Utilization of Prophylactic Antibiotics After Nasal Packing for Epistaxis.

BACKGROUND: There have been few investigations examining the benefits, consequences, and patterns of use for prophylactic antibiotics for nasal packing in the emergency department setting. Given the frequency of epistaxis in the emergency department, it is an ideal setting to study the efficacy and utilization patterns of prophylactic antibiotics in nasal packing. OBJECTIVE: Our aim was to assess both rates of utilization and evidence of benefit for prophylactic antibiotics in patients with nasal packing for epistaxis. METHODS: A single-institution retrospective review of 275 cases of anterior nasal packing in an urban emergency department between September 2013 and April 2017 was performed. Chi-square statistical analysis was used to evaluate results. RESULTS: Among 275 cases studied, there were no instances of toxic shock syndrome. Roughly 73% of patients with nonabsorbable packing received prophylactic antibiotics. Only one (1.1%) case of sinusitis was noted among the nonabsorbable packing with prophylaxis group, with no such complication in the nonprophylaxis group. In contrast, 95% of patients with absorbable nasal packing were not given prophylactic antibiotics. Analysis of all cases given prophylactic antibiotics vs. no prophylaxis, regardless of packing type, revealed no statistically significant difference in the development of acute sinusitis (1% vs. 0.56%; p = 0.6793). CONCLUSIONS: There was no observed advantage or disadvantage to using prophylactic antibiotics in anterior nasal packing in the emergency department, regardless of whether patients received absorbable or nonabsorbable packing. However, patients who receive nonabsorbable nasal packing were more likely to receive antibiotic prophylaxis.

A New Paradigm Shift in Acute Ischemic Stroke, Large Vessel Occlusions, and Endovascular Therapy.

BACKGROUND: In the past three years, there have been several major studies published on the use of endovascular therapy (EVT) in large vessel occlusion (LVO) acute ischemic stroke. With multiple publications in such a short amount of time, it is difficult to keep up with the evolving landscape of ischemic stroke therapy. OBJECTIVE: This narrative review discusses recent randomized controlled trials evaluating EVT and its effects on acute ischemic stroke management. DISCUSSION: Ischemic stroke is the most common type of stroke overall, and recanalization is the predominant focus in stroke therapy to improve outcomes. Treatment first focused on systemic thrombolysis for ischemic stroke, followed by studies evaluating the use of thrombolysis with EVT. Early research did not find a benefit to EVT; however, recent studies using current devices and with narrow selection criteria demonstrate significant benefit to EVT in LVOs. In patients with LVOs and perfusion mismatches, reperfusion rates are higher with EVT compared with systemic thrombolysis alone. Recognition of patients with small infarct cores and large areas of ischemic but salvageable brain tissue up to 24 h after symptom onset stresses the need for advanced imaging to recognize the target group. CONCLUSIONS: EVT technology for acute ischemic stroke has now become more efficient, minimizing complications and improving the efficacy of EVT. Several viable interventions for a small subgroup of patients with ischemic stroke up to 24 h after symptoms onset can significantly improve patient outcomes.

Dynamic stabilization of the Rayleigh-Bénard instability by acceleration modulation.

This paper presents the results of an experimental investigation of the parametric stabilization of Rayleigh-Bénard convection through the imposition of sinusoidal vibration. The ability to dynamically stabilize Rayleigh-Bénard convection using acceleration modulation is of interest to groups who design and study thermoacoustic machines as the introduction of parasitic convection can have deleterious effects on the desired operation and thermodynamic efficiency of the device. These performance issues caused by suspected convective instability have been seen both in traveling wave thermoacoustic refrigerators and cryogenic pulse tube chillers. This paper reports the results of an experiment intended to determine the vibratory, fluidic, and geometric conditions under which a small, rectangular container of statically unstable fluid may be stabilized by vertical vibration with comparison to the computational methods of R. M. Carbo [J. Acoust. Soc. Am. 135, 654-668 (2014)]. Measurements are obtained using a large-displacement kinematic shaker of an original design with the convecting gas characterized using both thermal transport measurements and flow visualization employing tracer particles illuminated by a diode laser light sheet phase-locked to the shaker. These experiments are believed to be the first demonstrating the suppression of convection through vibration in rectangular containers.

Do Mechanical Devices Improve Return of Spontaneous Circulation Over Manual Chest Compressions in Out-of-Hospital Cardiac Arrest?

Data are inadequate to determine whether recent devices (either load-distributing band or piston-driven) confer benefit or harm, though early trial data suggest they do not.

Global emergency medicine journal club: a social media discussion about the Age-Adjusted D-Dimer Cutoff Levels To Rule Out Pulmonary Embolism trial.

STUDY OBJECTIVE: Annals of Emergency Medicine collaborated with an educational Web site, Academic Life in Emergency Medicine (ALiEM), to host an online discussion session featuring the 2014 Journal of the American Medical Association publication on the Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism (ADJUST-PE) trial by Righini et al. The objective is to describe a 14-day (August 25 to September 7, 2014) worldwide academic dialogue among clinicians in regard to 4 preselected questions about the age-adjusted D-dimer cutoff to detect pulmonary embolism. METHODS: Five online facilitators hosted the multimodal discussion on the ALiEM Web site, Twitter, and Google Hangout. Comments across the social media platforms were curated for this report, as framed by the 4 preselected questions, and engagement was tracked through various Web analytic tools. RESULTS: Blog and Twitter comments, as well as video expert commentary involving the ADJUST-PE trial, are summarized. The dialogue resulted in 1,169 page views from 391 cities in 52 countries on the ALiEM Web site, 502,485 Twitter impressions, and 159 views of the video interview with experts. A postdiscussion summary on the Journal Jam podcast resulted in 3,962 downloads in its first week of publication during September 16 to 23, 2014. CONCLUSION: Common themes that arose in the multimodal discussions included the heterogeneity of practices, D-dimer assays, provider knowledge about these assays, and prevalence rates in different areas of the world. This educational approach using social media technologies demonstrates a free, asynchronous means to engage a worldwide audience in scholarly discourse.

The Safety of Topical Anesthetics in the Treatment of Corneal Abrasions: A Review.

BACKGROUND: Despite the fact that topical anesthetics provide superb analgesia to the painful eye, they are not prescribed routinely to patients when they are discharged from the emergency department because of concerns for delayed healing and corneal erosion. OBJECTIVE: To summarize the evidence for the safety of topical proparacaine and tetracaine for pain relief in patients with corneal abrasions. METHODS: This is a systematic review looking at the use of topical anesthetic agents in the treatment of corneal abrasions in the emergency department. RESULTS: Our literature search produced two emergency department-based, randomized, double blind, placebo-controlled studies on human patients with corneal abrasions. Additionally, we found four studies that investigated the application of topical anesthetics in patients who underwent photorefractive keratectomy. All six studies demonstrated that a short course of dilute topical anesthetic provided efficacious analgesia without adverse effects or delayed epithelial healing. CONCLUSION: Limited available data suggests that the use of dilute topical ophthalmologic proparacaine or tetracaine for a short duration of time is effective, though their safety for outpatient use is inconclusive.

Do emergency medicine residents receive appropriate video laryngoscopy training? A survey to compare the utilization of video laryngoscopy devices in emergency medicine residency programs and community emergency departments.

BACKGROUND: Video laryngoscopy (VL) has emerged as a critical tool in the "difficult airway" armamentarium of emergency physicians. The resultant increase in the types of available VL devices has made Emergency Medicine Residency (EMR) training in VL increasingly challenging. Additionally, the prevalence of VL devices in the community is unknown. Because Emergency Medicine (EM) residents go on to work in diverse settings, many in non-EMR emergency departments (EDs), it is preferable that they receive training on the airway modalities they will encounter in practice. OBJECTIVE: To compare the prevalence and type of VL devices in EMR programs to non-EMR EDs. METHODS: This was a survey study conducted from July 2012 to October 2012 of Accreditation Council for Graduate Medical Education-accredited, MD EMR programs in the United States and non-EMR EDs in New York State. A chi-squared test was performed to determine whether the difference in VL prevalence was significant. RESULTS: There were 158 EMR programs and 132 non-EMR EDs surveyed; 97.8% of EMR and 84.3% of non-EMR EDs reported having some form of VL in their departments. The difference in proportion of EMR vs. non-EMR EDs that have VL was χ(2) = 13 (p < 0.001). The Glidescope® device (Verathon Medical, Bothell, WA) was present in 87.7% of EMR programs and 79.3% of non-EMR EDs. CONCLUSIONS: The majority of EMR programs trained residents in VL. The Glidescope device was used most frequently. Non-EMR EDs in New York State had a lower presence of VL devices, with the Glidescope device again being the most common. These results demonstrate that VL is pervasive in both practice environments.

Inactivation of HCoV-NL63 and SARS-CoV-2 in aqueous solution by 254 nm UV-C.

Ultraviolet germicidal irradiation (UVGI) is a highly effective means of inactivating many bacteria, viruses, and fungi. UVGI is an attractive viral mitigation strategy against coronaviruses, including the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of the coronavirus disease-2019 (COVID-19) pandemic. This investigation measures the susceptibility of two human coronaviruses to inactivation by 254 nm UV-C radiation. Human coronavirus NL63 and SARS-CoV-2 were irradiated in a collimated, dual-beam, aqueous UV reactor. By measuring fluence and integrating it in real-time, this reactor accounts for the lamp output transients during UVGI exposures. The inactivation rate constants of a one-stage exponential decay model were determined to be 2.050 cm2/mJ and 2.098 cm2/mJ for the NL63 and SARS-CoV-2 viruses, respectively. The inactivation rate constant for SARS-CoV-2 is within 2% of that of NL63, indicating that in identical inactivation environments, very similar UV 254 nm deactivation susceptibilities for these two coronaviruses would be achieved. Given the inactivation rate constant obtained in this study, doses of 1.1 mJ/cm2, 2.2 mJ/cm2, and 3.3 mJ/cm2 would result in a 90%, 99%, and 99.9% inactivation of the SARS-CoV-2 virus, respectively. The inactivation rate constant obtained in this study is significantly higher than values reported from many 254 nm studies, which suggests greater UV susceptibility to the UV-C than what was believed. Overall, results from this study indicate that 254 nm UV-C is effective for inactivation of human coronaviruses, including SARS-CoV-2.