Post-traumatic catatonia in a teenaged patient.

Catatonia is a poorly understood and underrecognized psychomotor condition characterized by three or more catatonic symptoms, commonly including abnormalities in speech, affect, and movement. Catatonia is generally associated with psychiatric disorders such as bipolar disorder and schizophrenia, but may be seen in general medical conditions and rarely after physical trauma. Here, we present the first pediatric case of catatonia following traumatic brain injury as well as the first case of catatonia in any patient following minor traumatic brain injury.

Patient controlled analgesia for the management of acute pain in the emergency department: A systematic review.

BACKGROUND: The most common presenting complaint to the emergency department (ED) is pain. Several studies have shown that a large proportion of ED patients either receive no or sub-optimal analgesia. Patient-controlled analgesia (PCA) pumps used in the post-operative setting has shown to decrease total opioid consumption and has increased patient and nurse satisfaction. OBJECTIVE: The purpose of this systematic review was to evaluate clinical trials that have used PCAs in the ED setting, to evaluate safety and efficacy as well as patient and healthcare provider experience. METHODS: A search of PubMed, MEDLINE, and the Cochrane Database was conducted using the MESH search terms emergency department, patient-controlled analgesia, and acute pain up to September 2021. These terms were searched in all fields of publication and were limited to the English-language articles, clinical "human" studies, and studies that included the use of patient-controlled analgesia in the setting of the emergency department. RESULTS: The search initially identified 227 potentially relevant articles and a total of 10 studies met criteria for inclusion. ED use of PCA therapy was associated with increased patient satisfaction, decreased pain scores, and an overall increase in opioid consumption. CONCLUSION: The quality, the differences in study methods and outcome measures used, and heterogeneity of the studies performed to date do not provide adequate evidence to support its widespread use in the ED. Well-designed studies conducted in the ED are still needed to evaluate the ideal patient population to whom these PCAs may provide the most benefit as well as a robust cost-analysis to ensure feasibility of use in the future.

Ketamine for acute suicidality in the emergency department: A systematic review.

INTRODUCTION: There are no emergent pharmaceutical interventions for acute suicidal ideation, a common presenting complaint in the ED. Ketamine is a NMDA agonist frequently used by ED physicians for sedation and analgesia. Prior evidence from studies conducted in inpatient psychiatry units suggests that ketamine may have a role in alleviating treatment-resistant depression as well as suicidal ideation. METHODS: PubMed, MEDLINE, and Cochrane reviews were queried for articles related to keywords ketamine, suicidality, suicidal ideation, and emergency department/room. Relevant articles were selected and reviewed by two separate authors. RESULTS: Three relevant, prospective studies were identified with a mean sample size of 25.7. Each was performed using 0.2 mg/kg ketamine for individuals receiving active treatment. Each study reported a decrease in depressive symptoms among those receiving ketamine. One study reported a significant reduction in SI when compared to placebo at 90 min that became non-significant by 230 min. No significant adverse events were reported in any study. CONCLUSION: Current evidence suggests that ketamine is a promising, safe potential intervention for acute suicidality in the ED. Convincing evidence for efficacy of ketamine for acute suicidal ideation remains lacking, and this promising potential intervention should be further investigated.

Validity and Repeatability of Single-Sensor Loadsol Insoles during Landing.

Clinically feasible methods for quantifying landing kinetics could help identify patients at risk for secondary anterior cruciate ligament injuries. The purpose of this study was to evaluate the validity and between-day repeatability of the loadsol insole during a single-hop and bilateral stop-jump. Thirty healthy recreational athletes completed seven single-hops and seven stop-jumps while simultaneous loadsol (100 Hz) and force plate (1920 Hz) measurements were recorded. Peak impact force, loading rate, and impulse were computed for the dominant limb, and limb symmetry was calculated between limbs for each measure. All outcomes were compared between the loadsol and force plate using intraclass correlation coefficients (ICC) and Bland⁻Altman plots. Fifteen participants completed a second day of testing to assess between-day repeatability of the loadsol. Finally, an additional 14 participants completed the first day of testing only to assess the validity of the newest generation loadsol, which sampled at 200 Hz. At 100 Hz, validity ICC results were moderate to excellent (0.686⁻0.982), and repeatability ICC results were moderate to excellent (0.616⁻0.928). The 200 Hz loadsol demonstrated improved validity ICC (0.765⁻0.987). Bland⁻Altman plots revealed that the loadsol underestimated load measures. However, this bias was not observed for symmetry outcomes. The loadsol device is a valid and repeatable tool for evaluating kinetics during landing.

The i-gel® supraglottic airway device compared to endotracheal intubation as the initial prehospital advanced airway device: A natural experiment during the COVID-19 pandemic.

Objective: Unlike randomized controlled trials, practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings where there may be reluctance to adopt new practices. We present the results of a natural experiment that was driven by mandated COVID-19 pandemic-driven shift from endotracheal intubation (ETI) to the i-gel® supraglottic airway (SGA) as a primary advanced airway management device in the prehospital setting to reduce emergency medical services (EMS) personnel exposure to potentially infectious secretions. The objective was to compare first-pass success and timing to successful airway placement between ETI and the i-gel® SGA under extenuating circumstances. Methods: This pre/post study compared airway placement metrics in prehospital patients requiring advance airway management for non-trauma-related conditions. Data from EMS records were extracted over 2 years, 12 months pre-pandemic, and 12 months post-pandemic. During the pre-COVID-19 year, the EMS protocols utilized ETI as the primary advanced airway device (ETI group). Post-pandemic paramedics were mandated to utilize i-gel® SGA as the primary advanced airway device to reduce exposure to secretions (SGA group). Results: There were 199 adult patients, 83 (42%) in the ETI group and 116 (58%) in the SGA group. First-pass success was significantly higher with SGA 96% (92%-99%) than ETI 68% (57%-78%) with paramedics citing the inability to visualize the airway in 52% of ETI cases. Time to first-pass success was significantly shorter in the SGA group (5.9 min [5.1-6.7 min]) than in the ETI group (8.3 min [6.9-9.6 min]), as was time to overall successful placement at 6.0 min (5.1-6.8 min) versus 9.6 min (8.2-11.1 min), respectively. Multiple placement attempts were required in 26% of ETI cases and 1% of the SGA cases. There were no statistically significant differences in the number and types of complications between the cohorts. Return of spontaneous circulation (on/before emergency department [ED] arrival), mortality at 28 days, intensive care unit length of stay, or ventilator-free days between the groups were not statistically different between the groups. Conclusion: In this natural experiment, the SGA performed significantly better than ETI in first-pass airway device placement success and was significantly faster in achieving first-pass success, and overall airway placement, thus potentially reducing exposure to respiratory pathogens. Practical real-world studies can offer important information about implementation of prehospital interventions, particularly in community settings and in systems with a low frequency of tracheal intubations.

Age and sex differences in blood product transfusions and mortality in trauma patients at a level I trauma center.

Objectives: Hemorrhage is a common complication of trauma. We evaluated age and sex differences in treatment with blood product transfusions and massive transfusions as well as in-hospital mortality following trauma at a Level 1 Trauma Center. Methods: This cross-sectional study evaluated trauma data from a Level 1 trauma center registry from January 2013 to December 2017. The primary outcome was amount of blood products (packed red blood cells (PRBCs), plasma, platelets), and massive transfusion (MT) by biological sex and by age group: 16-24 (youth), 25-59 (middle age), and >=60 (older age) The secondary outcome was in-hospital mortality to hospital discharge. Results: There were 13596 trauma patients in the registry, mean age was 48 years, 4589 (34%) female and 9007 (66%) male, and median ISS of 9. Male patients received significantly more PRBC transfusions than female patients within 4-hours 6.6% vs 4.4%, and 24-hours 6.7% vs 4.5% respectively. Older patients received significantly fewer PRBC transfusions within 4-hours and 24-hours than their younger counterparts, with 6.9% in the youth group, 6.8% in the middle age group, and 3.9% in the older group (p<0.001). When adjusted for injury severity, the odds of receiving a blood transfusion within 4 hours of injury was significantly lower in older females. Using multivariate analysis, predictors of mortality included (in order of significance) injury severity, older age, transfusion within 4 hours of injury, penetrating trauma, and male sex. Conclusion: In this large trauma cohort, older female trauma patients were less likely to receive blood products compared to younger females and to their older male counterparts, even after adjusting for injury severity. Predictors of mortality included injury severity, older age, early transfusion, penetrating trauma, and male sex. Following trauma, older women appear vulnerable to undertreatment. Further study is needed to determine the reasons for these differences and their impact on patient outcomes.

Comparison of the cytotoxic effects of beta-sitosterol oxides and a cholesterol oxide, 7beta-hydroxycholesterol, in cultured mammalian cells.

Phytosterols are plant sterols found in foods such as oils, nuts and vegetables. Phytosterols, in the same way as cholesterol, contain a double bond and are susceptible to oxidation. The objective of the present study was to assess the potential toxic effects of beta-sitosterol oxides on U937 cells. The effects of increasing concentrations (0-120 microm) of beta-sitosterol oxides on cellular cytotoxicity, apoptosis, antioxidant status and genotoxicity was assessed over 12, 24 and 48 h exposure periods. Following 12 h, the viability of cells treated with 120 microm-beta-sitosterol oxides was reduced to 51.7 % relative to control. At 24 and 48 h, both 60 and 120 microm-beta-sitosterol oxides caused a significant decrease in cell viability. For comparison, a decrease in viability of cells treated with a cholesterol oxide, 7beta-hydroxycholesterol (7beta-OH, 30 microm), was evident at 24 h. An increase in apoptotic cells, assessed using Hoechst 33342, indicates that the mode of cell death in U937 cells following exposure to 7beta-OH (30 microm) and beta-sitosterol oxides (60 and 120 microm) was by apoptosis. The increase in apoptotic cells after 12 h following treatment with 120 microm-beta-sitosterol oxides was accompanied by a decrease in cellular glutathione. Similarly, 7beta-OH (30 microm) treatment resulted in decreased glutathione at 12 h. Catalase activity was not affected by any of the treatments. beta-Sitosterol oxides had no genotoxic effects on U937 and V79 cells as assessed by the comet and sister chromatid exchange assays respectively. In general, the results indicate that thermally oxidised derivatives of beta-sitosterol demonstrate similar biological effects as 7beta-OH in U937 cells, but at higher concentrations.