C3-C4 cervical disc herniation producing Brown-Séquard syndrome: A case report and review of the literature.

Brown-Séquard Syndrome (BSS) is a rare form of incomplete spinal cord injury and is characterized by ipsilateral motor deficit and contralateral sensory loss. BSS is commonly associated with traumatic etiologies, but non-traumatic causes should be considered as well. A 38-year-old woman presented with a 3-week history of weakness in her right upper extremity, and she has developed numbness and tingling in her left upper and lower extremities over the past week and a half, along with some motor difficulty. Imaging showed a large right paracentral disc protrusion at the C3-C4 level causing severe spinal canal narrowing and resulting in abnormal cord signal. The patient subsequently underwent a C3-4 cervical total disk replacement. Hemovac placed during surgery was removed on post-op day one, and she was re-evaluated by PT/OT and recommended for outpatient therapies on post-op day two. Our case, along with a review of the literature, highlights those non-traumatic causes of BSS should be considered as a cause of BSS. BSS produced by a herniated cervical disc is extremely rare and is often misdiagnosed.

Cyclobenzaprine utilization for musculoskeletal back pain: Analysis of 2007-2019 National Hospital Ambulatory Medical Care Survey Data.

BACKGROUND: With musculoskeletal back pain being one of the most common presentations in the emergency department, evidence-based management strategies are needed to address such complaints. Along with other medications, cyclobenzaprine is a muscle relaxant commonly prescribed for patients complaining of musculoskeletal pain, in particular, pain associated with muscle spasms. However, with recent literature questioning its efficacy, the role of cyclobenzaprine use in patients with musculoskeletal back pain remains unclear. OBJECTIVES: The objective of the study is to investigate trends of cyclobenzaprine utilization among patients presenting to the emergency department (ED) in the United States. METHODS: This is a retrospective cohort review of data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2007 and 2019. We analyzed ED visits of patients 18 years and older. Visits during which cyclobenzaprine was administered in the ED or prescribed at discharge were identified. Trends were described using a time series analysis of patients' visits who received administration and prescriptions of cyclobenzaprine. RESULTS: Between 2007 and 2019, we identified an estimated 1.35 billion ED visits, 57.2% (772.6 million) were female. From that sample, 2.4% (32.7 million) of all visits received cyclobenzaprine prescription in the ED only, and 0.5% (6.6 million) of total visits were both given the drug in the ED and were prescribed the drug at discharge). Overall trend analysis shows a slight decrease in annual percentages of cyclobenzaprine administration and prescriptions during the study period. Visits of certain subgroups: 26-44 years, white showed relatively higher percentages of administration and prescription of cyclobenzaprine. CONCLUSIONS: Although there was a slight decrease, our study still shows significant cyclobenzaprine utilization in the ED, despite conflicting evidence demonstrating efficacy for patients with musculoskeletal complaints and the concern for adverse effects. Additional studies are needed to examine its overall effectiveness and risk-benefit analysis in treating patients with such conditions.

Suprapubic catheter encasement by bladder stone.

Complications of suprapubic catheterization including acute urinary retention present often to the emergency department. Patients with chronic indwelling catheters are at increased risk of bladder calculi and recurrent infections, especially without appropriate follow up care. We describe a case of suprapubic catheter failure secondary to complete circumferential encrustation of the distal catheter tip by a bladder calculus. This case demonstrates the need for thorough evaluation of any case of catheter dysfunction and for careful consideration of bladder calculi in those patients at risk.

Early palliative intervention in septic patients reduces healthcare utilization.

INTRODUCTION: While the role of palliative care in the emergency department is recognized, barriers against the effective integration of palliative interventions and emergency care remain. We examined the association between goals-of-care and palliative care consultations and healthcare utilization outcomes in older adult patients who presented to the emergency department (ED) with sepsis. METHODS: We performed a retrospective review of 197 patients aged 65 years and older who presented to the ED with sepsis or septic shock. Healthcare utilization outcomes were compared between patients divided into 3 groups: no palliative care consultation, palliative care consultation within 4 days of admission (i.e., early consultation), and palliative care consultation after 4 days of admission (i.e., late consultation). RESULTS: 51% of patients did not receive any palliative consultation, 39% of patients underwent an early palliative care consultation (within 4 days), and 10% of patients underwent a late palliative care consultation (after 4 days). Patients who received late palliative care consultation had a significantly increased number of procedures, total length of stay, ICU length of stay, and cost (p < .01, p < .001, p < .05, p < .001; respectively). Regarding early palliative care consultation, there were no statistically significant associations between this intervention and our outcomes of interest; however, we noted a trend towards decreased total length of stay and decreased healthcare cost. CONCLUSION: In patients aged 65 years and older who presented to the ED with sepsis, early palliative consultations were associated with reduced healthcare utilization as compared to late palliative consultations.

Prostate Cancer Targeted X-Ray Fluorescence Imaging via Gold Nanoparticles Functionalized With Prostate-Specific Membrane Antigen (PSMA).

PURPOSE: The gold nanoparticle (GNP) as a promising theranostic probe has been increasingly studied. The tumor-targeting efficiency of GNPs is crucial to increase the therapeutic ratio. In this study, we developed PSMA-targeted GNPs to enhance GNP uptake in prostate cancer and developed an x-ray fluorescence imaging system to noninvasively monitor and assess GNP delivery. METHODS AND MATERIALS: For targeted therapy of prostate cancer, anti-prostate-specific membrane antigen (PSMA) antibodies were conjugated onto PEGylated GNPs through 1-ethyl-3-(-3-dimethylaminopropyl) carbodiimide (EDC) and N-hydroxysuccinimide (NHS) (EDC/NHS) chemistry. In vivo imaging was implemented using an in-house-developed dual-modality computed tomography (CT) and x-ray fluorescence CT (XFCT) system on mice bearing subcutaneous LNCaP prostate tumors. After intravenous administration of GNPs (15 mg/mL, 200 µL), the x-ray fluorescence signals from the tumor were collected at various time points (5 minutes to approximately 30 hours) for GNP pharmacokinetics analysis. At 24 hours after administration, x-ray fluorescence projection (XRFproj) and XFCT imaging were conducted to evaluate the prostate tumor uptake of active- and passive-targeting GNPs. Inductively coupled plasma mass spectrometry analysis was adopted as a benchmark to verify the quantification accuracy of XRFproj/XFCT imaging. RESULTS: Fluorescence microscopic imaging confirmed the enhanced (approximately 4 times) targeting efficiency of PSMA-targeted GNPs in vitro. The pharmacokinetics analysis showed enhanced tumor uptake/retention of PSMA-targeted GNPs and revealed that the peak tumor accumulation appeared at approximately 24 hours after intravenous administration. Both XRFproj and XFCT imaging presented their accuracy in quantifying GNPs within tumors noninvasively. Moreover, XFCT imaging verified its unique capabilities to simultaneously determine the heterogeneous spatial distribution and the concentration of GNPs within tumors in vivo. CONCLUSIONS: In conjunction with PSMA-targeted GNPs, XRFproj/XFCT would be a highly sensitive tool for targeted imaging of prostate cancer, benefiting the elucidation of mechanisms of GNP-assisted prostate-cancer therapy.

Pharmacotherapy in COVID-19; A narrative review for emergency providers.

INTRODUCTION: The COVID-19 pandemic has been particularly challenging due to a lack of established therapies and treatment guidelines. With the rapid transmission of disease, even the off-label use of available therapies has been impeded by limited availability. Several antivirals, antimalarials, and biologics are being considered for treatment at this time. The purpose of this literature review is to synthesize the available information regarding treatment options for COVID-19 and serve as a resource for health care professionals. OBJECTIVES: This narrative review was conducted to summarize the effectiveness of current therapy options for COVID-19 and address the controversial use of non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs). PubMed and SCOPUS were queried using a combination of the keywords "COVID 19," "SARS-CoV-2," and "treatment." All types of studies were evaluated including systematic reviews, case-studies, and clinical guidelines. DISCUSSION: There are currently no therapeutic drugs available that are directly active against SARS-CoV-2; however, several antivirals (remdesivir, favipiravir) and antimalarials (chloroquine, hydroxychloroquine) have emerged as potential therapies. Current guidelines recommend combination treatment with hydroxychloroquine/azithromycin or chloroquine, if hydroxychloroquine is unavailable, in patients with moderate disease, although these recommendations are based on limited evidence. Remdesivir and convalescent plasma may be considered in critical patients with respiratory failure; however, access to these therapies may be limited. Interleukin-6 (IL-6) antagonists may be used in patients who develop evidence of cytokine release syndrome (CRS). Corticosteroids should be avoided unless there is evidence of refractory septic shock, acute respiratory distress syndrome (ARDS), or another compelling indication for their use. ACE inhibitors and ARBs should not be discontinued at this time and ibuprofen may be used for fever. CONCLUSION: There are several ongoing clinical trials that are testing the efficacy of single and combination treatments with the drugs mentioned in this review and new agents are under development. Until the results of these trials become available, we must use the best available evidence for the prevention and treatment of COVID-19. Additionally, we can learn from the experiences of healthcare providers around the world to combat this pandemic.

Lung Nodule Manager App Review.

Intermediate lung nodules are frequently discovered in CT imaging as either incidental or part of cancer screening. The Lung Nodule Manager allows for a quick retrieval of guidelines by physicians and health care professionals to determine the proper management and follow-up for patients.

Plasmonic Optical Imaging of Gold Nanorods Localization in Small Animals.

Gold nanoparticles (GNP) have been intensively investigated for applications in cancer imaging and therapy. Most imaging studies focused on microscopic imaging. Their potential as optical imaging probes for whole body small animal imaging has rarely been explored. Taking advantage of their surface plasmon resonance (SPR) properties, we aim to develop a noninvasive diffuse optical imaging method to map the distribution of a special type of GNP, gold nanorods (GNR), in small animals. We developed an integrated dual-modality imaging system capable of both x-ray computed tomography (XCT) and diffuse optical tomography (DOT). XCT provides the animal anatomy and contour required for DOT; DOT maps the distribution of GNR in the animal. This SPR enhanced optical imaging (SPROI) technique was investigated using simulation, phantom and mouse experiments. The distribution of GNR at various concentrations (0.1-100 nM, or 3.5 ug/g-3.5 mg/g) was successfully reconstructed from centimeter-scaled volumes. SPROI detected GNR at 18 µg/g concentration in the mouse breast tumor, and is 3 orders more sensitive than x-ray imaging. This study demonstrated the high sensitivity of SPROI in mapping GNR distributions in small animals. It does not require additional imaging tags other than GNR themselves. SPROI can be used to detect tumors targeted by GNR via passive targeting based on enhanced permeability and retention or via active targeting using biologically conjugated ligands.

Virtual Reality as a Clinical Tool for Pain Management.

PURPOSE OF REVIEW: To evaluate the use of virtual reality (VR) therapies as a clinical tool for the management of acute and chronic pain. RECENT FINDINGS: Recent articles support the hypothesis that VR therapies can effectively distract patients who suffer from chronic pain and from acute pain stimulated in trials. Clinical studies yield promising results in the application of VR therapies to a variety of acute and chronic pain conditions, including fibromyalgia, phantom limb pain, and regional specific pain from past injuries and illnesses. Current management techniques for acute and chronic pain, such as opioids and physical therapy, are often incomplete or ineffective. VR trials demonstrate a potential to redefine the approach to treating acute and chronic pain in the clinical setting. Patient immersion in interactive virtual reality provides distraction from painful stimuli and can decrease an individual's perception of the pain. In this review, we discuss the use of VR to provide patient distraction from acute pain induced from electrical, thermal, and pressure conditions. We also discuss the application of VR technologies to treat various chronic pain conditions in both outpatient and inpatient settings.

Advances in Diabetes Pharmacotherapy: An Update for the Emergency Provider.

BACKGROUND: Diabetes mellitus is a disease that affects millions of Americans, and its prevalence is only anticipated to increase in coming years. It is estimated that diabetes-related visits account for 1% of all emergency department (ED) encounters. In recent years, there have been several new categories of medications approved for the treatment of diabetes, including new insulins, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, an amylin analogue, and sodium-glucose cotransporter-2 inhibitors. OBJECTIVE OF THE REVIEW: This review presents recently approved agents to treat diabetes, with a focus on basic mechanism, place in therapy, and toxicities the ED provider may encounter. DISCUSSION: Many of these new therapies have been incorporated as first- and second-line agents for the management of diabetes. Recently approved diabetes medications often have different mechanisms of action and adverse effect and overdose profiles compared to traditional agents, such as sulfonylureas and metformin. CONCLUSIONS: Emergency providers will encounter patients taking these newly approved medications, as well as treat those presenting with adverse effects and overdoses from them. As such, emergency providers must have a basic understanding of these new therapies so that they can optimally care for diabetic patients.

Emerging Utility of Virtual Reality as a Multidisciplinary Tool in Clinical Medicine.

OBJECTIVE: Among the more recent products borne of the evolution of digital technology, virtual reality (VR) is gaining a foothold in clinical medicine as an adjunct to traditional therapies. Early studies suggest a growing role for VR applications in pain management, clinical skills training, cognitive assessment and cognitive therapy, and physical rehabilitation. MATERIALS AND METHODS: To complete a review of the literature, we searched PubMed and MEDLINE databases with the following search terms: "virtual reality," "procedural medicine," "oncology," "physical therapy," and "burn." We further limited our search to publications in the English language. Boolean operators were used to combine search terms. RESULTS: The included search terms yielded 97 potential articles, of which 45 were identified as meeting study criteria, and are included in this review. These articles provide data, which strongly support the hypothesis that VR simulations can enhance pain management (by reducing patient perception of pain and anxiety), can augment clinical training curricula and physical rehabilitation protocols (through immersive audiovisual environments), and can improve clinical assessment of cognitive function (through improved ecological validity). CONCLUSION: Through computer-generated, life-like digital landscapes, VR stands to change the current approach to pain management, medical training, neurocognitive diagnosis, and physical rehabilitation. Additional studies are needed to help define best practices in VR utilization, and to explore new therapeutic uses for VR in clinical practice.

Dysuria: An Uncommon Presentation in Emergency Department Following Bladder Neck Disruption.

Prostate cancer is the most common life-threatening cancer diagnosed in men. Complications of prostatectomies vary and often include urinary incontinence, erectile dysfunction and pain, while other complications go unreported. While emergency physicians are already familiar with the more common post-operative complications presenting to their departments, including urinary retention, ileus, surgical site infections, venous thromboembolisms and urinary tract infections, they must have a high index of suspicion for rarer complications. We report a case of posterior bladder neck disruption as a complication of a robotic assisted laparoscopic prostatectomy that presented to the emergency department as dysuria and abdominal pain following urination.

Tension Pneumothorax, Pneumoperitoneum, and Cervical Emphysema following a Diagnostic Colonoscopy.

Colonoscopy is currently a widespread procedure used in screening for colorectal cancer. Iatrogenic colonic perforation during colonoscopy is a serious and potentially life-threatening complication that can cause significant morbidity and mortality. "Triple pneumo" (a combination of pneumothorax, pneumomediastinum, and pneumoperitoneum) following colonoscopy is a rare but a serious condition requiring immediate diagnosis and emergent intervention. In majority of these cases a colonic perforation is the initial injury that is followed by pneumothorax and pneumomediastinum through the potential anatomical connection with retroperitoneal and mediastinal spaces. In this rare case report we are presenting a case of "triple pneumo" with no evidence of colonic perforation. This patient developed a simultaneous pneumoperitoneum, pneumomediastinum, and a tension pneumothorax requiring immediate tube thoracostomy. This case may raise the awareness on the likelihood of these serious complications after colonoscopy.

Incidental identification of right atrial mass using bedside ultrasound: cardiac angiosarcoma.

BACKGROUND: Emergency ultrasound is now used in both community and academic hospitals for rapid diagnosis and treatment of life-threatening conditions. Bedside emergency echocardiography can rapidly identify significant pathology such as pericardial effusions and tamponade, right ventricle dilatation due to pulmonary embolism, and cardiac hypokinesis, and aid in the diagnosis and management of patients in emergency department (ED). CASE REPORT: A 41-year-old man presented twice to the ED with history of abdominal pain and was diagnosed with primary cardiac angiosarcoma with point-of-care ultrasound. CONCLUSION: This case is illustrative of how bedside cardiac ultrasound in the ED can dramatically change a patient's hospital course.