Implementation of an education session on buprenorphine induction in the emergency department, a resident-led initiative.

INTRODUCTION: Many physicians including emergency medicine physicians report insufficient training and education on prescribing buprenorphine for opioid use disorder. As emergency departments implement buprenorphine induction protocols, educational sessions can provide physicians with further familiarity with the treatment of opioid use disorder. This quality improvement project aimed to address the barrier of physician education in the implementation of buprenorphine initiation in the emergency department and presents a model for resident-led education sessions of emergency medicine physicians. METHODS: The project was a resident-led educational quality improvement project on educating members of the Department of Emergency Medicine on buprenorphine induction. The thirty-minute educational session included a pre-test survey, lecture, practice case workshop, questions, post-test survey, and a discussion. The survey questions were designed for physicians including residents and faculty, but medical students were invited to complete the session. RESULTS: Physicians including faculty and resident physicians responded positively to the educational survey, with an increase from 42.5 to 100% responding that they understood the risks and benefits of prescribing buprenorphine in the emergency department pre and post-survey respectively. Based on post-survey results, 88.5% of physicians responded that they planned to prescribe buprenorphine in the emergency department for patients meeting clinical criteria after completing the educational session. CONCLUSION: The results suggest that a resident-led training session can encourage peer involvement in buprenorphine induction to treat opioid use disorder in the emergency department.

An Analysis of Clinical Outcomes of Exploratory Pediatric Metformin Ingestions Reported to the Texas Poison Center Network From 2011 to 2021.

Background: Poison centers develop triage threshold guidelines for pediatric metformin ingestions. Our network uses 1700 mg, or 85 mg/kg. Objective: To describe the dose, clinical course, and outcomes for inadvertent metformin ingestions in children 5 years old and younger reported to our statewide poison center network. Methods: We searched the poison center database 2011 to 2021 for metformin ingestions in patients 5 years and younger. Variables included age, sex, weight, dose, symptoms, outcome, and more. We used descriptive statistics with medians and interquartile ranges (IQR) for continuous variables. Results: Of 669 cases, exposures by age were 208 (31.1%) 1 to 2 years, and 275 (41.1%) 2 years. Weight was recorded in 342 (51.1%) (median 13.5 kg; IQR: 3.7 kg), and dose in 149 (22.3%) (median 500 mg; IQR: 500 mg). Milligram/kilogram values were available for 103 (15.4%) with median 42.4 mg/kg, IQR: 39 mg/kg. Most (647, 98.5%) exposures were unintentional. Most (445/669, 66.5%) were managed at a non-healthcare facility, while 204 (30.7%) were already at or referred to a healthcare facility. Of these 204 patients, 169 (82.8%) were evaluated and treated at the emergency department and discharged. Four (2%) were admitted to critical care, and 7 (3.4%) to the ward. Medical outcomes by effect were 5 (0.7%) minor, 2 (0.3%) moderate, 253 (37.8%) none, 292 (43.6%) not followed (minimal effects possible), and no major effects or deaths. Of 20 clinical occurrences reported, vomiting was most common (8, 1.2%). Conclusion: Despite little recorded dosage information, pediatric metformin ingestions under 85 mg/kg had predominantly uneventful medical outcomes.

Two Cases of Thyrotoxicosis due to Redotex Ingestion, a Mexican Weight Loss Drug.

BACKGROUND: Redotex™ is a Mexican weight-loss supplement that is not U.S. Food and Drug Administration-approved. It consists of the following five ingredients: tri-iodothyronine 75 µg, atropine 0.36 mg, diazepam 8 mg, aloin 16 mg, and d-norpseudoephedrine 50 mg per tablet. There are few case reports with clinically severe ingestions. We report two cases of clinical thyrotoxicosis due to use of Redotex. CASE REPORTS: A 29-year-old woman presented to the emergency department (ED) with anxiety and palpitations. She reported taking Redotex daily for 1 week. Her temperature was 37.1°C, blood pressure (BP) was 166/104 mm Hg, and heart rate (HR) was 140 beats/min. Laboratory analysis was significant for a bicarbonate level of 20 mmol/L (reference 22-29 mmol/L), free T4 0.75 ng/dL (reference 0.93-1.70 ng/dL), and thyroid-stimulating hormone (TSH) 0.05 uIU/mL (reference 0.27-4.20 uIU/mL). She was treated with 2 mg i.v. lorazepam and 20 mg oral propranolol. A 37-year-old woman presented with chest pain, palpitations, and nausea after taking Redotex 1 to 2 tablets daily for 6 weeks. Her HR was 134 beats/min and BP was 130/66 mm Hg. Thyroid function tests on initial presentation showed a TSH of 0.013 uU/mL, free T4 of 0.24 ng/dL, and free T3 of >30 pg/mL. She was treated with propranolol 1 mg i.v. twice per day and 2 doses of lorazepam 1 mg. Both patients had resolution of their symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When taken chronically and at recommended doses, Redotex can present with clinically significant T3 thyrotoxicosis. This has not been seen in prior reports.

Intersectin-s interaction with DENND2B facilitates recycling of epidermal growth factor receptor.

Epidermal growth factor (EGF) activates the EGF receptor (EGFR) and stimulates its internalization and trafficking to lysosomes for degradation. However, a percentage of EGFR undergoes ligand-independent endocytosis and is rapidly recycled back to the plasma membrane. Importantly, alterations in EGFR recycling are a common hallmark of cancer, and yet, our understanding of the machineries controlling the fate of endocytosed EGFR is incomplete. Intersectin-s is a multi-domain adaptor protein that is required for internalization of EGFR Here, we discover that intersectin-s binds DENND2B, a guanine nucleotide exchange factor for the exocytic GTPase Rab13, and this interaction promotes recycling of ligand-free EGFR to the cell surface. Intriguingly, upon EGF treatment, DENND2B is phosphorylated by protein kinase D and dissociates from intersectin-s, allowing for receptor targeting to degradation. Our study thus reveals a novel mechanism controlling the fate of internalized EGFR with important implications for cancer.

Obstructive Sleep Apnea and the Adult Perioperative Patient.

Obstructive sleep apnea (OSA) is a chronic condition of upper airway obstruction during sleep. It is associated with significant morbidity and mortality and increases the perioperative risks of surgical patients. Thus, it is essential that perianesthesia nurses understand how to identify and manage patients with known or suspected OSA. This continuing education article will review the pathophysiology of OSA, discuss the effects of anesthesia and opioids on the sleep architecture of the OSA patients, describe the effects of OSA on postoperative complications, review the latest evidence on screening for undiagnosed OSA in the adult surgical patient, and review the perioperative management principles for patients with OSA.

Fasciotomy following North American pit viper envenomation in Texas 2004-2021.

INTRODUCTION: North American pit viper envenomation occurs over 4,000 times annually in the United States, with polyvalent Fab antivenom being the primary treatment. Fasciotomy is occasionally performed due to concerns about compartment syndrome. We utilized our direct access to Texas Poison Center Network data to create a new snakebite abstraction form and database on relevant available information between 2004 and 2021 and to identify, describe, and estimate the incidence of fasciotomy following pit viper envenomation in Texas. METHODS: We searched the Texas Poison Center Network database for cases during 2004-2021 using keywords such as fasciotomy, surgery, compartment pressure, and compartment syndrome. Descriptive statistics summarized the data. RESULTS: Of 16,911 reported envenomations, 0.69 percent involved fasciotomies (n = 117). Most common bite sites were digits/hands and lower extremities. Patients who underwent fasciotomy were typically male, aged 20-59, and 10 years younger than the total snakebite population. Only 6 percent of reported compartment syndrome cases had a compartment pressure measurement. Antivenom was administered in 101 (86.3 percent) cases, 92 (91.1 percent) of which received only Fab antivenom product. Patients with bites from rattlesnakes (47.9 percent) were associated with most fasciotomies. DISCUSSION: Our findings suggest a potential increase in snakebite exposures, accompanied by a decrease in fasciotomies. Overall, copperheads constituted the majority of snakebites, but most fasciotomies were from rattlesnake envenomations (47.9 percent). In this cohort, compartment syndrome diagnosis and decisions regarding fasciotomy were primarily based on clinical evaluation/surgeon expertise without compartment pressure measurements. Despite the efficacy of antivenom, only 86.3 percent of patients in our study received antivenom. CONCLUSIONS: Fasciotomy after North American pit viper envenomation in Texas is uncommon (0.69 percent) and has decreased over time, possibly due to increased antivenom use or surgeon comfort with nonsurgical management.

Virulence of Burkholderia mallei quorum-sensing mutants.

Many Proteobacteria use acyl-homoserine lactone-mediated quorum-sensing (QS) to activate specific sets of genes as a function of cell density. QS often controls the virulence of pathogenic species, and in fact a previous study indicated that QS was important for Burkholderia mallei mouse lung infections. To gain in-depth information on the role of QS in B. mallei virulence, we constructed and characterized a mutant of B. mallei strain GB8 that was unable to make acyl-homoserine lactones. The QS mutant showed virulence equal to that of its wild-type parent in an aerosol mouse infection model, and growth in macrophages was indistinguishable from that of the parent strain. Furthermore, we assessed the role of QS in B. mallei ATCC 23344 by constructing and characterizing a mutant strain producing AiiA, a lactonase enzyme that degrades acyl-homoserine lactones. Although acyl-homoserine lactone levels in cultures of this strain are very low, it showed full virulence. Contrary to the previous report, we conclude that QS is not required for acute B. mallei infections of mice. QS may be involved in some stage of chronic infections in the natural host of horses, or the QS genes may be remnants of the QS network in B. pseudomallei from which this host-adapted pathogen evolved.

A randomized controlled trial of sleep study surveillance with targeted autoregulated positive airway pressure therapy for obstructive sleep apnea in pregnancy.

BACKGROUND: Obstructive sleep apnea is associated with adverse pregnancy outcomes. The impact therapy for obstructive sleep apnea has on these pregnancy outcomes remains under investigated. OBJECTIVE: This study aimed to determine the effects of targeted autoregulated positive airway pressure in women at risk of obstructive sleep apnea on adverse pregnancy outcomes, cost, and natural history of obstructive sleep apnea. STUDY DESIGN: Pregnant women at high risk of obstructive sleep apnea were randomized to either a sleep study screening group receiving autoregulated positive airway therapy or a group not screened for obstructive sleep apnea receiving standard obstetrical care (control). Women in the sleep study-screened group received a sleep study at 2 periods during pregnancy, early (6-16 weeks of gestation) and late (27-33 weeks of gestation), with initiation of autoregulated positive airway therapy if their Apnea Hypopnea Index indicated ≥5 events per hour. Women of both groups had a sleep study 3 months after delivery. The primary outcome was effect on adverse pregnancy outcomes, a composite of hypertension, preterm birth, low birthweight, stillbirth, and diabetes mellitus. The secondary outcomes included obstructive sleep apnea severity and hospital costs. RESULTS: Among 193 women randomized (100 in the sleep study-screened group and 93 in the control group; 6 lost to follow-up), there was no significant difference in composite adverse pregnancy outcomes (46.4% screened vs 43.3% control; P=.77), hypertension (23.7% screened vs 32.0% control; P=.25), preterm birth (13.4% screened vs 10.0% control; P=.5), low birthweight (5.2% screened vs 6.7% control; P=.76), stillbirth (1% screened vs 0% control; P=1), gestational diabetes (19.6% screened vs 13.3% control; P=.33), or mean cost ($12,185 screened vs $12,607 control). The Apnea Hypopnea Index increased throughout pregnancy, peaking at 3 months after delivery (P<.001). There were 24 subjects (25.8%) who had a new diagnosis of obstructive sleep apnea, with 6 in whom autoregulated positive airway was prescribed. The autoregulated positive airway compliance rates were poor with usage rates ranging from 2% (1 of 64 days) to 43% (6 of 14 days). CONCLUSION: Targeted autoregulated positive airway therapy for obstructive sleep apnea did not decrease composite adverse pregnancy outcomes or hospital costs in the sleep study-screened high-risk pregnancy group compared with the group that received no obstructive sleep apnea screening. However, a small sample size, low autoregulated positive airway prescription rates, and poor compliance resulted in difficulty in drawing a definitive conclusion. The prevalence and severity of obstructive sleep apnea worsened throughout pregnancy, with the highest rates detected in the postpartum period. Large, multicenter clinical trials that are adequately powered are needed.

Enhancing behavioral sleep care with digital technology: study protocol for a hybrid type 3 implementation-effectiveness randomized trial.

BACKGROUND: Insomnia affects almost one in four military service members and veterans. The first-line recommended treatment for insomnia is cognitive-behavioral therapy for insomnia (CBTI). CBTI is typically delivered in-person or online over one-to-four sessions (brief versions) or five-to-eight sessions (standard versions) by a licensed doctoral or masters-level clinician with extensive training in behavioral sleep medicine. Despite its effectiveness, CBTI has limited scalability. Three main factors inhibit access to and delivery of CBTI including restricted availability of clinical expertise; rigid, resource-intensive treatment formats; and limited capacities for just-in-time monitoring and treatment personalization. Digital technologies offer a unique opportunity to overcome these challenges by providing scalable, personalized, resource-sensitive, adaptive, and cost-effective approaches for evidence-based insomnia treatment. METHODS: This is a hybrid type 3 implementation-effectiveness randomized trial using a scalable evidence-based digital health software platform, NOCTEM™'s Clinician-Operated Assistive Sleep Technology (COAST™). COAST includes a clinician portal and a patient app, and it utilizes algorithms that facilitate detection of sleep disordered patterns, support clinical decision-making, and personalize sleep interventions. The first aim is to compare three clinician- and system-centered implementation strategies on the reach, adoption, and sustainability of the COAST digital platform by offering (1) COAST only, (2) COAST plus external facilitation (EF: assistance and consultation to providers by NOCTEM's sleep experts), or (3) COAST plus EF and internal facilitation (EF/IF: assistance/consultation to providers by NOCTEM's sleep experts and local champions). The second aim is to quantify improvements in insomnia among patients who receive behavioral sleep care via the COAST platform. We hypothesize that reach, adoption, and sustainability and the magnitude of improvements in insomnia will be superior in the EF and EF/IF groups relative to the COAST-only group. DISCUSSION: Digital health technologies and machine learning-assisted clinical decision support tools have substantial potential for scaling access to insomnia treatment. This can augment the scalability and cost-effectiveness of CBTI without compromising patient outcomes. Engaging providers, stakeholders, patients, and decision-makers is key in identifying strategies to support the deployment of digital health technologies that can promote quality care and result in clinically meaningful sleep improvements, positive systemic change, and enhanced readiness and health among service members. TRIAL REGISTRATION: ClinicalTrials.gov NCT04366284 . Registered on 28 April 2020.

Effect of Obstructive Sleep Apnea on Neurocognitive Performance.

This article reviews the effects of obstructive sleep apnea on neurocognitive performance, proposed mechanisms of cognitive impairment, and the effects of continuous positive airway pressure on performance. Obstructive sleep apnea can affect several domains of neurocognitive performance to include attention and vigilance, memory and learning, psychomotor function, emotional regulation, and executive function. Proposed mechanisms include intermittent hypoxemia, sleep deprivation and fragmentation, hypercapnia, and disruption of the hypothalamic-pituitary-adrenal-axis. Continuous positive airway pressure can improve cognitive defects associated with obstructive sleep apnea. More data are needed to determine whether other therapies improve cognitive function.

Characteristics of prior emergency departments visits associated with subsequent opioid overdose.

OBJECTIVES: In this study, we aim to identify and discuss the clinical and demographic characteristics of previous emergency department (ED) patient visits, at one of the only two medical centers in Staten Island, the epicenter of the opioid epidemic within Staten Island, who subsequently present to the ED with an opioid overdose. DESIGN: This was a retrospective, observational study of all patients presenting to the emergency ED between July 1, 2010 and December 31, 2015. SETTING: The study was conducted at Staten Island University Hospital. The ED has a census of 120,000 patient visits per year. PATIENTS: All adult patients ≥ 18 years of age, with an ICD-9 code consistent with opioid intoxication and a history of intentional or unintentional overdose were included. MAIN OUTCOME MEASURE: Clinical and demographic characteristics of previous ED patient visits who subsequently presented to the ED with an opioid overdose. RESULTS: One hundred and twenty-four subjects with a median age of 30 years [interquartile range, 24-40] were reviewed. Eighty-seven (70 percent) were males. Fifty-five subjects were admitted, 68 discharged, and one death. Patients were not more likely to present at any specific time of day. The most common past medical history was anxiety (21 percent), depression (20 percent), back pain (15 percent), hypertension (14 percent), and seizure disorder (11 percent). The most common past surgical history was a prior orthopedic procedure (11 percent). CONCLUSIONS: This study identified clinical and demographic characteristics of previous ED patient visits who subsequently present to the ED with an opioid overdose. These characteristics will be vital toward an increased understanding of subjects who subsequently experience an opioid overdose.

Does Part D abet advantageous selection in Medicare Advantage?

The use of risk-adjustment formulae in setting payments to Medicare Advantage (MA) plans reduces the potential for advantageous selection on factors included in the formulae, but can theoretically worsen overall selection if plans are able to target beneficiaries based on excluded factors. Since MA medical risk-adjustment excludes prescription drug utilization, demand for drugs can be exploited by plans to induce advantageous selection. We show evidence that the introduction of Medicare Part D provided a mechanism for MA plans to increase selection, and that consumers responded, increasing MA market shares among beneficiaries taking drugs associated with the strongest advantageous selection incentives. For the average Medicare beneficiary in our sample, we estimate that this change in advantageous selection following the introduction of Medicare Part D increased the probability of enrolling in an MA plan by about 7.1%.

Postthrombotic syndrome complicating a case of May-Thurner syndrome despite endovascular therapy: case report and review.

External compression of the left iliac vein is a common finding in the general population. It may predispose patients to the development of deep vein thrombosis (DVT) of the left leg and may also lead to a more complicated course than in other types of DVT. This entity has been well-described by other authors. External compression of the left iliac vein should be suspected in cases of complicated DVT or in cases of DVT with no predisposing factors. We describe a case of May-Thurner syndrome that involved a complicated treatment course, and a review of current options for diagnosis and therapy.

Wegener's granulomatosis presenting with diffuse alveolar hemorrhage and negative antineutrophilic cytoplasmic antibody test.

One of the causes of diffuse pulmonary infiltrates can be blood from diffuse alveolar hemorrhage. Other causes include malignancy, edema fluid, infections, and protein (blood, pus, water, cells, or protein). Autoimmune vasculitis, such as Wegener's granulomatosis, should be considered in the setting of diffuse pulmonary infiltrates, anemia, systemic symptoms, and recurrence despite antibiotic therapy. Antineutrophilic cytoplasmic antibody testing can be useful but is not always diagnostic. Early tissue biopsy should be considered to guide therapy. We present a case of Wegener's granulomatosis that presented with diffuse alveolar hemorrhage. Diagnosis was made through renal biopsy; however, antineutrophilic cytoplasmic antibody testing was negative. A brief overview of pulmonary-renal vasculitides is also presented.

Max-confidence boosting with uncertainty for visual tracking.

The challenges in visual tracking call for a method which can reliably recognize the subject of interests in an environment, where the appearance of both the background and the foreground change with time. Many existing studies model this problem as tracking by classification with online updating of the classification models, however, most of them overlook the ambiguity in visual modeling and do not consider the prior information in the tracking process. In this paper, we present a novel visual tracking method called max-confidence boosting (MCB), which explores a new way of online updating ambiguous visual phenomenon. The MCB framework models uncertainty in prior knowledge utilizing the indeterministic labels, which are used in updating models from previous frames and the new frame. Our proposed MCB tracker allows ambiguity in the tracking process and can effectively alleviate the drift problem. Many experimental results in challenging video sequences verify the success of our method, and our MCB tracker outperforms a number of the state-of-the-art tracking by classification methods.

Detection of sudden pedestrian crossings for driving assistance systems.

In this paper, we study the problem of detecting sudden pedestrian crossings to assist drivers in avoiding accidents. This application has two major requirements: to detect crossing pedestrians as early as possible just as they enter the view of the car-mounted camera and to maintain a false alarm rate as low as possible for practical purposes. Although many current sliding-window-based approaches using various features and classification algorithms have been proposed for image-/video-based pedestrian detection, their performance in terms of accuracy and processing speed falls far short of practical application requirements. To address this problem, we propose a three-level coarse-to-fine video-based framework that detects partially visible pedestrians just as they enter the camera view, with low false alarm rate and high speed. The framework is tested on a new collection of high-resolution videos captured from a moving vehicle and yields a performance better than that of state-of-the-art pedestrian detection while running at a frame rate of 55 fps.