The Use of Dexmedetomidine in the Emergency Department: A Cohort Study.

INTRODUCTION: Management of sedation, analgesia, and anxiolysis are cornerstone therapies in the emergency department (ED). Dexmedetomidine (DEX), a central alpha-2 agonist, is increasingly being used, and intensive care unit (ICU) data demonstrate improved outcomes in patients with respiratory failure. However, there is a lack of ED-based data. We therefore sought to: 1) characterize ED DEX use; 2) describe the incidence of adverse events; and 3) explore factors associated with adverse events among patients receiving DEX in the ED. METHODS: This was a single-center, retrospective, cohort study of consecutive ED patients administered DEX (January 1, 2017-July 1, 2019) at an academic, tertiary care ED with an annual census of ~90,000 patient visits. All included patients (n= 103) were analyzed for characterization of DEX use in the ED. The primary outcome was a composite of adverse events, bradycardia and hypotension. Secondary clinical outcomes included ventilator-, ICU-, and hospital-free days, and hospital mortality. To examine for variables associated with adverse events, we used a multivariable logistic regression model. RESULTS: We report on 103 patients. Dexmedetomidine was most commonly given for acute respiratory failure, including sedation for mechanical ventilation (28.9%) and facilitation of non-invasive ventilation (17.4%). Fifty-four (52.4%) patients experienced the composite adverse event, with hypotension occurring in 41 patients (39.8%) and bradycardia occurring in 18 patients (17.5%). Dexmedetomidine was stopped secondary to an adverse event in eight patients (7.8%). Duration of DEX use in the ED was associated with an increase adverse event risk (adjusted odds ratio, 1.004; 95% confidence interval, 1.001, 1.008). CONCLUSION: Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.

Mice Lacking Brain-Derived Serotonin Have Altered Swallowing Function.

The intricate sensorimotor neural circuits that control swallowing are heavily reliant on serotonin (5-hydroxytryptamine [5-HT]); however, the impact of 5-HT deficiency on swallow function remains largely unexplored. We investigated this using mice deficient in tryptophan-hydroxylase-2 (TPH2), the enzyme catalyzing the rate-limiting step in 5-HT synthesis. Videofluoroscopy was utilized to characterize the swallowing function of TPH2 knockout (TPH2-/-) mice as compared with littermate controls (TPH2+/+). Results showed that 5-HT deficiency altered all 3 stages of swallowing. As compared with controls, TPH2-/- mice had significantly slower lick and swallow rates and faster esophageal transit times. Future studies with this model are necessary to determine if 5-HT replacement may rescue abnormal swallowing function. If so, supplemental 5-HT therapy may have vast applications for a large population of patients with a variety of neurologic disorders resulting in life-diminishing dysphagia, particularly amyotrophic lateral sclerosis and Parkinson's disease, for which 5-HT deficiency is implicated in the disease pathogenesis.

Papilledema: Point-of-Care Ultrasound Diagnosis in the Emergency Department.

Point-of-care ultrasound (POCUS) has the potential to diagnose papilledema, a sign of increased intracranial pressure, through optic disc elevation as well as optic nerve sheath diameter measurements. Idiopathic intracranial hypertension (IIH) is a syndrome resulting in increased intracranial pressure. We present a case of IIH where the emergency physician diagnosed papilledema by POCUS via presence of both optic disc elevation and a widened optic nerve sheath diameter.

Biopsy of parotid masses: Review of current techniques.

Definitive diagnosis of parotid gland masses is required optimal management planning and for prognosis. There is controversy over whether fine needle aspiration cytology (FNAC) or ultrasound guided core biopsy (USCB) should be the standard for obtaining a biopsy. The aim of this review is to assess the current evidence available to assess the benefits of each technique and also to assess the use of intra-operative frozen section (IOFS). Literature searches were performed using pubmed and google scholar. The literature has been reviewed and the evidence is presented. FNAC is an accepted and widely used technique. It has been shown to have variable diagnostic capabilities depending on centres and experience of staff. USCB has a highly consistent diagnostic accuracy and can help with tumour grading and staging. However, the technique is more invasive and there is a question regarding potential for seeding. Furthermore, USCB is less likely to be offered as part of a one-stop clinic. IOFS has no role as a first line diagnostic technique but may be reserved as an adjunct or for lesions not amenable to percutaneous biopsy. On balance, USCB seems to be the method of choice. The current evidence suggests it has superior diagnostic potential and is safe. With time, USCB is likely to supplant FNAC as the biopsy technique of choice, replicating that which has occurred already in other areas of medicine such a breast practice.

Right iliac fossa lymphoma in an HIV positive patient: A diagnostic dilemma.

Lymphoma should be considered early in patients with HIV when there is a history of weight loss. Although B-cell lymphoma is an AIDS-defining cancer, and many reports of lymphoma in HIV positive patients exist in the literature, this case report illustrates that even in patients with well-controlled HIV the diagnosis must be considered, and puts forward an unusual presentation in an otherwise asymptomatic patient. A 52 year old woman presented for a routine HIV follow-up appointment and was found to be experiencing weight loss. An abdominal examination revealed a right iliac fossa mass. Subsequent CT thorax, abdomen, pelvis imaging confirmed a large mass but did not allow determination of the primary source. Serological tumour marker investigations were unyielding. Trans-vaginal ultrasound guided biopsy of the mass demonstrated diffuse large B-cell lymphoma. This case report emphasises the importance of having a high index of suspicion for these cancers even in patients with low viral load who are on anti-retroviral treatment. It also demonstrates the importance of taking a multidisciplinary approach to diagnosis of the condition to enable prompt treatment and thus improve the outcome for the patient.