currently a severe paucity of rural epidemiologic data on urogenital schistosomiasis in the Republic of Chad in north-central Africa that is hindering national control strategies. Our study describes a mobile medical team's 4-year effort to collect data and provide mass therapeutic and preventive chemotherapy in the Salamat Region of Chad, a previously uninvestigated rural area. To overcome severe limitations in time, resources, support, and infrastructure, the team employed several time- and cost-saving techniques that included: (1) traveling by request and referral to utilize local knowledge to find the areas of highest need, (2) conducting convenience sampling for screening, (3) using simple but validated tools to expedite treatment and data gathering, and (4) working within cultural contexts to find and treat the most school-age children possible. The team managed a total of 11,832 patient encounters and found a 55% rate of hematuria (n=6,495) among school-age children, roughly double previous estimates. Rates of hematuria were higher in males (61%, n=3,955/6,466) than females (48%, n=2,301/4,806) and among adolescents (> 65% in all age groups aged 10 years and older). These methods outline an efficient and effective strategy implemented under real-world conditions to enact therapeutic and preventive chemotherapy campaigns in resource-limited settings by engaging village leadership and developing locally driven solutions. Our data highlight the need for continued local epidemiologic efforts to treat the substantial number of children severely affected with schistosomiasis.

Metabolomics in Placental Tissue from Women Living with HIV.

It is unknown whether antiretroviral (ARV) drugs in women living with HIV (WLHIV) are associated with mitochondrial toxicity and altered fat oxidation and branched-chain amino acid metabolism in the placenta and fetus. Immediately after delivery, we froze placental biopsies from 20 WLHIV and 20 matched uninfected women. We analyzed global biochemical profiles using high-performance liquid chromatography/tandem mass spectrometry and gas chromatography/mass spectrometry. We used t-tests, principle component analysis, hierarchical clustering, and random forest analysis (RFA) in our analysis. Twelve WLHIV were on protease inhibitors, six on non-nucleoside reverse inhibitors, and two on integrase strand inhibitors with optimized backbone. Mean birth weight of HIV-exposed neonates was significantly lower than unexposed neonates (3,075 g vs. 3,498 g, p = .01) at similar gestational age. RFA identified 30 of 702 analytes that differentiated the placental profiles of WLHIV from uninfected women with 72.5% predictive accuracy. Placental profiles of non-nucleoside reverse transcriptase inhibitor (NNRTI)-treated WLHIV exhibited lower levels of amino acids, including essential and branched-chain amino acids, and some medium-chain acylcarnitines. Placental metabolism may be altered in WLHIV, possibly associated with ARV exposure. The lower birth weight among neonates of WLHIV suggests the need for further studies considering potential deleterious effects of altered placenta metabolism on fetal growth and development.

Tongue protrusion as the presenting symptom of parapharyngeal abscess.

Deep neck space infections are commonly seen in the pediatric population. The diagnosis, however, can be challenging to make and requires a high degree of suspicion because of developmental and age-related factors in children and non-specific presenting symptoms. Diagnosis becomes further complicated in patients whose comorbid conditions mask some of the more severe systemic symptoms. We present a case of a 2-year-old female with Trisomy 21 who presented with a chief concern of "tongue swelling" per parents. After initially failing treatment for presumed angioedema caused by an angiotensin-converting enzyme inhibitor, she was ultimately diagnosed with a parapharyngeal abscess with extension and mass effect causing tongue protrusion. This case represents a novel early presentation of a common infection and highlights the challenges of diagnosing deep neck space infections in children.